ORIGINAL ARTICLE

The Impact of Hospital-Acquired Methicillin-Resistant

Staphylococcus aureus in a Burn Population After
Implementation of Universal Decolonization Protocol
Arthur T. Johnson, MD, Rachel M. Nygaard, PhD, Ellie M. Cohen, MD,
Ryan M. Fey, MD, and Anne Lambert Wagner, MD, FACS

Hospital-acquired (HA) methicillin-resistant Staphylococcus aureus (MRSA) is a leading

cause of HA infections and a significant concern for burn centers. The use of 2%
chlorhexidine-impregnated wipes and nasal mupirocin significantly decreases the rate
of HA-MRSA in adult intensive care units. The aim of this study was to examine the
impact of universal decolonization on the rate of MRSA conversion in an ABA verified
adult and pediatric burn center. Universal decolonization protocol consisting of daily
chlorhexidine baths and a 5-day course of nasal mupirocin was implemented in the burn
unit. MRSA screening both on admission and weekly and contact isolation practices were
in place in both pre-decolonization and post-decolonization protocol. Patient data were
analyzed 2 years before and 1 year after implementation of the protocol. The incidence
rate of MRSA was significantly decreased after the implementation of the decolonization
protocol (11.8 vs 1.0 per 1000 patient days, P < .001). Secondary to the loss of the skin
barrier and suppressed immune systems, burn patients are at greater risk for invasive
infection leading to severe complications and death. The prevalence of HA-MRSA
at our institutions burn center was significantly decreased after the implementation
of a universal decolonization protocol. (J Burn Care Res 2015;XXX:0000)

Hospital-acquired (HA) infections are major causes

of preventable illness and death in the United States.1
Methicillin resistant Staphylococcus aureus (MRSA) is
a leading cause of HA infection and the predominant
pathogen causing skin and soft tissue infections in
the United States.1,2 MRSA was first isolated in the
1960s, but by the early 2000s more than 50% of S.
aureus isolates collected by the National Nosocomial
Infections Surveillance System in the United States
were of an MRSA resistance profile.3,4 Although the
relative burden of MRSA in the United States has
declined recently, the overall prevalence remains
alarmingly high, with more than 80,000 new infections in 2011.2
From the Department of Surgery, Hennepin County Medical
Center, Minneapolis, MN
This study was supported by the HCMC Research and Education
Fund.
Address correspondence to: Rachel M. Nygaard, PhD, Department
of Surgery, Hennepin County Medical Center, 701 Park Ave
Minneapolis, MN 55415. E-mail: [email protected]
Copyright 2015 by the American Burn Association
1559-047X/2015
DOI: 10.1097/BCR.0000000000000301

HA-MRSA is of particular concern because of the

bacterias virulence, disease spectrum, and multidrug
resistant profile. The estimated 30-day mortality
after MRSA bacteremia is 28 to 38%, with a 1-year
mortality of 55%.4,5 The high prevalence of MRSA
not only affects patient health, but also has important financial implications. In 2007, the average cost
of a hospital stay for patients infected with MRSA
was $14,000 compared with $7600 for similar stays
but not infected with MRSA. In addition, the hospital length of stay for those with MRSA was 10 vs 4.6
days for non-MRSA admissions.6
At an even greater risk than patients admitted
to medical and surgical intensive care units, burn
patients are especially susceptible to HA infections
because of their loss of protective skin and mucous
membrane barriers, relative immunosuppressed
state, and prolonged hospitalizations.710 Burn
wound infection contributes to 50 to 75% of mortality in the burn patient population, with increase in
mortality as the size and degree of burn increases.11
Efforts to decrease the rate of new HA-MRSA infections have been in place for many years.3 The most
1

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Journal of Burn Care & Research

Month/XXX 2015

2Johnson et al

effective methods to date are screening and surveillance cultures of new admissions, the establishment
of contact precautions and isolation status of those
found to carry MRSA, and universal decolonization
protocols.12 Given the importance of HA infections
in the burn population, we hypothesized that the
implementation of a universal decolonization protocol would decrease the rate of HA-MRSA infections
in our adult and pediatric burn center.

