Nasal Decolonization to Reduce Surgical Site Infections
Main Article Content
Abstract
Background: Surgical site infections is one of the most common healthcare-associated infections. Staphylococcus aureus remains the most common etiologic agent causing surgical site infections. Studies confirm Staphylococcus aureus carriage increases the risk of Staphylococcus aureus surgical site infections. The purpose of this paper is to review the strategies to reduce surgical site infections due to Staphylococcus aureus focusing on nasal decolonization.
Results: Published studies indicate screening patients for Staphylococcus aureus nasal carriage and decolonizing carriers during the preoperative period decreases the risk of S aureus surgical site infections in cardiac and orthopedic surgery. Most studies use combined chlorhexidene bathing and mupirocin for patients colonized with Staphylococcus aureus since colonization of multiple body sites is common and combination chlorhexidene bathing and intranasal mupirocin has been shown to be more effective at eradicating Staphylococcus aureus colonization. Mupirocin remains the best topical agent at eradicating nasal Staphylococcus aureus. Mupirocin has been shown to eliminate nasal colonization by over 90% with a five-day course, however, concerns over resistance have led to development of alternative agents. Nasal povidone-iodine, alcohol-based nasal antiseptic, and photodynamic therapy are promising new interventions, but more studies are needed.
Conclusions: Short term nasal mupirocin is still the most studied and effective topical agent in eradicating Staphylococcus aureus nasal colonization. However, increasing mupirocin resistance remains an ongoing concern and newer agents are needed.
Keywords:
nasal decolonization, surgical site infections, mupirocin, healthcare-associated infections
Article Details
How to Cite
SEPTIMUS, Edward J..
Nasal Decolonization to Reduce Surgical Site Infections.
Medical Research Archives, [S.l.], v. 10, n. 12, dec. 2022.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/3476>. Date accessed: 20 apr. 2024.
doi: https://doi.org/10.18103/mra.v10i12.3476.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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doi: 10.1056/NEJMoa1801550
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3. Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis. Mar 1 2003; 36(5):592-8. doi: 10.1086/367653
4. Noskin GA, Rubin RJ, Schentag JJ, et al. National trends in Staphylococcus aureus infection rates: impact on economic burden and mortality over a 6-year period (1998-2003). Clin Infect Dis. Nov 1 2007;45(9):1132-40. doi: 10.1086/522186
5. Wertheim HF, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. Dec 2005;5(12):751-62. doi: 10.1016/s1473-3099(05)70295-4
6. Kline SE, Neaton JD, Lynfield R, et al. Randomized controlled trial of a self-administered five-day antiseptic bundle versus usual disinfectant soap showers for preoperative eradication of Staphylococcus aureus colonization. Infection control and hospital epidemiology. Sep 2018;39(9):1049-1057. doi: 10.1017/ice.2018.151
7. Sim BL, McBryde E, Street AC, Marshall C. Multiple site surveillance cultures as a predictor of methicillin-resistant Staphylococcus aureus infections. Infection control and hospital epidemiology. Aug 2013;34(8):818-24. doi: 10.1086/671273
8. VandenBergh MF, Yzerman EP, van Belkum A, Boelens HA, Sijmons M, Verbrugh HA. Follow-up of Staphylococcus aureus nasal carriage after 8 years: redefining the persistent carrier state. Journal of clinical microbiology. Oct 1999;37(10):3133-40.
9. Nouwen JL, Fieren MW, Snijders S, Verbrugh HA, van Belkum A. Persistent (not intermittent) nasal carriage of Staphylococcus aureus is the determinant of CPD-related infections. Kidney international. Mar 2005;67 (3):1084-92. doi: 10.1111/j.1523-1755.2005.00174.x
10. Kluytmans JA, Mouton JW, Ijzerman EP, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. The Journal of infectious diseases. Jan 1995;171(1):216-9.
11. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. The New England journal of medicine. Jun 13 2002;346 (24):1871-7. doi: 10.1056/NEJMoa003069
12. Kalra L, Camacho F, Whitener CJ, et al. Risk of methicillin-resistant Staphylococcus aureus surgical site infection in patients with nasal MRSA colonization. Am J Infect Control. Dec 2013;41(12):1253-7.
doi: 10.1016/j.ajic.2013.05.021
13. Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. The Journal of hospital infection. Sep 1995;31(1):13-24.
14. Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. The New England journal of medicine. Jan 7 2010;362(1):9-17.
doi: 10.1056/NEJMoa0808939
15. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. Bmj. Jun 13 2013;346:f2743. doi: 10.1136/bmj.f2743
16. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. Jama. Nov 22 2006;296(20):2460-6.
doi: 10.1001/jama.296.20.2460
17. Cimochowski GE, Harostock MD, Brown R, Bernardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. The Annals of thoracic surgery. May 2001;71(5):1572-8; discussion 1578-9.
18. Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA. Jun 2 2015;313(21):2162-71. doi: 10.1001/jama.2015.5387
19. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. Aug 15 2002;35(4):353-8. doi: 10.1086/341025
20. Ward A, Campoli-Richards DM. Mupirocin. A review of its antibacterial activity, pharmacokinetic properties and therapeutic use. Drugs. Nov 1986;32(5):425-44. doi: 10.2165/00003495-198632050-00002
21. Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. Apr 1 2009;48(7):922-30. doi: 10.1086/597291
22. van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. The Cochrane database of systematic reviews. Oct 8 2008;(4):Cd006216. doi: 10.1002/14651858.CD006216.pub2
23. Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infection control and hospital epidemiology. Dec 2005;26(12):916-22. doi: 10.1086/505453
24. Perez-Fontan M, Rosales M, Rodriguez-Carmona A, Falcon TG, Valdes F. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. American journal of kidney diseases : the official journal of the National Kidney Foundation. Feb 2002;39(2):337-41.
25. Vasquez JE, Walker ES, Franzus BW, Overbay BK, Reagan DR, Sarubbi FA. The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans' Affairs hospital. Infection control and hospital epidemiology. Jul 2000; 21(7):459-64. doi: 10.1086/501788
26. Walker ES, Vasquez JE, Dula R, Bullock H, Sarubbi FA. Mupirocin-resistant, methicillin-resistant Staphylococcus aureus: does mupirocin remain effective? Infection control and hospital epidemiology. May 2003; 24(5):342-6. doi: 10.1086/502218
27. Fawley WN, Parnell P, Hall J, Wilcox MH. Surveillance for mupirocin resistance following introduction of routine peri-operative prophylaxis with nasal mupirocin. The Journal of hospital infection. Mar 2006;62(3):327-32. doi: 10.1016/j.jhin.2005.09.022
28. Hayden MK, Lolans K, Haffenreffer K, et al. Chlorhexidine and Mupirocin Susceptibility of Methicillin-Resistant Staphylococcus aureus Isolates in the REDUCE-MRSA Trial. Journal of clinical microbiology. Nov 2016;54(11):2735-2742. doi: 10.1128/jcm.01444-16
29. Hill RL, Casewell MW. The in-vitro activity of povidone-iodinecream against Staphylococcus aureus and its bioavailability in nasal secretions. The Journal of hospital infection. Jul 2000;45(3):198-205.
doi: 10.1053/jhin.2000.0733
30. Rezapoor M, Nicholson T, Tabatabaee RM, Chen AF, Maltenfort MG, Parvizi J. Povidone-Iodine-Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study. The Journal of arthroplasty. Sep 2017;32(9):2815-2819. doi: 10.1016/j.arth.2017.04.039
31. Phillips M, Rosenberg A, Shopsin B, et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infection control and hospital epidemiology. Jul 2014;35(7):826-32. doi: 10.1086/676872
32. Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA surgery. May 2015;150 (5):390-5. doi: 10.1001/jamasurg.2014.3480
33. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. American journal of infection control. Dec 2002;30(8):S1-46.
34. Steed LL, Costello J, Lohia S, Jones T, Spannhake EW, Nguyen S. Reduction of nasal Staphylococcus aureus carriage in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antiseptic. American journal of infection control. Aug 2014;42(8):841-6. doi: 10.1016/j.ajic.2014.04.008
35. Mullen A, Wieland HJ, Wieser ES, Spannhake EW, Marinos RS. Perioperative participation of orthopedic patients and surgical staff in a nasal decolonization intervention to reduce Staphylococcus spp surgical site infections. American journal of infection control. May 1 2017;45(5):554-556. doi: 10.1016/j.ajic.2016.12.021
36. Street CN, Pedigo L, Gibbs A, Loebel NG. Antimicrobial photodynamic therapy for the decolonization of methicillin-resistant Staphylococcus aureus from the anterior nares. SPIE; 2009:16.
