Mini-CAT Assignment – Andrew Simon's E-Portfolio

Furuncle Prevention

Clinical Question: The question is “Jackson is a 28 year old man with recurrent furunculosis for the past 8 months. These episodes have been treated with drainage and several courses of antibiotics, but keep recurring. He wonders if using some kind of antibacterial skin wash might help prevent this from happening in the future.”

PICO Question:
– Does the use of antiseptic wash lead to reduction of recurrent furunculosis?

P: Pt’s suffering from furunculosis, adults I: Antibacterial skin wash
C: Incision and drainage
O: Reduced recurrent furuncles

Search Strategy:

Searched terms – Furuncles, prevention, antiseptic washes, infections
PubMed – 62 articles found
Cochrane – 5 articles
Google scholars – 17,000 article (Narrowed search to last 5 years – 4810 articles) Filters – Last 10 years

Selection of articles was based on studies and data surrounding different methods of decontaminating areas of the body. Multiple studies on the uses of antiseptic washes, cloths, chlorhexidine, and mupirocin as a form of removing the presence of S. aureus from different areas. The articles stated their results explicitly which coincided with the clinical question. The studies had to include different geographical/structural, for example Military camps, hospitals, Long term care, facilities, and etc.

Articles Chosen for Inclusion (please copy and paste the abstract with link):

1. Xiao G, Chen Z, Lv X. Chlorhexidine-based body washing for colonization and infection of methicillin-resistant Staphylococcus aureusand vancomycin-resistant Enterococcus: an updated meta-analysis. Infect Drug Resist. 2018 Sep 13;11:1473-1481. doi: 10.2147/IDR.S170497. PMID: 30254478; PMCID: PMC6143131.

3.Millar EV, Schlett CD, Law NN, Whitman TJ, Ellis MW, Tribble DR, Bennett JW. Opportunities and Obstacles in the Prevention of Skin and Soft-Tissue Infections Among Military Personnel. Mil Med. 2019 Nov 1;184(Suppl 2):35-43. doi: 10.1093/milmed/usz105. PMID: 31778193; PMCID: PMC6886584.
4. Ibler KS, Kromann CB. Recurrent furunculosis – challenges and management: a review. Clin Cosmet Investig Dermatol. 2014 Feb 18;7:59-64. doi: 10.2147/CCID.S35302. PMID: 24591845; PMCID: PMC3934592.

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc)	Outcome(s) studied	Key Findings	Limitations and Biases
Xiao, G et al Feb 2018	I: Meta-analysis and systematic review	17 records (total participants 467,484) – intervention: 247,605 -Control: 219,879 MRSA colonization: 9 studies -colonization specific: 438 – control: 660 MRSA infection: 10 studies -intervention: 137 -control: 193 VRE colonization: 8 studies -intervention: 197	Moderate to strong decreases in the risk of IRR of MRSA colonization, VRE colonization, and MRSA infection	Incidence ratio (IRR): MRSA colonization: 0.61, 95% CI 0.48-0.77, P<0.001 MRSA infection: 0.65, 95% CI 0.52-0.81, P<0.001 VRE colonization: IRR 0.58, 95% CI 0.42–0.80, P=0.001 VRE infection: IRR 0.61, 95% CI 0.30–1.25, P = 0.176 CHW significantly decreases the risk of MRSA and VRE colonization, and MRSA infection. More evidence is needed to assess the effect CHW has on VRE infection. The results for VRE were insignificant.	In choosing the articles themselves, two authors independently assessed study bias using the Cochrane risk of bias tool. 1) Different study designs: inter-study heterogeneity which increases variability in the data. Most of the studies were observational and retrospective → high risk of selection bias and confounding variables 2) Small number of studies that the researchers needed to interpret the results with caution, but no evidence of publication bias. Researchers did not explain further. 3) Different baseline features among the study participants and the different medical units they came from potentially could have led to