METHODS
A universal decolonization protocol was implemented
on February 4, 2013 in the burn unit. The universal
decolonization protocol consisted of a 5-day course
of mupirocin applied twice daily (repeated monthly)
to the nares. Patients were provided a daily bath
with 2% chlorhexidine gluconate wipes to intact skin
or diluted chlorhexidine gluconate soap in water
to open wounds and grafted areas throughout the
patients entire hospitalization. Skin grafts were
bathed after first post-op dressing takedown. Contact
isolation practices consisted of private patient rooms,
hand washing before and after entering the patient
rooms, and donning of gloves and gown after hand
washing but before entering the patient rooms. The
contact isolation practices were in effect before and
after implementation of the decolonization protocol.
Upon IRB approval, patient data were retrospectively
gathered for all patients housed in the burn unit

2years before and 1 year after implementation of the

protocol. Patients both preprotocol and postprotocol
were screened by nasal and wound swabs on admission and weekly during their stay for the presence of
bacterial and fungal colonizers.
All patients admitted to the burn unit who underwent nasal and wound swabs on admission during
the study period were included in the analysis. Data
collected include age, injury severity score, length of
hospital stay, and degree of burn. Patient comorbidities were also evaluated including history of diabetes, renal and pulmonary diseases, and the presence
of other concomitant trauma on admission. Only
patients with negative MRSA admission screening
cultures were included for hospital analysis of outcomes. Statistical analysis was performed using the
Students t-test for continuous variables and the
Fishers exact test for categorical variables. A P value
of less than or equal to .05 was considered to be
statistically significant. All analyses were conducted
using STATA 12.1 (StataCorp College Station, TX).
Definitions of HA infections were in accordance
with the Centers for Disease Control and Prevention
and National Healthcare Safety Network.1315

RESULTS
The patient populations were similar in both pre
universal and postuniversal decolonization protocol (Table1). More than 70% of the patients were

Table 1. Characteristics of the preuniversal and postuniversal decolonization cohorts

Characteristics
Age (yr), mean (SD)
Gender, % male
ISS, mean (SD)
LOS (d), mean (SD)
TBSA, mean (SD)
% 2nd
% 3rd
Comorbidities
Diabetes, %
Renal disease, %
Respiratory disease, %
Associated trauma, %
MRSA history, %
Mortality, %
Screening cultures (nasal), N
Positive MRSA on admission, N (%)
Nasal swab, N (%)
Wounds swab, N (%)

Pre-decolonization,
N = 303

Post-decolonization,
N = 251

P*

40.5 (23.0)
75.0
6.0 (6.9)
14.7 (19.0)

38.5 (22.0)
71.0
8.0 (7.2)
9.2 (13.0)

.290
.287
.001
.720

10.4 (9.1)
9.4 (12.0)

6.0 (7.1)
8.5 (12.0)

.001
.540

9.5
5.6
13.0
3.3
1.9
4.3
1484
17 (5.6)
16 (5.6)
6 (2.0)

9.5
3.1
12.0
2.3
3.9
1.2
1050
20 (8.0)
18 (7.9)
10 (4.0)

1.000
.280
.610
.610
.204
.040
.307
.290
.204

ISS, injury severity score; LOS, length of stay; MRSA, methicillin-resistant Staphylococcus aureus.
*Students t-test for continuous variables and the Fishers exact test for categorical variables.

