The Case for Universal Nasal Decolonization

Inside the paradigm shift that’s changing a prevalent infection prevention protocol.

It’s probably a good policy to avoid sticking your nose in everyone’s business. But when it comes to infection prevention, hospitals and surgery centers have undeniable success when they stick their business in everybody else’s nose.

It’s becoming abundantly clear that universal nasal decolonization is an infection control practice worth adding.

“We’re seeing folks thinking about universal decolonization versus targeted colonization, and there’s a paradigm shift that’s going on,” says Connie Steed, MSN, RN, CIC, FAPIC, an infection prevention consultant. “There’s an emerging sensibility that it’s best to protect all patients.”

The nose knows

The nares are associated with more than three-quarters of surgical site infections (SSIs), with the exception of those in the genital/urinary area. Published studies going all the way back to the 1930s have revealed the nose as the source of many SSIs.

It makes sense. There are numerous organisms that grow in the nasal vestibules, and every time a person breathes out, those organisms are dispensed into the immediate area. Since many surgical wounds are below the nose, every outgoing breath showers the wound with microorganisms.

“We’ve recognized the nose as the source for 80 percent of infections, but we just haven’t been able to figure out the best way to treat it,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, adjunct faculty member in the division of infectious diseases at University of North Carolina’s School of Medicine in Chapel Hill.

She calls nasal decolonization “the missing link” in preventing infections. SSIs still represent 30 percent to 40 percent of all healthcare-associated infections (HAIs) and nasal decolonization provides an opportunity to improve those numbers.

Available options

SCARY AREA The nares are a major reservoir of S. aureus, bacteria that can lead to harmful and even fatal infections.

There are currently three options available for nasal decolonization: mupirocin (an antibiotic cream), povidone-iodine swabs and alcohol-based antiseptics.

Of all options, mupirocin is generally the most problematic. For starters, it’s an antibiotic, and hospitals and surgery centers often try to decrease the use of any unnecessary antibiotics because all organisms seem to develop effective ways to resist them. When the antibiotic cream is placed in the nose, high levels of resistance quickly develop. Plus, patients generally aren’t fans of it.

“The problem with mupirocin is you need to apply it twice a day for five days before the surgery. You’re relying on patients at home filling the prescription, and studies show only about half do,” says Ms. Hoffmann. “And then you’re relying on them to give themselves this goopy cream up their nose, and less than half of them do that.” Ultimately, she says, when patients don’t like something, they’re not going to comply.”

All three options are effective in controlling infections. But deciding which patients get nasal decolonization prior to surgery is also a point of discussion. “We know what’s effective, and we know this is the missing link on what is an effective as part of the (SSI) bundle,” says Ms. Hoffmann, adding that providers aren’t adjusting what the reservoir is for 30% of the population who come in carrying staph at any one time. “We’re just randomly looking at where can we preserve this antibiotic, so it doesn’t become widely resistant or slow the resistance down by only using it on high-risk patients, like cardiothoracic and orthopedic patients,” she says.

Universal approach

So why don’t all patients receive preoperative nasal decolonization? More and more people are coming around to the belief that the approach for hospitals and surgical centers should be universal nasal decolonization for both patients and staff members.

Although the Centers for Disease Control (CDC) suggests that only the high-risk patient population be targeted for nasal decolonization, the Association of periOperative Registered Nurses (AORN) has updated and expanded its guideline to suggest that a universal approach to nasal decolonization is an effective infection control strategy.

“I personally like the ‘protect all patients’ route, because you truly do protect all patients,” says Ms. Steed. “You give them an antiseptic in their nose, and it has a pretty close to immediate effect.”

The downsides to treating all patients preoperatively with nasal decolonization are that patients generally don’t like the product being used, don’t comply with the IFUs, or the cost may be prohibitive for hospitals and surgery centers.

Post-op treatment

There are three key considerations to examine when it comes to postoperative nasal decolonization, according to Ms. Steed:

• Will you perform universal or targeted nasal decolonization?
• What product will you use?
• How will you implement the protocol?

The AORN guideline addresses the concept of expanding decolonization past the pre-op stage into hospitalization if the patient is hospitalized, through post-discharge until the incision is healed by primary intention.

I personally like the ‘protect all patients’ route, because you truly do protect all patients. You give them an antiseptic in their nose, and it has a pretty close to immediate effect.
Connie Steed, MSN, RN, CIC, FAPIC

The suggestion is that some hospitals and facilities have done so and have seen tremendous benefit from continuing to administer the antiseptic postoperatively.

AORN suggests expanding the use of the antiseptic until after the surgical wound heals. That would mean extra patient education to ensure compliance, as decolonization agents must always be used properly by patients to remain effective.

Cost and compliance

Scott Arden, RN, BSN, CIC, a retired infection preventionist, believes all patients’ nares should be decolonized before surgery. At his last job before retiring — at AdventHealth North Pinellas in Tarpon Springs, Fla. — administration implemented a very aggressive program for nasal decolonization. Although the hospital didn’t require the staff to participate in the decolonization program, about 98 percent administered nasal decolonization to themselves as well as their patients. These interventions, he says, completely eliminated the facility’s HAIs — both SSIs and non-surgical site infections.

“We looked at multiple products on the market and the one we chose was pleasant, clean and didn’t leave a residue,” says Mr. Arden. “The product is basically hand sanitizer for the nose; that’s the easiest way to put it. And the results were astronomical. There are very few hospitals that can claim that they have zero infections.”

It was a win-win for everybody, says Mr. Arden, who adds that it helped that staff used it themselves, because they then better understood what the nasal decolonization experience was actually like for their patients, and were better equipped to educate their patients on its efficacy and usage.

Knowing that one of the drawbacks to using a nasal decolonization approach on all patients would be cost, Mr. Arden had a plan. He anticipated that the hospital’s chief financial officer would need to know exactly how much the facility would spend on treating all patients with nasal decolonization. “I did a complete analysis on what we were spending on isolation and testing certain populations. I was able to address the savings, which was far greater than what I was asking them to spend,” says Mr. Arden. “We spent $160,000 in the first year on the product. However, we had net reduction in cost related to that of almost $700,000 (in terms of costs associated by SSIs). After the first year, I sat down with the CFO and asked what he thought of the program and he said, ‘We are definitely continuing it.’”

It makes sense

The focus among hospitals and surgery centers continues to be protecting all patients and mitigating the risk of SSIs. A universal approach to nasal decolonization is an effective way for facilities to do just that.

“We’re still in the early adopter stage, but protecting all patients just makes sense,” says Ms. Steed. “I think there’s very good rationale for it from looking at the literature.” OSM