		-control: 296 VRE infection: 6 studies -intervention: 20 -control: 37			significant heterogeneity in the outcomes.
Ibler, K, S et al February 2014	I: systematic review	N/a	Topical Mupirocin and chlorhexidine may reduce the incidence of S. Aureus infections.	Mupirocin and chlorhexidine have shown variable efficacy The management of recurrent furunculosis is problematic and may be disappointing.	Published 8 years ago
Toeman DPR, et al Feb 2019	I: Meta Analysis	reviewed over 4,951 articles and chose 54 articles.	In patients with recurrent staphylococcus infections and no other comorbidities such as ICU, MRSA etc., there was no benefit to antibacterial skin washes for furunculosis. -Used soldiers as the subject group	No significant difference in decreasing infections : 95% CI -7.5 to 1.7% Using Mupirocin and hexachlorophene body wash to prevent Skin infection was not superior to prevent infections Meta- Analysis found In non surgical patients using mupirocin as prophylaxis leads to a 49% reduction with RR 0.51 and 95% CI:0.40- 0.65 in S.aureus infections Non-blinded cluster randomized study did not with CI: -0.81 to 1.57 and P=0.53 found using chlorhexidine-gluconate daily baths	Different studies were used throughout the article. Study participants were different in most 54 studies presented No collaborative data uniting 54 studies into numerical data. No result sections for the articles were compiled together into a single finding Does not specify where the infections are in some articles chosen for this analysis. I.e Nose infection vs. soft skin etc.

				does not decrease the the rate of getting a staph infection in ICU patients compared to using regular antimicrobial baths. In soldiers, Chlorhexidine gluconate body wash was not superior to plain soap in preventing Soft and Skin Tissue infections	From meta-analysis – Degrees of heterogeneity between studies with an I squared = 66%
Millar, Eugene V, et al, 2019	II: RCT	-Study done in 2007 at the Marine Corps Base Quantico 1500 trainees included in the trial -Study done from 2010-2012 in Fort Benning, study of over 30,000 infantry trainee -Military experiment using combat medic (16 week trial)	-The 2007 experiment after 6 weeks concluded there was no significant difference between experimental and control group. But the study concluded there was a decrease in the presence of MRSA in areas such as the Axilla and Nares. -The 2010-12 Fort Benning experiment was broken into 3 parts (Standard, Enhanced standard, and Experimental), each receiving an escalating level of hygiene instruction. The study concluded no significant difference in rate of infection. -The Military experiment, tracked combat medics for 16 weeks, while conducting a	The study at Marine Corps Base Quantico and the study at Fort Benning, concluded there was no significant difference in infection rates. The article concluded there is no potential benefit for using a chlorhexidine wash or cloth to prevent risk of Skin and soft tissue infections. The Military experiment conducted on Combat medic, the 16 week experiment, concluded no significant difference. Those who received treatment vs those who received placebo produced a difference of 10.6% to 7,7%.	One limitation that was clearly stated by the trial was personal hygiene. Military trainees had differences in understanding of personal hygiene that influenced and disrupted the decontamination of S. Aureus from the body using the Chlorhexidine wipes. -Environment in which the experiment was conducted was not sterile, this could perpetuate the contamination cycle. -The Date for two of the three trials studied was not presented by the article. –

randomized trial comparing placebo and IN mupirocin. Study concluded a decrease in MRSA colonization in the nares, but no significant difference in rate of infections.

