Breaking Down Universal Decolonization With Nasal Antiseptics

Whether you use a universal or a targeted protocol, it pays to focus on the nares.

Studies show 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. hospital patients are also colonized with Methicillin-resistant Staphylococcus aureus (MRSA). Higher risks of dangerous — even deadly — infections from the presence of S. aureus are real risks for patients.

They are also expensive to treat and possibly litigate. Knowing how prevalent staph infections are, and how serious they can be, is a good place for facilities to start as they begin the process of learning why it’s vitally important to start a focused or universal nasal decolonization program. Once armed with that knowledge, it’s easier to get your staff on board with such a crucial infection prevention initiative.

The big three

Currently, three primary agents are used at many surgical facilities for preoperative nasal decolonization of patients: mupirocin, povidone-iodine (PI) and alcohol-based antiseptic. Independent Infection Prevention Consultant Maureen Spencer, M. Ed, BSN, RN, FAPIC, says that evidence supports the use of these decolonization agents, but further studies are needed to assess resistance, especially among gram-negative organisms. “The strongest evidence exists for using decolonization as a strategy to prevent surgical site infections,” says Ms. Spencer. “Nasal colonization can lead to infections and transmission, making decolonization a crucial preventive measure. Patients colonized with S. aureus are at a significantly higher risk of developing infections compared to noncolonized individuals.”

• Mupirocin is the traditional, most studied approach, in use since the ‘80s. While effective, two issues with the agent have led providers and researchers to explore alternatives.

First, the regimen requires a high degree of diligence and compliance on the part of the patient, as they must apply an ointment to their nares at home twice a day for five days before surgery. Second, there has been concern about bacterial resistance resulting from the agent’s wide long-term use, although the true scope and impact of this resistance remains under investigation. Mupirocin remains widely used and highly effective, but many providers would prefer an agent that is easier to use and doesn’t require unsupervised patient compliance.

• Povidone-iodine (PI) is an alternative that has grown in popularity over the last several years. It’s much simpler to apply than mupirocin and doesn’t require any patient compliance at home. PI is an antiseptic as opposed to mupirocin, which is an antibiotic, and bacterial resistance to PI is not currently known to be an issue.

Application is extremely simple. PI is simply applied to the patient’s nares in the pre-op area by a nurse or other provider. The entire process only takes about a minute, and it’s generally well-tolerated by patients.

While PI doesn’t eliminate organisms in the long-term, it’s perfect for same-day surgical settings. PI has been shown to temporarily but rapidly suppress growth of S. aureus for several hours. In terms of effectiveness, Ms. Spencer points to a study on a randomized clinical trial of a nasal povidone-iodine antiseptic as compared to mupirocin nasal ointment in which there were only six SSIs in 842 surgeries (0.7%) for the PI group versus 14 SSIs in 855 surgeries (1.6%) for the mupirocin group. The findings prompted the study’s authors’ to state: “Nasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI.”

It should be noted that generic over-the-counter PI swabs, while relatively inexpensive, are not suitable for preoperative nasal decolonization.

• Alcohol-based antiseptic, like PI, is a short-duration agent applied in pre-op that has proven effective for nasal decolonization before surgery and is growing in use. It too is generally well-tolerated by patients.

However, as compared with PI, there remains disagreement about how many doses are necessary, and when they should be applied. PI is recommended by the CDC, the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC). The Association of periOperative Registered Nurses (AORN) endorses PI and alcohol-based antiseptic.

ASCs are not immune to SSIs

Nasal decolonization programs aren’t exclusively a hospital practice. A universal protocol, or one that targets only high-risk patients, can be implemented in ambulatory surgery centers as well, even though infection rates are generally lower at those sites than in hospitals. Considering the types of surgeries performed at your center is a good place to start your thought process.

“Cardiac and orthopedic surgeries can present a higher risk for poor health outcomes from staphylococcal SSIs,” notes Benjamin D. Galvan, MLS(ASCP)CM, CIC, an infection prevention director in the Tampa Bay area. “For these cases, there’s a pretty strong case to be made for adopting a focused nasal decolonization program to treat all patients before surgery with nasal antiseptics, even if the upfront costs to implement it could be significant.”

At ASCs with less risky service lines, cost is more of a factor when deciding whether to treat all patients with an immediate-acting nasal antiseptic or a select population with mupirocin. This is where a facility risk assessment comes into play, as it will help you understand the rates, or burden, of MRSA and MSSA that exist within your patient population. You’ll need to be armed with data that shows your past infection rate to argue for spending money on a new decolonization protocol. Some vendors can help with this, as they have risk-assessment tools that can take your data and generate a report about whether a program is justified.

That report should also note that SSIs are potentially deadly and that the cost to treat them can be astronomical, notes Mr. Galvan. “The cost of hospital admissions, reimbursements withheld by CMS or fines levied by them are strong considerations, as is the fact that somewhere between 70% to 80% of SSIs come from S. aureus in patients’ own nares,” he says. “Once leadership sees those numbers, you’ll be well on your way to obtaining the buy-in needed for your nasal decolonization program.”

The use of nasal antiseptics, products that are alcohol- or povidone-iodine-based, are often especially appealing for ASCs. They’re simply more convenient for patients, as they can be applied to patients preoperatively. OSM