Originally published by 2 Minute Medicine® (view original article). Reused on AccessPediatrics with permission.

1. Mupirocin was shown to have an overall primary decolonization efficacy of 95% when used to treat Staphylococcus aureus among infants <24 months old admitted to the neonatal intensive care unit (NICU).

2. Almost half of all treated patients who demonstrated primary decolonization and remained in the hospital at day 22 also demonstrated persistent decolonization.

Evidence Rating Level: 1 (Excellent)

Study Rundown:

S. aureus colonization is a major source of sepsis, morbidity, and mortality among infants admitted to the NICU. Previous studies have shown prophylactic mupirocin administration among adults admitted to the intensive care unit to be efficacious in preventing hospital acquired MRSA infections, however its effect on critically ill infants has not been studied. In this trial, researchers evaluated the safety and efficacy of mupirocin (intranasal, periumbilical, and perianal) versus no mupirocin in reducing primary and persistent colonization with S. aureus (both methicillin-sensitive, MSSA, and methicillin-resistant, MRSA) among NICU patients <24 months old. Results showed mupirocin use had an overall efficacy of about 95% in primary colonization with S. aureus in the study population. Almost half of the infants who demonstrated primary decolonization and who remained in the hospital at day 22 also demonstrated persistent decolonization. Rash was the only adverse reaction noted significantly more often in treated patients. This study was limited by potential reporting bias in that nurses were asked to examine all treated patients for rash prior to mupirocin application. Although this study was not powered to determine the efficacy of mupirocin use in preventing S. aureus infections, results suggest mupirocin use at several body sites could be used to decrease S. aureus colonization rates among infants in the NICU.

In-depth [randomized controlled trial]:

This study analyzed the efficacy and safety of mupirocin versus no mupirocin in S. aureus decolonization. Participants included 155 infants <24 months old (56% male) who were accepted to remain in the NICU for >14 days and who tested positive for S. aureus via nasal swab shortly after admission. Patients were stratified into 4 groups, initially based on gestational and postnatal age (27% <28 weeks gestation), then by methicillin sensitivity (86% MSSA, 14% MRSA or MRSA+MSSA). Patients were randomly assigned in a 1:1 ratio to receive 5 days of mupirocin (applied to the intranasal, periumbilical, and perianal regions) vs. no mupirocin. Patients were monitored for adverse events and swabbed in all 3 regions at days 8 and 22 to evaluate for primary and persistent decolonization. Results showed primary decolonization occurred in 94% of treated patients vs. 5% of control patients (overall efficacy 95%). Of the infants remaining in the hospital at day 22, 46% of treated infants vs. 2% of the control group demonstrated persistent decolonization. Rash was the only adverse reaction which occurred significantly more often among patients in the treatment group vs. control (22% vs 5%, OR 5.1, 95% CI 1.5-21.7, p = .004). Two infants (3%) in the treatment group compared to none in the control group developed severe apnea within 5 minutes of treatment. No differences in decolonization were observed based on age or methicillin susceptibility. Of note, infants colonized with mupirocin-resistant S. aureus at time of admission increased throughout the study period, from 0% during study months 0-14 to 6% during the final year (p = .05). All resistant strains were observed at the center with the highest enrollment.

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