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Journal of Burn Care & Research

Volume XXX, Number XXX

Johnson et al3

Table 2. Effect of decolonization on HA infections

Any positive, N (%)

MRSA, N (%)
Nasal swab
Wound swab
Gram positive, N (%)
Gram negative, N (%)
Candida, N (%)
Bloodstream infection, N (%)
CAUTI, N (%)
CLABSI, N (%)

Pre-decolonization,
N = 286

Post-decolonization,
N = 231

P*

127 (44.4)
49 (17.1)
45 (15.7)
7 (2.5)
64 (22.4)
64 (22.4)
35 (12.2)
31 (10.8)
25 (8.7)
19 (6.6)

78 (33.8)
2 (0.9)
2 (0.9)
0 (0)
49 (21.2)
33 (14.3)
19 (8.2)
5 (2.2)
6 (2.6)
1 (0.4)

.015
<.001
<.001

1.000
.039
.244
<.001
.004
<.001

The pre-decolonization and post-decolonization N values exclude all patients who tested positive for MRSA on admission.
CAUTI, catheter-associated urinary tract infection; CLABSI, central line-associated blood stream infection; MRSA, methicillin-resistant Staphylococcus aureus.
*Students t-test for continuous variables and the Fishers exact test for categorical variables.

male and between the ages of 1 month and 100 years.

Comorbidities and the number of patients admitted
with associated trauma did not differ between the two
groups. Patients in the post-decolonization cohort
had more severe injuries, as measured by injury severity score (Table1, P = .001). The TBSA covered
with second degree burns was significantly higher in
the post-decolonization group; however, there was
no significant difference between the two groups in
regard to third degree burns (Table1). There was no
significant difference between those who had a history of testing positive for MRSA (P = .204). There
was also no significant difference in positive admission cultures, both nasal and wound, between the two
groups (Table1, P = .290 and P = .204, respectively)
In patients with negative MRSA screening cultures on admission, there were decreases in all HA
infections, most notably in HA-MRSA (Table2,
P < .001). There were also significant decrease in
the rates of bloodstream infections, catheter associated urinary tract infections (CAUTI) and central

line-associated blood stream infections (CLABSI;

Table2).
In patients with HA-MRSA or bloodstream infections, the mean time to positive was slighting longer post-decolonization, but the difference was not
statistically discernible (Table3). There were no
significant differences in the incidence of bloodstream infections. The duration of hospital stay
and total cost of the hospitalization were significantly decreased in the post-decolonization group
(Table3). The mortality rate was lower in the postdecolonization group, but this did not approach significance (Table3, P = .102).

DISCUSSION
The addition of a universal decolonization protocol in an adult and pediatric burn center led to
a decrease in the rates of all HA infections. We
observed a very significant decrease in the incidence
rate of HA-MRSA. Given the morbidity, mortality,

Table 3. Impact of decolonization on HA infections

Incidence rate (per 1000 patient days)

MRSA
Bloodstream infection
Time to positive (d)
MRSA, mean (SD)
Bloodstream infection, mean (SD)
LOS (d), mean (SD)
Mortality, %
Hospital cost, mean (SD)

Pre-decolonization,
N = 286

Post-decolonization,
N = 231

P*

11.8
7.45

1.0
2.40

<.001
.005

12.4 (11.7)
10.7 (6.2)
14.5 (19.3)
3.9
161.4 (308.4)

15 (1.4)
16.6 (17.6)
9.0 (12.6)
1.3
76.7 (138.0)

.757
.158
<.001
.102
<.001

MRSA, methicillin-resistant Staphylococcus aureus; LOS, length of stay.

*Students t-test for continuous variables and Fishers exact test for categorical variables and incidence rate.
Mean hospital cost reported per 1000 USD.

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Journal of Burn Care & Research

