THIS WEEK'S ARTICLES
Povidone-Iodine Gains Support for Nasal Decolonization
Its quick, easy, fast-acting nature continues to grow its appeal.
A promising 2019 study has shown that povidone-iodine could be a viable alternative to mupirocin for nasal decolonization with great potential for use in perioperative settings.
Researchers applied 10% povidone-iodine to patients' nostrils and nares. A statistically significant reduction in the average levels of methicillin-resistant Staphylococcus aureus (MRSA) 12 and 24 hours after the application was not shown. However, the researchers did discover a potent and rapid reaction to S. aureus, as the level of the bacteria both one and six hours after povidone-iodine application was low enough to demonstrate that a single preoperative nasal dose suppresses S. aureus long enough to be effective for most outpatient surgeries.
Each study participant received two swabs saturated with povidone-iodine per nostril. For a total of 15 seconds, each swab was rotated with slight pressure at least six times each, first around the nostrils' circumferences, then in the anterior nares with care taken to cover all surfaces. After the study, participants were surveyed to determine if any had experienced potential adverse effects, including eye irritation, unpleasant odor or taste, or nasal itching, redness or irritation. None was reported.
The study, published last year in the American Journal of Infection Control, demonstrates that povidone-iodine can be an effective nasal decolonization method for patients undergoing orthopedic procedures, and potentially most surgical patients. The researchers note that povidone-iodine is a more cost-effective option than a five-day treatment of the more widely used mupirocin as a nasal decolonization agent. The study also expresses concerns about strains of S. aureus becoming resistant to mupirocin, and notes that other research suggests that resistance could be less likely with povidone-iodine because it has multiple cellular targets.
While five-day mupirocin treatments are effective for short periods of time, the study showed that it, too, did not achieve reductions in S. aureus 12 hours after doses.
Because S. aureus can be present on other areas of the body, the study notes it could be beneficial to accompany nasal treatments with use of chlorhexidine gluconate bathing.
Why This Epidemiologist Prefers Povidone-Iodine for Nasal Decolonization
Three key reasons make it a more effective option than mupirocin in outpatient settings.
With so much competing research battling for your attention about the best nasal decolonization methods, sometimes it feels like you need to do your own research to make sure you make the right choice. But who has the time for that?
Fortunately, there are several useful resources that can make your work relatively easy. The Association for Professionals in Infection Control and Epidemiology (APIC), for example, has an archive of free webinars. One is titled "Nasal Decolonization to Prevent Staphylococcus aureus Infections", presented by researcher Marin Schweizer, PhD, an epidemiologist and associate professor of general internal medicine at the University of Iowa. Dr. Schweizer has performed multiple research studies in an effort to determine whether nasal decolonization, in fact, prevents S. aureus infections.
In her hour-long presentation, Dr. Schweizer discusses several of her national, multi-center studies in which she evaluated multiple nasal decolonization interventions, with a focus on real-world variables that have acted as barriers to implementing good nasal decolonization protocols as well as factors that have facilitated their use. Another focus is Dr. Schweizer's body of evidence into the different levels of success nasal decolonization has been shown to have on different patient populations, including surgical patients, in preventing S. aureus. She even breaks down the prevention rates by types of surgeries.
In the section dedicated to povidone-iodine, Dr. Schweizer explains how it facilitates nasal decolonization in ways that mupirocin does not. First, nurses can pull it off the shelf without a doctor's prescription. Second, because it's administered on the day of surgery by a nurse, there are no patient compliance concerns. Finally, with no worries about resistance, povidone-iodine can be used for all surgical patients, not just those who test positive for S. aureus.
The presentation includes an overview of WHO and CDC healthcare facility-acquired S. aureus infections as well as a discussion of the pros and cons of various decolonizing methods on the market today.
Nasal Decolonization Pre-operatively is the Best Recommended Practice
Answering your questions about resistance rates, compliance, and antiseptic nares decolonization.
The administration of a nasal decolonization agent before surgery is an inexpensive preventative intervention for surgical site infections (SSIs). The nares are a common site for colonization with Staphylococcus aureus. Outpatient facilities have the opportunity to plan ahead with their patients for the most reliable and effective nasal decolonization regimen. Marc-Oliver Wright, MT (ASCP), MS, CIC, FAPIC, Clinical Science Liaison, Central Region, PDI, answers the most common question about pre-operative nasal decolonization.
Question: What's wrong with what I am doing now?
My practice group already performs nasal decolonization pre-operatively. We give the patient a prescription for mupirocin ointment to be applied to the nares twice daily for 5 days prior to surgery. We do this for all of our patients and have done so for the last 5 years. What is wrong with that?
Marc-Oliver Wright responds:
Congratulations! By decolonizing pre-operatively, your practice has already adopted recommended best practices for preventing surgical site infections in colonized patients. With a reported 85% DNA match between Staphylococcus aureus in the nares and Staphylococcus aureus wound infections and an associated 9-fold higher risk of infection, decolonization is certainly the way to go. However, with mupirocin there are a couple of things you might want to consider. Here are a few important ones to think about:
Did They Do It?
Decolonization with mupirocin requires the patient to self-apply an ointment to their anterior nares a couple of times a day for 5 days leading up to their procedure. Activities of daily living (ADLs) including self-care activities such as getting dressed, bathing, homemaking and leisure are going to vary from patient to patient. The patient is going to have to remember and be able to apply the ointment as prescribed. They also need to be able to afford the out-of-pocket expense of the prescription. In one study, 54% of surveyed respondents said it was too expensive and 19% of the respondents refused to use mupirocin (Bosco et al)1 Even asking the patient on the day of surgery if they used mupirocin is no guarantee that they did. Just ask any dental hygienist how often the patient's response to a question about flossing matches up with what they actually see!
