MRSA: to decolonize or not to decolonize?

Although the Dutch system of "search and destroy" has given the Netherlands one of the lowest rates of MRSA colonization and infection, testing everyone in a hospital for MRSA and subsequently treating is not generally recommended. Numerous studies have advocated colonization screening and mupirocin decolonization for outbreaks, but it has not been proven to reduce infections in endemic areas. This study from Kauffman, et al is widely cited and makes a few key points:
1) reduction of MRSA colonization is not necessarily correlated to reduction of MRSA infection in facilities without high infection rates
2) mupirocin resistance is increasing with prolonged use
3) intranasal mupirocin is only an effective decolonizer if all other colonized areas of the body are treated with mupirocin as well

Mupirocin is widely used, especially in dermatology, for recurrent superficial infections and wound healing in high-risk individuals. It will be interesting to follow the trend of mupirocin resistance amongst strains of MRSA. Mupirocin is by far the most effective agent in decolonization although new medications are under review. There are two types of mupirocin resistance, high-level (plasmid-mediated) and low-level (still mupirocin susceptible at the commonly used dosage). High-level resistance is most concerning and was shown to increase with widespread mupirocin use in the above study.

Kauffman CA, Bradley SF, Terpenning MS. Methicillin-resistant Staphylococcus aureus in long-term care facilities. Infect Control Hosp Epidemiol. 1990;11:600–603.

Scott and White to test all patients for MRSA

Now here's an interesting piece of news! Scott & White hospitals in Round Rock and Temple, TX are going to start testing all patients for MRSA colonization through nasal cultures. This will surely provide some interesting epidemiological data, but the bigger question is, what will they do with this information? Are they going to try to treat everyone who is colonized? Study after study does not recommend this unless the patient has recurring infections. This is going to be an important question in the coming years, should asymptomatic MRSA carriers be treated? The Netherlands maintains one of the world's lowest MRSA colonization and infection rates by screening for MRSA upon hospital admission and subsequently treating all colonizers. Does the US have the resources for this? Also, with mupirocin-resistant MRSA emergence, is it a waste of resources to treat patients who are asymptomatic? And would treatment involve just topical antibiotics? Antiseptic washes? Oral antibiotics? I'm eager to see how this information is handled and if hospital MRSA infection rates are decreased.