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4Johnson et al

and financial implications of HA infections, particularly HA-MRSA, this study underscores the potential benefit of universal decolonization in the burn
patient population.
The significant decrease in HA-MRSA infections observed after universal decolonization was
likely because of several factors. First, the universal
decolonization protocol treated all patients identically regardless of culture status on admission. At
our institution, preliminary MRSA culture results
are reported within 24 hours, but final results are
not available for 48 to 72 hours. Compared with a
targeted treatment strategy, which requires evidence
of positive MRSA cultures before action is taken, the
universal strategy avoids any delay in treatment, thus
decreasing the potential for MRSA transmission to
unaffected patients. Additionally, daily bathing with
chlorhexidine has been shown to decrease both skin
colonization and the overall environmental microbial burden.1619 These reductions help to limit the
potential for secondary infections and decrease the
risk of patient-to-patient transmission. Our results
provide additional support for the utilization of universal decolonization to decrease HA infections.
The incidence of device related infections (CLABSIs and CAUTIs) after implementation of decolonization protocols has shown mixed results in previous
reports. Numerous studies have shown a significant
decrease in the rate of CLABSI after chlorhexidine
bathing.12,16,20,21 In contrast, the rates of CAUTI
after decolonization have been mixed. MartnezResndez et al22 found a significant decrease in the
rate of CAUTIs; but Noto et al,23 in a larger multisite study, found no significant decrease in the rates
of CAUTI after the use of daily chlorhexidine baths.
Our study found a significant decrease in both the
rates of CLABSIs and CAUTIs after decolonization,
which is in concordance with Popp et al,24 which also
examined the effect of chlorhexidine baths in the
burn population. Burn units have the highest rates of
CLABSI and second highest rates of CAUTI within
the inpatient setting.25 This is likely, in part, because
of the nature of burn patients injuries, specifically
altered innate and adaptive immune responses.7,9
Given the high rate of device-related infections in
the burn unit, a small but effective protocol change
can have a substantial effect in decreasing the rates of
CLABSIs and CAUTIs.
Despite ample evidence documenting increased
mortality after MRSA infections,5,2628 no studies
have shown significant decrease in mortality after
implementation of decolonization protocols.12,29
Our study also failed to show a significant decrease
in mortality, despite significant decrease in HA

infections. This may have been because of the small

sample sizes in each cohort and limited duration of
data collection.
The costs associated with universal decolonization have been criticized. Several recent studies
have shown more efficient use of resources using
a targeted treatment strategy rather than universal screening and treatment.3033 However, these
studies were all completed in surgical and medical
intensive care units. Because of the nature of their
injuries, burn patients are much more susceptible to
HA-MRSA infections.710 If MRSA carriers admitted to burn units are not quickly identified, isolated,
and treated, the risks of further MRSA transmission
are substantial.34 Our results found a significant
decrease in both length and cost of hospitalization
negating the increased costs associated with universal
decolonization.
Additional critiques of universal decolonization
protocols include the concern for mupirocin and
chlorhexidine resistance. To date, studies have not
shown widespread community or hospital MRSA
mupirocin or chlorhexidine resistance.35,36 However,
MRSA strains resistant to mupirocin or chlorhexidine persist despite decolonization and can create
the potential for an MRSA outbreak, as was seen in
Canada between 1999 and 2002.37,38 This emphasizes the importance of weekly surveillance cultures
to identify any increase in HA-MRSA that may suggest the development of mupirocin or chlorhexidine
resistance.
Resistances to either mupirocin or chlorhexidine
were not specifically examined creating a possible
limitation in our study. However, we observed very
few HA-MRSA conversions in the year after implementation of the decolonization protocol. This suggests resistance did not develop during this period.
Studies are in process to examine the potential
changes in bacterial resistance profiles in our burn
population. A further limitation was the relatively
short time period during which this study was conducted. Further data collection is ongoing to assess
whether the significant reductions in HA-MRSA
infections seen after implementation of the universal
decolonization protocol can be maintained beyond
1 year.

CONCLUSION
Because of their decreased immune defenses, burn
patients are at increased risk for HA infections.
HA-MRSA is of particular concern due its potential to cause severe morbidity and high mortality.
The implementation of a universal decolonization

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Journal of Burn Care & Research

Volume XXX, Number XXX

protocol in an adult and pediatric burn center led to

a significant decrease in the rate of HA-MRSA infections. Further close monitoring is needed to determine if these reductions can be maintained.

ACKNOWLEDGMENTS
We thank Angela Whitley for her helpful discussion in
preparation of this manuscript. We thank the HCMC burn
center staff and infection prevention staff for their work
implementing the decolonization protocol.
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