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Epidemiology and Surveillance

Chlorhexidine and Mupirocin Susceptibilities of Methicillin-Resistant Staphylococcus aureus from Colonized Nursing Home Residents

Jennifer S. McDanel, Courtney R. Murphy, Daniel J. Diekema, Victor Quan, Diane S. Kim, Ellena M. Peterson, Kaye D. Evans, Grace L. Tan, Mary K. Hayden, Susan S. Huang
Jennifer S. McDanel
Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Courtney R. Murphy
School of Social Ecology and Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California, USA
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Daniel J. Diekema
Department of Pathology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USADepartment of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Victor Quan
Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Irvine, California, USA
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Diane S. Kim
Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Irvine, California, USA
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Ellena M. Peterson
Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Irvine, California, USA
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Kaye D. Evans
Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Irvine, California, USA
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Grace L. Tan
Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Irvine, California, USA
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Mary K. Hayden
Section of Infectious Diseases, Rush University Medical Center, Chicago, Illinois, USA
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Susan S. Huang
Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine, Irvine, California, USA
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DOI: 10.1128/AAC.01623-12
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    Fig 1

    Distribution of chlorhexidine MICs of 829 MRSA isolates from residents of 25 nursing homes.

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    Fig 2

    MRSA resistant to mupirocin (HLMR, LLMR, and all resistant [MR]) at each of 25 nursing homes in Orange County.

Tables

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  • Table 1

    Characteristics of 26 nursing homes in Orange County, 2009

    CharacteristicMedian value (range)
    Nursing home characteristics
        No. of beds99 (24–255)
        Annual no. of admissionsa262 (18–1,526)
        Median length of stay (days)101 (17–753)
        MRSA point prevalence (% MRSA+ residents)26 (0–52)
    Demographics (as % of all facility residents)
        Age over 85 yrsa25 (2–72)
        Male42 (21–67)
        Non-Caucasian race16 (1–88)
        Less than high school education24 (0–64)
        Admitted from acute hospital82 (15–98)
    Comorbidities (as % of all facility residents)
        Diabetes27 (11–59)
        Skin lesions72 (4–100)
        Indwelling devices2 (0–46)
        History of MRSA11 (0–69)
        Multidrug-resistant MRSA isolate68 (0–100)
    Functional status (avg score among all facility residents)
        RUG scoreb0.92 (0.81–1.43)
        ADL score19.82 (10.77–26.90)
    • ↵a After excluding the 4 psychiatric facilities, the median annual admissions was 300 and the percentage of facility residents over 85 years old was 39%. The medians for the other variables did not differ substantially after excluding the 4 psychiatric nursing homes.

    • ↵b The RUG score is a facility-level score that reflects the average level of care required by residents, based upon residents' comorbidities, ability to perform activities of daily living, and the required amount of physical and occupational therapy.

  • Table 2

    Susceptibility of Orange County nursing home MRSA isolates (n = 829) to 13 antimicrobial agents

    Antimicrobial agentMIC data (μg/ml)% resistant
    RangeMIC50MIC90
    Chlorhexidine0.5–424NAa
    Clindamycin≤0.12 to >16>16>1655
    Erythromycin≤0.25 to >32>32>3290
    Tetracycline≤0.5 to >64≤0.5≤0.54
    Trimethoprim-sulfamethoxazole≤0.25 to >32≤0.25≤0.252
    Gentamicin≤0.5 to >64≤0.56412
    Levofloxacin≤0.25 to >3232>3298
    Vancomycin0.5–2110
    Daptomycin≤0.5–4≤0.5≤0.5NA
    Quinupristin-dalfopristin≤0.5–4≤0.5≤0.5<1
    Linezolid≤1–822<1
    Rifampin≤0.5 to >4≤0.5≤0.51
    Mupirocinb
        Low-level resistance isolates3
        High-level resistance isolates9
    • ↵a NA, not available, because the Clinical and Laboratory Standards Institute has not yet established breakpoints for resistance to this agent.

    • ↵b Disk diffusion testing was performed, and so no MICs are reported here.

