Search and destroy is so last century...

A few weeks ago, Dick Wenzel and I responded to a letter in the New England Journal of Medicine regarding our editorial on Susan Huang's paper on targeted vs universal MRSA decolonization. We have long argued that active detection and isolation (AKA search-and-destroy, a vertical strategy) wasn't a necessary or particularly wise approach. A letter refuted this. In our response, we stated:

The key question remains: given an optimally functioning horizontal program (i.e., near perfect compliance with hand hygiene and chlorhexidine bathing), what is the incremental benefit of a superimposed vertical strategy?

Voila! A new study in Lancet Infectious Diseases by Marc Bonten et al addresses our question. In this 3-year study in 13 European ICUs, involving over 8,500 patients, there was a baseline data collection phase (6 months), followed by a hygiene improvement phase (hand hygiene campaign + universal chlorhexidine bathing for 6 months), followed by cluster randomization to a rapid screening group + contact precautions for carriers or a conventional screening group + contact precautions for carriers. Both screening groups used chromogenic agar to detect MRSA, VRE and ESBL; the rapid screening group also used PCR testing for MRSA and VRE. Primary endpoints were the acquisition of MRSA, VRE or MDR-GNR.

The study showed:

• Hand hygiene increased from 52% in phase 1, to 69% in phase 2, and 77% in phase 3.
• Chlorhexidine bathing was 0% in phase 1, and 100% in phases 2 and 3.
• Improved hand hygiene + chlorhexidine bathing (phase 2) resulted in a significant decrease in MRSA acquisition, with no change for VRE or MDR-GNR.
• Neither search-and-destroy strategy resulted in any further reduction for any of the targeted pathogens.
• There was no change in the prevalence of chlorhexidine resistance genes in MRSA isolates in phase 1 vs. phase 3 (13% vs 14%).

So we now have another study demonstrating the lack of need for active detection and isolation to control multidrug resistant pathogens. Will the search-and-destroyers finally pack it up and go home?

Photo:  Jeff Swensen, New York Times