37. Bryce E, Wong T, Forrester L, et al. Nasal photodisinfection and chlorhexidine wipes decrease surgical site infections: a historical control study and propensity analysis. The Journal of hospital infection. Oct 2014;88(2):89-95. doi: 10.1016/j.jhin.2014.06.017
38. Sławiński G, Lewicka E, Kempa M, Budrejko S, Raczak G. Infections of cardiac implantable electronic devices: Epidemiology, classification, treatment, and prognosis. Adv Clin Exp Med. Feb 2019;28(2):263-270. doi: 10.17219/acem/80665
39. Sandoe JA, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). The Journal of antimicrobial chemotherapy. Feb 2015;70(2):325-59. doi: 10.1093/jac/dku383
doi: 10.1056/NEJMoa1801550
2. Hidron AI, Edwards JR, Patel J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infection control and hospital epidemiology. Nov 2008;29 (11):996-1011. doi: 10.1086/591861
3. Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis. Mar 1 2003; 36(5):592-8. doi: 10.1086/367653
4. Noskin GA, Rubin RJ, Schentag JJ, et al. National trends in Staphylococcus aureus infection rates: impact on economic burden and mortality over a 6-year period (1998-2003). Clin Infect Dis. Nov 1 2007;45(9):1132-40. doi: 10.1086/522186
5. Wertheim HF, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. Dec 2005;5(12):751-62. doi: 10.1016/s1473-3099(05)70295-4
6. Kline SE, Neaton JD, Lynfield R, et al. Randomized controlled trial of a self-administered five-day antiseptic bundle versus usual disinfectant soap showers for preoperative eradication of Staphylococcus aureus colonization. Infection control and hospital epidemiology. Sep 2018;39(9):1049-1057. doi: 10.1017/ice.2018.151
7. Sim BL, McBryde E, Street AC, Marshall C. Multiple site surveillance cultures as a predictor of methicillin-resistant Staphylococcus aureus infections. Infection control and hospital epidemiology. Aug 2013;34(8):818-24. doi: 10.1086/671273
8. VandenBergh MF, Yzerman EP, van Belkum A, Boelens HA, Sijmons M, Verbrugh HA. Follow-up of Staphylococcus aureus nasal carriage after 8 years: redefining the persistent carrier state. Journal of clinical microbiology. Oct 1999;37(10):3133-40.
9. Nouwen JL, Fieren MW, Snijders S, Verbrugh HA, van Belkum A. Persistent (not intermittent) nasal carriage of Staphylococcus aureus is the determinant of CPD-related infections. Kidney international. Mar 2005;67 (3):1084-92. doi: 10.1111/j.1523-1755.2005.00174.x
10. Kluytmans JA, Mouton JW, Ijzerman EP, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. The Journal of infectious diseases. Jan 1995;171(1):216-9.
11. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. The New England journal of medicine. Jun 13 2002;346 (24):1871-7. doi: 10.1056/NEJMoa003069
12. Kalra L, Camacho F, Whitener CJ, et al. Risk of methicillin-resistant Staphylococcus aureus surgical site infection in patients with nasal MRSA colonization. Am J Infect Control. Dec 2013;41(12):1253-7.
doi: 10.1016/j.ajic.2013.05.021
13. Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. The Journal of hospital infection. Sep 1995;31(1):13-24.
14. Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. The New England journal of medicine. Jan 7 2010;362(1):9-17.
doi: 10.1056/NEJMoa0808939
15. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. Bmj. Jun 13 2013;346:f2743. doi: 10.1136/bmj.f2743
16. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. Jama. Nov 22 2006;296(20):2460-6.
doi: 10.1001/jama.296.20.2460
17. Cimochowski GE, Harostock MD, Brown R, Bernardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. The Annals of thoracic surgery. May 2001;71(5):1572-8; discussion 1578-9.
18. Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA. Jun 2 2015;313(21):2162-71. doi: 10.1001/jama.2015.5387
19. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. Aug 15 2002;35(4):353-8. doi: 10.1086/341025
20. Ward A, Campoli-Richards DM. Mupirocin. A review of its antibacterial activity, pharmacokinetic properties and therapeutic use. Drugs. Nov 1986;32(5):425-44. doi: 10.2165/00003495-198632050-00002
21. Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. Apr 1 2009;48(7):922-30. doi: 10.1086/597291
22. van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. The Cochrane database of systematic reviews. Oct 8 2008;(4):Cd006216. doi: 10.1002/14651858.CD006216.pub2
23. Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infection control and hospital epidemiology. Dec 2005;26(12):916-22. doi: 10.1086/505453
24. Perez-Fontan M, Rosales M, Rodriguez-Carmona A, Falcon TG, Valdes F. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. American journal of kidney diseases : the official journal of the National Kidney Foundation. Feb 2002;39(2):337-41.
25. Vasquez JE, Walker ES, Franzus BW, Overbay BK, Reagan DR, Sarubbi FA. The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans' Affairs hospital. Infection control and hospital epidemiology. Jul 2000; 21(7):459-64. doi: 10.1086/501788
26. Walker ES, Vasquez JE, Dula R, Bullock H, Sarubbi FA. Mupirocin-resistant, methicillin-resistant Staphylococcus aureus: does mupirocin remain effective? Infection control and hospital epidemiology. May 2003; 24(5):342-6. doi: 10.1086/502218
27. Fawley WN, Parnell P, Hall J, Wilcox MH. Surveillance for mupirocin resistance following introduction of routine peri-operative prophylaxis with nasal mupirocin. The Journal of hospital infection. Mar 2006;62(3):327-32. doi: 10.1016/j.jhin.2005.09.022
28. Hayden MK, Lolans K, Haffenreffer K, et al. Chlorhexidine and Mupirocin Susceptibility of Methicillin-Resistant Staphylococcus aureus Isolates in the REDUCE-MRSA Trial. Journal of clinical microbiology. Nov 2016;54(11):2735-2742. doi: 10.1128/jcm.01444-16
29. Hill RL, Casewell MW. The in-vitro activity of povidone-iodinecream against Staphylococcus aureus and its bioavailability in nasal secretions. The Journal of hospital infection. Jul 2000;45(3):198-205.
doi: 10.1053/jhin.2000.0733
30. Rezapoor M, Nicholson T, Tabatabaee RM, Chen AF, Maltenfort MG, Parvizi J. Povidone-Iodine-Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study. The Journal of arthroplasty. Sep 2017;32(9):2815-2819. doi: 10.1016/j.arth.2017.04.039
31. Phillips M, Rosenberg A, Shopsin B, et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infection control and hospital epidemiology. Jul 2014;35(7):826-32. doi: 10.1086/676872
32. Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA surgery. May 2015;150 (5):390-5. doi: 10.1001/jamasurg.2014.3480
33. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. American journal of infection control. Dec 2002;30(8):S1-46.
34. Steed LL, Costello J, Lohia S, Jones T, Spannhake EW, Nguyen S. Reduction of nasal Staphylococcus aureus carriage in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antiseptic. American journal of infection control. Aug 2014;42(8):841-6. doi: 10.1016/j.ajic.2014.04.008
35. Mullen A, Wieland HJ, Wieser ES, Spannhake EW, Marinos RS. Perioperative participation of orthopedic patients and surgical staff in a nasal decolonization intervention to reduce Staphylococcus spp surgical site infections. American journal of infection control. May 1 2017;45(5):554-556. doi: 10.1016/j.ajic.2016.12.021
36. Street CN, Pedigo L, Gibbs A, Loebel NG. Antimicrobial photodynamic therapy for the decolonization of methicillin-resistant Staphylococcus aureus from the anterior nares. SPIE; 2009:16.
37. Bryce E, Wong T, Forrester L, et al. Nasal photodisinfection and chlorhexidine wipes decrease surgical site infections: a historical control study and propensity analysis. The Journal of hospital infection. Oct 2014;88(2):89-95. doi: 10.1016/j.jhin.2014.06.017
38. Sławiński G, Lewicka E, Kempa M, Budrejko S, Raczak G. Infections of cardiac implantable electronic devices: Epidemiology, classification, treatment, and prognosis. Adv Clin Exp Med. Feb 2019;28(2):263-270. doi: 10.17219/acem/80665
39. Sandoe JA, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). The Journal of antimicrobial chemotherapy. Feb 2015;70(2):325-59. doi: 10.1093/jac/dku383