  • Table 3

    PFGE types of high-level mupirocin-resistant MRSA (n = 78)

    PFGE typeNo. of isolates (%)No. of subtypesRelated USA typeNursing home(s) representeda
    A47 (60)171001–6, 8–10, 12, 14, 15
    B25 (32)113003, 4, 6–11, 13
    C5 (6)25005
    D1 (1)1NAb1
    • ↵a PFGE types A and B were both identified in nursing homes 3, 4, 6, 8, 9, and 10. PFGE types A and C were identified in nursing home 5. PFGE types A and D were identified in nursing home 1.

    • ↵b This isolate is not related to any of the current USA types (USA100 to USA1200).

  • Table 4

    Bivariate analysis of nursing home characteristics and partner hospital characteristics associated with high-level mupirocin-resistant MRSAa

    VariableOdds ratioP value
    Nursing home characteristics
        Annual no. of admissions0.990.58
        Length of stay (median no. of days)1.000.83
        MRSA point prevalence1.020.43
    Demographics (as % of all facility residents)
        Less than high school education1.030.88
        Admitted from acute hospital1.010.42
    Comorbidities (as % of all facility residents)
        Diabetes1.010.59
        Skin lesions1.150.40
        Indwelling device1.300.006
        History of MRSAb2.99<0.001
        Multidrug-resistant MRSA isolateb2.550.004
    Functional status (avg score among all facility residents)
        High RUG scorec2.970.04
        Avg ADL score1.280.001
    Partner hospital characteristicd
        % physicians who routinely decolonize patients who have MDROe1.040.78
        % MRSA+ patients who are decolonized0.790.13
        % that use mupirocin to decolonize MRSA+ patients0.540.26
    • ↵a Note that four psychiatric facilities were removed from the bivariate analyses.

    • ↵b Analyzed as a resident-level or isolate-level variable, not as a facility-level variable.

    • ↵c RUG is a facility-level score that reflects the average level of care required by residents, based upon residents' comorbidities, ability to perform activities of daily living, and the required amount of physical and occupational therapy. The RUG score was dichotomized into high and low values around the median.

    • ↵d A nursing home's partner hospital was the hospital that transferred the most patients to that nursing home in a year.

    • ↵e MDRO, multidrug-resistant organisms.

  • Table 5

    Multivariate analysisa of factors associated with high-level mupirocin-resistant MRSA

    VariableOdds ratio (95% CI)P value
    Multidrug-resistant MRSA isolateb2.69 (1.37, 5.28)0.004
    History of MRSAb2.34 (1.75, 3.12)<0.001
    Avg ADL scorec1.25 (1.07, 1.45)0.004
    • ↵a Note that four psychiatric facilities were removed from the multivariate analysis.

    • ↵b Analyzed as a resident-level or isolate-level variable, not as a facility-level variable.

    • ↵c The ADL score ranges from 0 (completely independent) to 28 (completely dependent) and is expressed per 1 point increase. The reported average ADL score is the average score among all residents of one facility. The ADL score was colinear with the presence of indwelling devices.

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Chlorhexidine and Mupirocin Susceptibilities of Methicillin-Resistant Staphylococcus aureus from Colonized Nursing Home Residents
Jennifer S. McDanel, Courtney R. Murphy, Daniel J. Diekema, Victor Quan, Diane S. Kim, Ellena M. Peterson, Kaye D. Evans, Grace L. Tan, Mary K. Hayden, Susan S. Huang
Antimicrobial Agents and Chemotherapy Dec 2012, 57 (1) 552-558; DOI: 10.1128/AAC.01623-12

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Chlorhexidine and Mupirocin Susceptibilities of Methicillin-Resistant Staphylococcus aureus from Colonized Nursing Home Residents
Jennifer S. McDanel, Courtney R. Murphy, Daniel J. Diekema, Victor Quan, Diane S. Kim, Ellena M. Peterson, Kaye D. Evans, Grace L. Tan, Mary K. Hayden, Susan S. Huang
Antimicrobial Agents and Chemotherapy Dec 2012, 57 (1) 552-558; DOI: 10.1128/AAC.01623-12
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