Table 3.
Clinical assessment of potential resistance to rifampicin, minocycline and/or chlorohexidine
| Citation | Study type (n patients) | Device; drug | Design | Measure of resistance | Results | After contact with the device, which of the following does the study show: (i) no change in resistance; (ii) selection for tolerant strains; or (iii) development of new resistance |
|---|---|---|---|---|---|---|
| Rifampicin (n = 1) | ||||||
| Bandyk et al., 200140 | retrospective (27) | vascular graft soaked in aqueous R (45–60 mg/mL) | Patient with graft infections had graft replaced with R-soaked graft | not stated | Failure from MRSA infection and recurrent R-resistant SE infection in 2 patients; 18 patients remained infection free and survived | selection for tolerant strains; discussion: ‘need for continued evaluation to determine whether R grafts select for resistant G+’ |
| Chlorhexidine (n = 14) | ||||||
| Batra et al., 201041 | retrospective (4570: 2480 pre, 2090 post) | CH bathing; Hibitane, 1% CH dusting powder, Hibiscrub | Assessed for MRSA infection pre- and post-antiseptic protocol | MBC (CLSI) | Decrease in MRSA infections by endemic strain but increase in MRSA infection by outbreak strain after initiation of CH baths; all outbreak strains had qacA/B genes and 3-fold higher MBCs than endemic strain | selection for tolerant strains |
| Choudhury et al., 201746 | prospective (77: 43, CH dressing, 34 no CH dressing) | CH dressings at catheter insertion sites | Prevalence of smr or qacA/B from DNA from skin with CH dressing versus skin with no (or non-CH) dressing | assessment of smr or qacA/B genes by PCR | No significant difference in frequency of qacA/B and smr recovered from CH dressing versus no CH dressing; no evidence that CH increases frequency of CH-tolerance genes at catheter sites | no change in resistance |
| Chung et al., 201548 | prospective (3054: 1514 pre, 1540 post) | CH wipes | Assessment of AN infections pre- and post-CH bathing | MIC microbroth dilution | Prevalence of AN decreased from 25.8% to 18.2%; no difference in CH MIC between 42 AN in pre-CH bathing and 56 AN in post-CH bathing | no change in resistance |
| Ho et al., 201238 | case–control (156: 96 MRSA; 60 MSSA) | CHXSS CVC (Arrowguard blue) | Assessment of MIC and qacA/B or smr genes from MRSA and MSSA catheter-related infection | MIC agar dilution; prevalence of genes by PCR | Significantly more MRSA isolates containing qacA/B genes caused CHXSS-impregnated CRBSI; MIC stratified for CHXSS catheter not assessed | selection for more tolerant strains |
| Lee et al., 201139 | case–control (150: 75 case; 75 control) | CH wipes for decolonization | Assessed risk factors for persistence of MRSA carriage after decolonization | presence of resistance genes by PCR | Genotypic CH resistance alone did not predict persistent MRSA carriage | no change in resistance |
| Lowe et al., 201747 | prospective (4037: 2039 controls, 1998 CH) | CH wipes | MRSA and VRE infections in 7 month intervention of CH bathing versus non-medicated soap/water bathing | MIC by agar dilution; presence of resistance genes by PCR | In intervention group, one MRSA and one MSSA contained resistance genes though MIC was susceptible; one MRSA had resistant MIC (8 mg/L) but was not PCR positive | no change in resistance |
| Mendoza-Olazaran et al., 201449 | prospective (149: 80 prior, 69 CH bath) | CH wipes | AN infections in 6 months prior and 6 month intervention of CH bathing | MIC agar dilution | AN isolates in the CH bathing period showed a significant decrease in CH MIC likely due to change in clonality of infecting isolate | no change in resistance |
| Maki et al., 199761 | RCT (403: 195 controls, 208 CHXSS) | CHXSS CVC | Susceptibility to CHXSS CVC in organisms cultured from CHXSS versus control catheters | ZOI | None of isolates from infected catheters showed resistance to fresh CHXSS catheters by ZOI | no change in resistance |
| McNeil et al., 201642 | retrospective (247) | CH wipes | Assessed CH MIC, smr and qacA/B over time; increased CH bathing over time | MIC microbroth dilution; prevalence of genes by PCR | Increased prevalence of smr and qacA/B in SA infections over time; however, non-significant difference of CH MIC for isolates positive and negative for genes | no change in resistance |
| Schlett et al., 201458 | cluster randomized trial (30 209: 10 030 CH bathing) | CH wipes, Hibiclens | MIC, qacA/B from MRSA SSTI among standard bathing versus CH bathing | MIC microbroth dilution; prevalence of genes by PCR | No difference in MIC or prevalence qacA/B in CH bathing versus control | no change in resistance |
