Infection Prevention: The 7S Bundle in Action

Universal decolonization with nasal antiseptics benefits patients, staff.

We know that the presence of healthcare-associated pathogens such as Staphylococcus aureus, enterococci and gram-negative organisms is associated with a heightened risk of infection. Fortunately, nasal decolonization is an evidence-based intervention that prevents these pathogens from causing surgical site infections (SSIs).

Safe and effective

Nasal antiseptics have emerged as a practical and effective alternative to traditional antibiotic ointments for achieving nasal decolonization of both gram-positive and gram-negative bacteria in patients and healthcare staff.

Several nasal decolonization agents, including mupirocin, povidone-iodine and alcohol-based antiseptics, have gained popularity. Although evidence supports their efficacy, further studies are necessary to evaluate resistance issues, particularly concerning gram-negative organisms.

Notably, the strongest evidence supports using decolonization as a strategy to prevent SSIs. Nasal colonization can lead to infections and further transmission, making decolonization an essential preventive approach. This is especially important because patients colonized with S. aureus face a significantly increased risk of developing infections compared to those who are not colonized.

Numerous recent studies have examined the effectiveness not just of nasal decolonization on SSI rates, but also produced data that compared the effectiveness of various nasal decolonization agents.

One study aimed at reducing SSIs in spine surgery patients by implementing preoperative universal alcohol-based nasal decolonization for patients, surgical staff and nursing personnel. Mean infection rates dropped dramatically by 81%, specifically from 1.76 to 0.33 per 100 surgeries over 15 months compared to a previous nine-month baseline. This demonstrates the potential effectiveness of alcohol-based nasal antiseptics in minimizing SSIs.

In a randomized clinical trial that compared nasal povidone-iodine antiseptics to mupirocin nasal ointments, the results were notable. The iodine group recorded only six SSIs out of 842 surgeries (0.7%), while the mupirocin group recorded 14 SSIs out of 855 surgeries (1.6%). This trial demonstrated that nasal povidone-iodine presents a viable alternative to mupirocin as a comprehensive nasal decolonization approach to reduce SSIs.

In a randomized, placebo-controlled, parallel-group clinical study involving 50 adult volunteers, half of the participants were randomly assigned to receive a nasal antiseptic solution containing povidone-iodine as the active ingredient, while the other half received a control solution. Nasal swabs were collected before application and at three points after application: five minutes, two hours and 24 hours.

After these swabs underwent next-generation sequencing analysis, they were cultured on agar plates. At baseline, a significant association was found with anaerobic species including Corynebacterium spp., Staphylococcus spp. and Dolosigranulumspp.

By decolonizing the nasal passages of healthcare workers, we could potentially minimize their risk of infection.

Following the application of povidone-iodine, a significant reduction in bioburden was noted as compared to the control group. Five minutes after the application of the nasal antiseptic solution, a higher and almost complete elimination of bacteria from the anterior nares was observed, compared to the control group. The primary species affected by the treatment included Cutibacterium acnes, Staphylococcus spp. and Corynebacterium spp. Importantly, none of the participants reported any adverse effects, nor were there any increases in mucociliary clearance time. The findings indicate that antiseptic solutions applied to the anterior nares can transiently and significantly reduce nasal bioburden.

Not just for patients

Approximately 70% to 90% of the general population are intermittent carriers of S. aureus, with around 20% being persistent carriers. Intermittent colonization accounts for about 60% of cases.

Moreover, roughly 4% of healthcare workers and 30% of patients are colonized with methicillin-resistant Staphylococcus aureus (MRSA), while 30% of patients are colonized with methicillin-sensitive Staphylococcus aureus (MSSA).

Decolonization also holds significant promise as a preventive strategy against healthcare-associated infections among operating room staff. By decolonizing the nasal passages of healthcare workers, we could potentially minimize their risk of infection, particularly during respiratory virus seasons, which may lead to reduced absenteeism and ensure a more consistent quality of care. While the initial evidence is encouraging, additional studies are necessary for validation.

The use of nasal antiseptics gained particular momentum during the COVID-19 pandemic. Today, some healthcare facilities are now implementing these measures in response to outbreaks of pathogens such as MRSA.

Perioperative leaders should closely monitor this trend and its influence on infection rates, as universal nasal decolonization among staff could serve as a valuable addition to infection prevention strategies, protecting both their colleagues and their patients. OSM