Decolonization of Staphylococcus aureus carriage

Discussed measure with restricted recommendations

Why does nasal decolonization play a role in SSI prevention

The guidelines describe this question clearly:
“S. aureus is the leading health care-associated pathogen in hospitals worldwide. These infections are associated with substantial morbidity and mortality and this trend is increasing due to the widespread dissemination of MRSA. […] Nasal carriage of S. aureus is now considered a well-defined risk factor for subsequent infection in various patient groups.” (WHO)1
A high proportion of SSIs caused by S. aureus is due to the fact that the patients themselves are nasal carriers of this pathogen. (KRINKO)2

Guidelines

Guideline

Recommendation

Category
(if mentioned)

CDC3

“No recommendation to preoperative apply mupirocin to nares to prevent SSI.”

Unresolved issue

WHO1

“The panel recommends that patients undergoing cardiothoracic and orthopaedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash.”

Strong recommendation, moderate quality of evidence


“The panel suggests considering to treat also patients with known nasal carriage of S. aureus undergoing other types of surgery with perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash.”Conditional recommendation, moderate quality of evidence

NICE4

“Consider nasal mupirocin in combination with a chlorhexidine body wash before procedures in which Staphylococcus aureus is a likely cause of a surgical site infection. This should be locally determined and take into account:

  • the type of procedure
  • individual patient risk factors
  • the increased risk of side effects in preterm infants
  • the potential impact of infection.“

-

“Maintain surveillance on antimicrobial resistance associated with the use of mupirocin.”

KRINKO2

In cardiac surgery and orthopaedic operations, patients with nasal colonization with S. aureus should undergo preoperative decolonization of the nose with mupirocin nasal ointment 2% alone or in combination with body washing with chlorhexidine gluconate.

Category IB

Alternatively, the use of antiseptics for the nose and skin may be useful in these patients.Category II
This treatment should also be carried out for other types of surgery with a high proportion of S. aureus as a pathogen of wound infections for S. aureus carriers.Category II

Recommended instructions

Practice routine decolonization with mupirocin nasal ointment with or without body washing with chlorhexidine
during cardiac surgery and orthopaedic operations in patients with nasal colonization with S. aureus1,2

Add-on
The recently updated SHEA compendium is broader on this aspect, moving it from an “additional approach” to “essential practice”. The SHEA recommends decolonization with an “antistaphylococcal agent” for all orthopaedic and cardiothoracic procedures and additionally for procedures with a high risk of staphylococcal SSI.5

Attention
However, with general decolonization there is a higher risk of developing resistance to mupirocin and chlorhexidine.2

Consider decolonization with mupirocin nasal ointment with or without body washing with chlorhexidine

  • in patients with known nasal carriage of S. aureus undergoing other types of surgery1

  • in other types of surgery with S. aureus as a probable cause of SSI2,4

Consider the following points when determining:4

  • type of procedure

  • individual patient risk

  • increased risk of side effects in

Alternatively2
to this procedure use antiseptics for the nose and skin2

SSI risk with S. aureus colonization compared to non-colonization

For orthopaedic operations, it is known that patients colonized with S. aureus have anapproximately five times higher risk of developing an SSI than non-colonized patients.2

Potential consequences of Staphylococcus infections in hospitalised patients 1

Results of a study of over 7 million hospital admissions in the USA regarding the possible consequences of Staphylococcus infections in hospitalized patients:
  1. WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.
  2. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention
    (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
  3. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.
  4. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020.
    www.nice.org.uk/guidance/ng125.
  5. Calderwood MS, et al. (2023) Strategies to prevent surgical site infection in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 44:
    695–720.

In focus

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