| Schuerer et al., 200753 | prospective (4630: 2079 pre, 2551 post) | CHXSS CVC | Assessment of CRBSI in control versus CHXSS | not conducted | No significant difference in rate of CRBSI or microbiological profile organisms cultured in control versus CHXSS | no change in resistance |
| Soma et al., 201250 | prospective (29 swabs: 4 no CH, 15 moderate CH, 10 heavy CH) | CH wipes | MIC, qacA/B among CoNS sampled from patients with no, moderate or heavy CH baths | MIC microbroth dilution; prevalence of genes by PCR | No significant difference in CH MIC in no versus moderate versus heavy CH samples. 11/17 CoNS had qacA/B | no change in resistance |
| Timsit et al., 200959 | RCT (1636: 819 controls, 817 CH sponge) | CH-impregnated sponges | Assessment of CRI, and MBC in CH sponge versus control | MBC | Reduction in CRI with use of CH sponge; no difference in MBC for control versus CH sponge | no change in resistance |
| Velazquez-Meza et al., 201751 | prospective (156: 61 pre, 52 during, 45 post) | CH wipes (2%) | MIC of SA isolates from pre-, during and post-CH bathing | MIC agar dilution | No isolates showed reduced susceptibility to CH in pre- versus during versus post-intervention | no change in resistance |
| M/R (n = 8) | ||||||
| Chatzinikolaou et al., 200354 | RCT (130: 66 M/R, 64 controls) | M/R CVC, haemodialysis | CRBSI; MIC of CoNS cultured from colonized catheters | MIC microbroth dilution | MIC of CoNS isolates from colonized catheters were similar in M/R versus control | no change in resistance |
| Chatzinikolaou et al., 200345 | retrospective (672: 212 M/R, 460 controls) | M/R CVC | CRBSI in BMT (M/R) versus leukaemia (no M/R) | MIC (CLSI) | All 67 SA and SE isolates were susceptible to M; one isolate (M/R) and 9 isolates (control) were resistant to R | no change in resistance |
| Gilbert et al., 201655 | RCT (1485: 502 controls, 486 M/R, 497 heparin) | M/R CVC | CRBSI in control versus M/R versus hep CVC | varied by centre (MIC) | 8/12 patients with MIC tested on BSI cultures were resistant to M, R or both: 3/5 control; 2/2 M/R; 3/5 heparin | no change in resistance |
| Hanna et al., 200456 | RCT (356: 182 M/R, 174 controls) | M/R CVC | MIC for organisms cultured from catheter and/or skin at insertion site | MIC microbroth dilution | Mean M and R MIC of SE from M/R catheter was lower than control catheters; no difference in MIC from skin cultures before insertion versus removal | no change in resistance |
| Raad et al., 199757 | RCT (298: 151 controls, 147 M/R) | M/R CVC | Colonization or CRBSI control versus M/R; ZOI with new M/R CVC from all organisms from colonized CVC; MIC (M, R) for SA, SE from M/R CVC versus insertion site | ZOI of new M/R CVC; MIC microbroth dilution | Significant reduction in colonization and CRBSI with M/R CVC; M/R CVC had activity by ZOI for all organisms isolated from patient CVC; SA or SE from M/R CVC and insertion site remained at ≤2 mg/L | no change in resistance |
| Ramos et al., 201143 | retrospective (4732 isolates: 2451 pre, 2281 post) | M/R CVC | Susceptibility of SA, SE to tetracycline and R prior to M/R (1999) and 7 years after use of M/R CVC (2006) | MIC (CLSI) | Decrease in percentage of SA and SE resistant to tetracycline or R after 7 years of M/R CVC use; all decreases were significant except R resistance in SA | no change in resistance |
| Turnbull et al., 201844 | retrospective (9703 isolates: 2818 pre, 6885 post) | M/R CVC | Susceptibilities of SA to tetracycline and R in ICU prior to and after use of M/R | not stated (reported at hospital) | Rate of R and tetracycline resistance unchanged prior to and after use of M/R CVC | no change in resistance |
| Wright et al., 200152 | prospective (40: 23 pre, 17 post) | M/R CVC | Susceptibilities of M and R in organisms cultured from CVC | MIC microbroth dilution | Pre: 3/12 SE isolates resistant to R; post: 8/8 SE isolates resistant to R; no other changes in susceptibility patterns | development of new resistance |
| Comparison of multiple drug combinations (n = 1) | ||||||
| Darouiche et al., 199960 | RCT (738: 356 M/R, 382 CHXSS) | M/R CVC, CHXSS CVC | Susceptibilities of M and R in organisms cultured from CVC or skin prior to insertion | MIC microbroth dilution | No differences in M or R MIC ranges for SE and EN cultured from M/R CVC, CHXSS CVC or skin | no change in resistance |
M, minocycline; R, rifampicin; CH, chlorhexidine; SS, silver sulfadiazine; MRSE, methicillin-resistant SE; EN, Enterococcus species; AN, Acinetobacter species; PS, Pseudomonas aeruginosa; SM, Stenotrophomonas maltophilia; EB, Enterobacter species; CB, Citrobacter species; CA, Candida albicans; G+, Gram-positive organisms; G-, Gram-negative organisms; CRBSI, catheter-related bloodstream infection; CRI, catheter-related infection; SSTI, skin and soft tissue infection; BMT, bone marrow transplant patients.