BACKGROUND: The effects of chlorhexidine-based body washing (CHW) on healthcare-associated infections have been reported in numerous studies, while their findings remain conflict- ing. This study aims to update the evidence for the effects of CHW on the risk of colonization or infection with hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistance enterococcus (VRE) have become the two most common causes of healthcare-associated infections (HAI) in the past decade. Due to its broad-spectrum antibacterial activity, Chlorhexidine gluconate (CHG) has been reported to reduce the overall bioburden of multi-drug resistant gram positive organisms, such as MRSA and VRE. Studies have shown that daily use of CHG reduced the rate of MRSA or VRE colonization and transmission, thus reducing infections associated with these organisms.
METHODS: Studies were chosen from PubMed, Embase, and the Cochrane Library under the guidance of a 27-item checklist of Preferred Reporting Items for Systematic Reviews and Meta-analysis. The inclusion criteria included 1) studies investigating the association between the use of chlorhexidine-based body washing and the risk of colonization or infection with hospital-acquired MRSA or VRE 2) study designs that were included cluster-randomized trial, before and after study, quasi-experimental study, interrupted time series study, and sequential group single-arm clinical trial 3) studies that reported incidence rate ratios (IRRs) and their 95% CIs or related data where IRR can be calculated. Random-effect models were used to calculate the summary IRRs for related associations.
RESULTS: Of 140 records identified, we obtained data from 17 relevant articles for meta-analysis. Compared with patients without antiseptic bathing, patients with CHW had a significantly lower risk of MRSA colonization (IRR 0.61, 95% CI 0.48–0.77) and VRE colonization (IRR 0.58, 95% CI 0.42–0.80). Similarly, we also noted that patients with CHW had a significantly lower risk of MRSA infection (IRR 0.65, 95% CI 0.52–0.81). However, no significantly lower risk of VRE infection (IRR 0.61, 95% CI 0.30–1.25) was noted in patients with CHW. Sensitivity analyses or trim-and-fill method confirmed the robustness of the findings.

CONCLUSIONS: Current evidence supports that patients with CHW had a significantly lower risk of MRSA or VRE colonization and a lower risk of MRSA infection. More evidence should be accumulated to reinforce these findings, especially on the effect of CHW on the risk of VRE infection.

2. Troeman DPR, Van Hout D, Kluytmans JAJW. Antimicrobial approaches in the prevention of Staphylococcus aureus infections: a review. J Antimicrob Chemother. 2019 Feb 1;74(2):281-294. doi: 10.1093/jac/dky421. PMID: 30376041; PMCID: PMC6337897. BACKGROUND: S.aureus is an important causative agent of infections in humans. Approximately thirty percent of healthy individuals are carriers of S. aureus. S. aureus can cause many infections from superficial ones (folliculitis) to potentially life-threatening infections such as sepsis. S.aureus plays a huge role in morbidity, mortality and increased health expenditure causing a 4.5 billion economic burden. Due to the heavy consequences that S. aureus can cause , preventing its infections can decrease health expenditure and decrease the risk of infections in susceptible groups. Implementation of using antimicrobials as a prophylactic application against Staphylococcus aureus (S. aureus) in clinical practice is very limited. However, there are multiple studies that show prophylactic applications of antimicrobials can prevent S.aureus infections. This article reviews the different type of antimicrobials that can have preventative measures against S.aureus infections.

METHODS: Cochrane Central Register of Controlled Trials, PubMed, MEDLINE and EMBASE database were used. Search terms: S. aureus, infections and prevention were inputted into these databases and only randomized controlled trials and systematic review articles were chosen for this study.

RESULTS: Most studies found that Mupirocin or Mupirocin used with Chlorhexidine was effective in preventing S.aureus infections in dialysis, surgery and carrier patients. Antimicrobial Honey, Prophylactic povidone – iodine and systemic antibiotics have limited evidence supporting their effectiveness in preventing S. aureus infections.
CONCLUSION: Based on the meta-analysis, in patients who are S.aureus carriers, in surgical patients and in dialysis patients, mupirocin can be used as a prophylaxis measure to prevent S.aureus infections. In other subjects or patients the use of other antimicrobial agents such as chlorhexidine, hexachlorophene and mupirocin has shown little to no benefit as prophylaxis for S. aureus infections.

OBJECTIVITY: The incidence of Skin and superficial skin infections is high among military personnel but much higher among recruits. The systematic review analyzes multiple trials conducted by the military, on their personnel. The goal of the studies was to determine the approach that would reduce/prevent the occurrence. The high incidence and close quarters deem these group as a high-risk population. Establishing a connection between decolonization

of staphylococcus aureus (main culprit behind superficial skin infection) and the effectiveness of agents such as Chlorohexidine gluconate and mupirocin washes, was the aim of multiple Randomized trials.
METHOD: The studies were done in the setting of training and in deployment. A total of four studies were reviewed, two randomized controls and two vaccine trials. The attempted strategy used by the military was to decolonize the presence of S. aureus on the skin by the means of intranasal mupirocin and the use of topical antiseptic chlorhexidine gluconate. The reasoning for the use of these agents was its effectiveness in hospitalized patients.

