Mupirocin patients

Pharmacologic management of infections should cover the gram-positive organisms that most frequently cause access-related infections. Patients who have positive blood cultures should receive treatment tailored to the organism isolated. Preventive measures for access-related infections include mupirocin at the exit site and povidone-iodine ointment. The recommendations of the NKF for treatment of infections associated with hemodialysis are listed in Table 23-9. 

Sodium chloride 0.9% is safe and effective in relieving rhinorrhoea. It is safer to use in children than topical nasal decongestants (xylometazoline), which are to be avoided in children under 6 years as the latter are more likely are cause side-effects (such as effects on sleep or hallucinations). Budesonide spray is used for allergic conditions and is not normally used in paediatric patients. Benzydamine spray is a throat spray intended to relieve pain in the throat. Mupirocin is indicated for staphylococcal infections. 

Mupirocin is indicated for topical treatment of minor skin infections, such as impetigo. Topical application over large infected areas, such as decubitus ulcers or open surgical wounds, has been identified as an important factor leading to emergence of mupirocin-resistant strains and is not recommended. Mupirocin is also indicated for intranasal application for elimination of methicillin-resistant S aureus carriage by patients or health care workers. 

Although the incidence of adverse reactions to mupirocin is typically low (occurring in less than 1.5% of patients), several local side effects such as burning, stinging, pain, erythema, and contact dermatitis have been reported. Resistance to mupirocin has been reported but is not common. Some strains of bacteria have a low level of resistance but succumb to high-dose of mupirocin.14 Due to this fact, it should be handled with extreme care, especially as prophylactic use, in order to prevent further resistance. 

Recurrent impetigo, furunculosis, or other staphylococcal infections may be a result of pathogenic nasal carriage of S. aureus. To reduce postoperative complications, eradication of nasal colonization of S. aureus has been extended to colonized health care workers and other susceptible patients.14 Mupirocin has been found to be the most effective topical antibiotic for the elimination and is effective in reducing subsequent infections. When applied intranasally four times daily for five days, it has been shown to reduce nasal carriage for up to 1 year.77... 

Fusidic acid and mupirocin has been proven to be equal in clinical efficacy 85-87 The risk of allergic contact dermatitis to fusidic acid in patients with AD can be considered very low. In an analysis of multicenter surveillance data in Germany, fusidic acid did not cause any case of sensitization in the subgroup of atopies.29 Topical neomycin, however, is rarely indicated not only because of inefficacy and high resistance rates, but also because of frequent development of allergic contact dermatitis.88,89... 

Rohr, U. et al., Methicillin-resistant Staphylococcus aureus whole-body decolonization among hospitalized patients with variable site colonization by using mupirocin in combination with octenidine dihydrochloride. J. Hosp. Infect. 54, 305-309, 2003. 

In a randomized, double-blind, placebo-controUed trial, 97 of 2012 patients treated with mupirocin reported adverse effects, such as rhinorrhea and itching at the site of application (1). 

Of 36 patients undergoing continuous ambulatory peritoneal dialysis (mean age 55 years 21 men), who had been applying mupirocin to the catheter exit site once weekly for an average of 3.1 years before the start of the study, three were nasal carriers of S. aureus, and there was only one mupirocin-resistant organism (5). Once-weekly application of mupirocin at catheter exit sites led to comparable rates of colonization by mupirocin-resistant S. aureus as did thrice-weekly or more frequent application. 

Patients who experience fever during HD should immediately have blood cultures obtained. If a temporary catheter is being used, it should be removed and the tip of the catheter cultured. Commonly used preventive approaches to catheter-related infections include minimizing use and duration of catheters, proper disinfection and sterile technique, and use of exit-site mupirocin or povidone-iodine ointment. Adoption of strict unit protocols that employ universal pre-... 

Bernardini J, Piraino B, Holley J, et al. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kidney Dis 1996 27 695-700. 

Colonization of the nares with Staphylococcus aureus is a well-described SSI risk factor. Two small prospective trials suggest that eradication of nasal S. aureus with mupirocin significantly reduces the incidence of SSI when compared with historical controls in patients undergoing both cardiac and upper gastrointestinal surgery. Larger prospective trials, however, are needed before this therapy can be advocated routinely. Other factors shown to increase the risk of SSI include age, length of preoperative hospital stay, and obesity. ... 

A third large study found that S. aureus nasal carriers had fewer S. aureus nosocomial infections of any site, but failed to show a reduction in S. aureus surgical site infections, the primary end point of the smdy. The accumulated evidence indicates that patients who stand to benefit from mupirocin prophylaxis are those with proven S. aureus nasal colonization plus risk factors for distant infection or a history of skin or soft tissue infections. General in-patient populations and individuals lacking specific risk factors for S. aureus infection are not likely to benefit from mupirocin prophylaxis. 

Mupirocin may cause irritation and sensitization at the site of application. Contact with the eyes should be avoided because it causes tearing, burning, and irritation that may take several days to resolve. Systemic reactions to mupirocin occur rarely, if at all. Polyethylene glycol present in the ointment can be absorbed from damaged skin. Application of the ointment to large surface areas should be avoided in patients with moderate to severe renal failure to avoid accumulation of polyethylene glycol. 

Mupirocin is effective in eradicating S. aureus carriage. The consensus is that patients who may benefit from mupirocin prophylaxis are those with proven S. aureus nasal colonization plus risk factors for distant infection or a history of skin or soft tissue infections. 

Pharmacokinetics and ciinical use Mupirocin is used topically and is not absorbed. This drag is indicated for impetigo caused by staphylococci (including methicillin-resistant strains), beta-hemolytic streptococci, and Streptococcus pyogenes. It is also used in-tranasally to eliminate staphylococcal carriage by patients and medical personnel. 

Yano, M., Doki, Y., Inoue, M., Tsujinaka, T., Shiozaki, H., and Monden, M. (2000) Preoperative intranasal mupirocin ointment significantly reduces postoperative infection with Staphylococcus aureus in patients undergoing upper gastrointestinal surgery. Surg. Today (Japan) 30, 16-21. 

A pilot study compared the use of 2% mupirocin nasal ointment and triclosan body wash (rou tine care) with 4% M. alternifolia essential oil nasal ointment and 5% tea tree oil body wash in 30 MRSA patients. The interventions lasted a minimum of 3 days, and screening for MRSA was undertaken 48 and 96 h posttreatment from sites previously colonized by the bacteria. There was no correlation between length of treatment and outcome in either group. Of the tea tree oil group, 33% were initially cleared of MRSA carriage, while 20% remained chronically infected at the end of treatment this was in comparison to routine care group of 13% and 53%, respectively. The trial was too small to provide signi cant results (Caelli et al., 2000). 

Johnson DW, MacGinley R, Kay TD, Hawley CM, Campbell SB, Isbel NM, Hollett P A randomized controlled trial of topical exit site mupirocin apphcation in patients with tunnelled, cuffed haemodialysis catheters. Nephrol Dial Transplant 2002 17 1802 1807. 

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