The review found that the evidence did not support routine use of mupirocin and/or chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus (MRSA) in all emergency department patients, but that this practice may benefit critically-ill intensive care unit patients. In view of the inconsistency of the evidence and numerous limitations in the review methodology, these conclusions should be regarded cautiously.

To evaluate the use of intranasal mupirocin and/or chlorhexidine body wash for the prevention and eradication of methicillin-resistant Staphylococcus aureus (MRSA).

CINAHL, the Cochrane Database of Systematic Reviews and PubMed were searched in February 2008 for studies published in English within the previous ten years. Search terms were reported.

Clinical trials of intranasal mupirocin and/or chlorhexidine body wash as the primary intervention for the prevention and control of MRSA colonisation (both intra- and extra-nasal) were eligible for inclusion. Trials of antibiotics or isolation procedures were excluded.

The outcomes reported in the review were the incidence of MRSA colonisation and infection.

All but one of the included trials focused on hospital- or nursing-home-acquired MRSA. The range of hospital settings included intensive care, orthopaedic surgery, gastroenterology, and/or medical units. One trial was conducted in the community among army personnel. Inclusion criteria varied with respect to MRSA status, but most trials included both MRSA-carriers and non-colonised participants. The intervention, in most cases, involved intranasal mupirocin with antiseptic body washes, which were given in varying regimes ranging from three to seven days (where stated). Control conditions included less intensive forms of the intervention, placebo or no treatment. The trials were conducted in Europe, the USA and Japan.

The author did not state how the papers were selected for the review or how many reviewers performed the selection.

The level of blinding of RCTs was reported, but the author did not state that validity was systematically assessed.

Data were extracted from each trial on incidence rates of MRSA colonisation or infection and/or changes from baseline.

The author did not state how the data were extracted for the review or how many reviewers performed the data extraction

The studies were combined in a narrative synthesis, grouped by study design and setting.

Twelve studies were included (n=13,301 patients), comprising four randomised controlled trials (RCTs, n=745 patients) and eight non-experimental studies (one cohort study with 484 patients; five before-and-after studies with approximately 7,630 patient; two long-term observational studies with 4,442 patients). Three of the RCTs were described as double-blinded. Duration of follow-up ranged from nine days to four years (where stated).

The RCTs found no decrease in MRSA (methicillin-resistant Staphylococcus aureus) infection rate or decolonisation rate in colonised carriers in an acute (three RCTs) or community (one RCT) setting. However, the three non-experimental studies, conducted in an intensive care unit setting, all reported a lower incidence of MRSA infection and/or colonisation associated with the intervention. Four out of five non-experimental studies, conducted in non-intensive care unit hospital settings, also reported a reduced incidence of MRSA infection associated with the intervention.

The evidence did not support routine use of mupirocin and/or chlorhexidine for the eradication of MRSA in all emergency department patients, although this practice may be of benefit for critically-ill intensive care unit patients.

The objectives and inclusion criteria of the review were clear and relevant sources were searched for studies. However, the search was limited by publication date, language and publication status, which meant that some relevant studies may have been missed and that the review was prone to language and publication biases. The review processes were not described, so it was unclear whether steps were taken to minimise the risk of reviewer error and bias by having more than one reviewer select studies and extract data (as the paper has only one author, this seems unlikely).

There was no indication that study validity was systematically assessed, making it difficult to determine the strength of the evidence. The nature of the intervention in the included studies was not always clear; in several cases it was not stated whether the antiseptic body washes contained chlorhexidine. The decision not to statistically pool the study data was appropriate, given study heterogeneity. The author gave some priority to the randomised evidence, but the results were difficult to interpret, as no measures of statistical significance were reported and no clear explanation for the inconsistency between randomised and non-experimental studies was suggested.

In view of the inconsistency of the evidence and numerous limitations in the review methodology, the author’s conclusions should be regarded cautiously.

Practice: The authors stated that efforts should be directed at public awareness and education about MRSA, and noted that mupirocin and chlorhexidine resistance may increase the difficulty of eradicating MRSA.

Research: The authors stated that research is needed on strategies for MRSA prevention and to support the development of clinical guidelines.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.