RESULTS: The study evaluating the effectiveness of using intranasal mupirocin, illustrated with a 95% CI, found that those given treatment had a -2.9% while the placebo was 0.8%. When comparing the placebo to treatment, in respect to patients who had nasal MRSA colonization, the percentages were 10.6% for placebo, and 7.7% for treatment. The second study focused on the use of Chlorhexidine wash as a preventative measure of developing skin and soft tissue infection. For this study after a 6 week training, the mean rate was not significantly different between the control and the wash group (0.094 vs. 0.071, respectively; p = 0.14). CONCLUSION: In conclusion both strategies for eliminating or reducing the number of Skin and soft tissue infections using these techniques were ineffective. Both methods did not yield significant difference in data to substantiate its presence in the clinical setting. These studies were limited by difference in military combat and training environments.

4. Ibler, K. S., & Kromann, C. B. (2014). Recurrent furunculosis – challenges and management: a review. Clinical, cosmetic and investigational dermatology, 7, 59–64. https://doi.org/10.2147/CCID.S35302
BACKGROUND: Furunculosis is a deep infection of the hair follicle leading to abscess formation with accumulation of pus and necrotic tissue. Furuncles appear as red, swollen, and tender nodules on hair-bearing parts of the body, and the most common infectious agent is Staphylococcus aureus, but other bacteria may also be causative. In some countries, methicillin resistant S. aureus is the most common pathogen in skin and soft tissue infections which is problematic since treatment is difficult. Furunculosis often tends to be recurrent and may spread among family members. Some patients are carriers of S. aureus and eradication should be considered in recurrent cases. Solitary lesions should be incised when fluctuant, whereas patients with multiple lesions or signs of systemic disease or immunosuppression should be treated with relevant antibiotics. The diagnostic and therapeutic approach to a patient suspected of staphylococcosis should include a thorough medical history, clinical examination, and specific microbiological and biochemical investigations. This is particularly important in recurrent cases where culture swabs from the patient, family members, and close contacts are mandatory to identify and ultimately control the chain of infection. Focus on personal,

interpersonal, and environmental hygiene issues is crucial to reduce the risk of contamination and recurrences.
AIM: To describe the characteristics and management of furunculosis. The article also gives an overview of furunculosis’ signs and symptoms, risk factors, MRSA, making the diagnosis of furunculosis, complications, treatment, prevention and its colonization.

DISCUSSION AND CONCLUSION: Ultimately, treatment of staphylococcosis depends on eradication of pathogenic strains in patients and carriers. Eradication should, however, be restricted to patients or families with recurrent SSTI. In most cases, colonization with S. aureus is not harmful, and the high number of asymptomatic carriers contradicts eradication in this population. Further studies are needed to elucidate the microbiome complexity in carriers of S. aureus, and to elucidate the effect and mechanisms of using, eg, probiotics, rather than antibiotics for bacterial population control.

Conclusion:
There is some clinical evidence that using an antiseptic/antibacterial wash can reduce the rate of Staph Aureus and MRSA infections; however, more evidence is needed to be accumulated to reinforce these findings. Given the different studies reviewed, there was no significant evidence indicating the use of washes, cloths, or method of decontamination produced superior prevention to proper hygiene. Xiao, G et al, demonstrated the reduction of VRE and MRSA colonization with decreased risk of MRSA infection, but could not further substantiate their results, citing the need for more evidence. Across the board the articles aligned in their research with either lack of sufficient evidence to make a clinical recommendation or no significant difference.

Clinical Bottom Line:
The case of Jackson’s recurrent furuncles there is no clinical significance in using antiseptic wash to reduce the risk of furunculosis. The best thing for Jackson would be to maintain good personal hygiene. As a general statement to patients, making the recommendation of using an antimicrobial wash will not contribute to reduction of soft tissue infection.