It's Time to Focus on Nasal Decolonization

Patient Safety Infection Prevention

By: Benjamin D. Galvan, MLS(ASCP)CM, CIC

Published: 5/19/2022

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Understanding the seriousness of staph infections can get your team to buy into infection-reducing protocols.


Studies have shown that up to 30% of the population may be colonized with Staphylococcus aureus (S. aureus) in their nares and up to 5% of U.S. hospitalized patients are colonized with methicillin-resistant Staphylococcus aureus (MRSA). Colonization with S. aureus can lead to a higher risk of surgical site infections (SSIs), which can be dangerous — even deadly — to patients and expensive for providers to treat and possibly litigate.

Understanding the prevalence and seriousness of staph infections is a good starting point to get facilities to see why it’s critically important to start a focused nasal decolonization program and to get their staff on board with such a critical initiative. 

 

A breeding ground for bacteria

Nasal decolonization programs target both methicillin-susceptible S. aureus (MSSA) and MRSA. Bacteria look for reservoirs where they can live, thrive and replicate. For MSSA and MRSA, that’s in the anterior nares of the nose. This is an issue in outpatient facilities because people naturally sneeze, cough and touch their faces, actions that lead to constant contamination of perioperative environments with S. aureus. Staff who practice in these environments can then contribute to the transmission of this endogenous bacteria to other patients and surfaces. Decolonization is crucial because S. aureus is a major contributor of healthcare associated infections (HAIs), including central line-associated bloodstream infections (BSI), ventilator-associated pneumonias and, of course, SSIs.

An estimated 30% of the population is colonized, and somewhere between 70% to 80% of SSIs come from S. aureus strains in patients’ own nares. Additionally, although other risk factors exist that increase the risk of S. aureus infections, research has shown that MRSA and MSSA carriers are more likely to suffer SSIs with S. aureus than non-carriers. Bottom line: Based on the numbers, nasal decolonization is one method you should implement to help reduce infection risk.

The primary antibiotic option for decolonization is mupirocin, a nasal ointment. It’s very effective, but the drawback is time. It takes up to five days for the product to be the most effective against S. aureus bacteria. Another challenge with mupirocin: High use of it can lead to increased antibiotic resistance. 

The other option — one that’s especially appealing for outpatient facilities — is the use of nasal antiseptics, products that are alcohol- or povidone-iodine-based. In addition to being much more convenient for patients (most patients don’t want to put mupirocin ointment in their nose), these povidone-iodine and alcohol-based antiseptics can be applied to patients preoperatively and are effective immediately. There are also no known issues of bacteria resistance, and you don’t need to worry about patients complying with an onerous administration regimen. After all, with mupirocin, there’s no way to monitor if they completed the twice-a-day regimen for five days prior to surgical procedures. It’s worth noting that this also goes for the application of chlorhexidine gluconate (CHG) wipes patients are often asked to use at home. If these wipes aren’t applied properly for five days before surgery, they may not be fully effective in lowering the colonization burden on their skin, so staff generally apply antiseptic swabs and CHG wipes to patients immediately before surgeries.

 
Breaking the Chain of Infection
SIMPLE STEPS
ANTISEPTIC SOLUTION Nasal antiseptics alleviate concerns about patients being resistant to antibiotic treatments to reduce S. aureus bacteria.

There are six links to what infection preventionists call the “chain of infection:”

  • the pathogen itself; 
  • a reservoir in which it can live; 
  • a portal of exit from which it can escape; 
  • a mode of transmission that allows it to spread; 
  • a portal of entry it can penetrate; and 
  • a susceptible host that can get infected. 

Using the colonization of the nares with methicillin-resistant Staphylococcus aureus (MRSA) as an example, MRSA is the pathogen; the nares are the reservoir; the nostrils are the portal of exit; the mode of transmission is direct or indirect contact with contaminated surfaces or healthcare workers’ hands; the portal of entry is the surgical wound; and the susceptible host is the patient. As infection preventionists, we implement various processes to break the chain. For instance, we prevent transmission of MRSA and methicillin-susceptible S. aureus (MSSA) through the use of proper hand hygiene and personal protective equipment (PPE) such as gloves and gowns. These barriers between providers and the bacteria are thrown away in the patient’s room and, with good hand hygiene afterward, allow us to walk through the rest of the facility without the increased risk of transmitting the bacteria to the next patient. We use nasal decolonization methods to reduce the burden of S. aureus in their reservoir, reducing its opportunity of leaving the nares. We also use environmental disinfection to reduce the risk of environmental transmission from contaminated surfaces. 

— Benjamin D. Galvan, MLS(ASCP)CM, CIC 

Preventing what you can control

ANTI-ANTIBIOTIC Nasal antiseptic used the day of surgery can immediately reduce the level of bacterial colonization in patients' nares.

Because such a high percentage of patients are likely already colonized with S. aureus and we’re sending them home after surgery, we want our infection prevention bundles to include mitigation strategies that aim to prevent SSIs through decolonization. While we can theoretically do everything perfectly to prevent transmission while patients are under our care, we can’t monitor how well they follow education aimed at preventing postoperative infections. The patients may, in fact, be giving themselves an infection if they’re not being as careful as possible with their wound care. But if we decolonize these patients ahead of time, it not only reduces the risk of infection during surgery, it could also reduce the chances of them infecting their wound after discharge.

There is a wealth of research on whether infection prevention programs should focus on focused nasal decolonization. Of course, the decision to treat all patients with an immediate-acting nasal antiseptic preoperatively or screen and treat a select population with mupirocin ultimately depends on a variety of facility-specific factors. There’s the type of surgery, surgeon preference and cost. Although it may be expensive upfront to implement a focused decolonization protocol, cardiac and orthopedic surgeries can present a higher risk for poor health outcomes from staphylococcal SSIs. For these cases, there’s a pretty strong case to be made for adopting focused nasal decolonization to treat all patients before surgery with nasal antiseptics.

The first thing you should do is perform a risk assessment to understand the rates, or burden, of MRSA and MSSA that exist within your patient population. Look at how many past infections you’ve had — data that you’ll need to support the additional expense this protocol will add. This isn’t always as labor-intensive as it sounds. Some nasal antiseptic vendors have risk assessment tools you can plug your facility’s numbers into to get a report you need to support nasal decolonization. Some will even do the calculations for you. Of course, the fact that SSIs are potentially deadly is the biggest risk factor. The cost to treat them can also be astronomical. You’ll also want to look at the cost of cases in which SSIs required hospital admissions, including any reimbursements withheld or penalties levied by CMS. Once leadership and staff see the numbers illustrating how prevalent these bacteria are, how often colonized patients suffer SSIs and how expensive those infections are to treat, you’ll be well on your way to obtaining the buy-in needed for your nasal decolonization program. OSM

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