Major Article
Oral rifampin for eradication of Staphylococcus aureus carriage from healthy and sick populations: A systematic review of the evidence from comparative trials

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Background

Rifampin has been used for the eradication of Staphylococcus aureus (S. aureus) colonization in various populations of healthy and sick people.

Methods

We performed a systematic review of the evidence from randomized and nonrandomized controlled trials that compared the effectiveness and safety of a rifampin-based regimen with another regimen in eradicating S. aureus colonization from healthy and sick people.

Results

Nine comparative trials (6 of which were randomized controlled trials) were included in our analysis. S. aureus was eradicated more commonly in patients receiving rifampin-containing regimens compared to monotherapy with other systemic agents (ciprofloxacin, cloxacillin, minocycline, or vancomycin), both during early and late (>1 month after therapy) post treatment evaluations (odds ratio [OR] 46.2, 95% confidence interval [CI] 14.4–148, and OR 8.8, 95% CI 3.4–22.5 respectively, 4 studies included). There was no statistically significant difference between rifampin monotherapy and combinations of rifampin with other topical (bacitracin) or systemic (cloxacillin and minocycline) antibiotics in eradicating S. aureus both in early and late evaluations (OR 1.5, 95% CI 0.5–4.4, and OR 1.6, 95% CI 0.7–3.7, respectively, 3 studies included). Eradication of methicillin-resistant S. aureus (MRSA) varied according to the type and duration of the rifampin-containing regimen. It ranged from 25% for the combination of rifampin with trimethoprim/sulfamethoxazole for 5 days to 100% for the combination of oral rifampin and minocycline for 14 days. Discontinuation of rifampin due to drug-related toxicity was necessary in 2% of 282 studied patients. Development of resistance of S. aureus to rifampin during and after treatment with a regimen containing rifampin ranged from 0% to 40% (7 studies) and overall 17% of the 236 patients for whom relevant data was reported.

Conclusion

The available evidence suggests that oral rifampin is an effective agent for the eradication of S. aureus carriage. However, development of antimicrobial resistance during and after treatment with rifampin occurs in a considerable proportion of patients; using rifampin in combination with another antimicrobial agent may decrease this resistance.

Section snippets

Searching

PubMed (January 1950 until March 2006) and the Cochrane Central Register of Controlled Trials were the databases in which we searched for relevant studies. Also, the references from relevant studies and review papers were checked. Search terms included: rifampin, rifampicin, Staphylococcus aureus, colonization, colonisation, carriage, randomized controlled trial, trial, and combinations of these terms. In addition, the search filter proposed by the Cochrane database for the identification of

Trial flow

Our literature search identified 39 potentially relevant clinical studies.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 Fig 1 is a flow diagram showing the steps we followed to identify the studies fulfilling the inclusion criteria of our review. As shown, 9 comparative trials were finally considered eligible for inclusion.19, 32, 33, 36, 40, 42, 46, 47, 48 Six of the analyzed studies

Discussion

Our analysis regarding the effectiveness and safety of rifampin when used to reduce the carriage of S. aureus in various populations revealed two main points. First, when comparing rifampin regimens with no treatment, it was shown that the antibiotic is effective in the eradication of S. aureus carriage.30, 31, 44 Second, an overview of the 4 studies that compared rifampin monotherapy or rifampin-based regimens with other antibiotics for the eradication of S. aureus carriage suggests that

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