Antibiotics → Antibiotic Resistance
Mupirocin was released to the market in 1985 and by 1987, resistance among S. aureus strains was already reported. In 2019, resistance rates for MRSA were reported as high as 12.6% in California patients2 and rates of resistance grew with increased use. In fact, when one hospital used mupirocin to decolonize patients, resistance increased from 2.7% to 65% in four short years.3 Many screening programs do not check for mupirocin resistance and if the isolate is resistant, decolonization will fail.
Mupirocin Compliance Does Not Guarantee Success
If patients are instructed and encouraged to complete mupirocin decolonization pre-operatively, and even if all the isolates are susceptible to the antibiotic, it does not mean that the treatment works. In 2020, researchers reported on their experience trying to decolonize cardiac surgery patients pre-operatively.4 Notably, they missed 32% of their patients because the procedure was emergent, and a single dose of mupirocin does not prevent SSIs. They screened 286 patients, 73 of whom were positive for susceptible strains and prescribed a decolonization regimen. On the day of surgery, they screened all of the patients again and of those 73 patients, 19 (26%) were still positive, 10% of whom developed mediastinitis surgical site infections. Additionally, patients who tested negative the first time tested positive on the day of surgery as well.
Antibiotics for nares decolonization require sequential days of application for patients, which may be difficult for some patients. Some patients find the cost of mupirocin financially burdensome. Antibiotics do not work when the isolates are resistant and increased use increases resistance rates. Even when the isolates are susceptible, the regimen can fail more than a quarter of the time. PDI's Profend® swabs provide single pre-operative applications for antiseptic nares decolonization, performed by the clinician, providing assurance of compliance and no demonstrable antibiotic resistance.
Note: For more information, go to https://pdihc.com/defendwithprofend/
1. Preventing surgical site infections: A randomized, open-label trial of nasal mupirocin
ointment and nasal povidone-iodine solution.
Infection Control and Hospital Epidemiology 2014; 35(7):826-832.
Orthopedics 2014(37:6 675-581)
2. N Engl J Med. 2019 Feb 14; 380(7): 638–650
3. Infect Control Hosp Epidemiol. 1996;17:811–3
4. J Ant Chemo, Volume 75, Issue 6, June 2020, Pages 1623–1630
Building Blocks of a Nasal Decolonization Program
Practical advice for adding an extra layer of protection against surgical site infections.
Hand hygiene. Personal protective equipment. Surface disinfection. Terminal cleaning. We hear about these infection prevention pillars all the time, and with good reason. Somehow, nasal decolonization of patients doesn't always make the list, and infection preventionist Sue Barnes, RN, BSN, CIC, FAPIC, can't understand why. After all, surgical site infections can have serious health ramifications for patients, including the nightmarish scenario of additional surgeries. Post-op infections are expensive to treat and even more expensive to litigate.
That's why Ms. Barnes has been an advocate of nasal decolonization or nasal sanitization for decades. The infection prevention consultant and former Kaiser Permanente national program leader of infection prevention and control points to a mountain of research that shows a consistently followed nasal decolonization program is effective in decreasing the risk of postoperative infections.
"This extra layer of protection should be standard practice at outpatient surgical facilities because the safest approach is universal nasal decolonization of all patients," suggests Ms. Barnes.
She generally advises against the use of mupirocin, mostly because of the ongoing development of methicillin-resistant Staphylococcus aureus (MRSA). And because mupirocin's efficacy isn't fully realized unless patients administer it properly for five days before a procedure, it requires 100% compliant patient compliance with pre-op administration. Povidone-iodine has no current resistance concerns and is administered one time, hours before the procedure, by a healthcare provider once the patient arrives for surgery.
To make any nasal decolonization program successful, Ms. Barnes suggests starting modestly, then expanding after small gains have been made. Make sure the product you select is backed by research and sold by a company that can instruct you how to get a fledgling nasal decolonization program of the ground. Once you select a product, formally evaluate what you picked by asking patients if the agent felt good, smelled pleasant and didn't trigger any adverse reactions.
Povidone-Iodine Trumps Mupirocin in NYU Langone Study
The easy-to-apply agent is an effective option for patients undergoing orthopedic procedures.
A study at NYU Langone Health concluded that nasal povidone-iodine appears to be a reasonable alternative to mupirocin ointment as part of a multi-faceted approach to reducing surgical site infections (SSIs).
Surgeons at Langone conducted the randomized, open-label trial because healthcare systems and providers face an important challenge to improve patient safety and control costs by identifying SSI risk factors that can be modified by interventions. The study notes the use of nasal mupirocin to suppress Staphylococcus aureus colonization and prevent subsequent invasive infections has proven to be effective in multiple controlled studies. In practice, however, patient compliance has been low because of side effects and out-of-pocket expenses. The fact that the patient must apply the ointment themselves for several days has also been noted by other healthcare providers and researchers as a barrier to mupirocin's success.
The trial compared SSI results in patients up to three months after they underwent arthroplasties or spine fusions. One group had received nasal mupirocin ointment applications twice a day in the five days before their surgeries. The other group received two applications of povidone-iodine solution into each nostril within two hours of their surgical incisions. Both groups utilized topical chlorhexidine wipes.
The study's intent-to-treat analysis showed that deep S. aureus SSIs developed after five of 855 surgeries in the mupirocin group and in one of 842 surgeries in the povidone-iodine group. The study's authors view these numbers as statistically relevant. The patients in the povidone-iodine group experienced lower rates of treatment-related symptoms and were also less likely to report application of the treatment as unpleasant, the study says.
The study's findings suggest that preoperative nasal povidone-iodine with topical chlorhexidine is similar to preoperative nasal mupirocin with topical chlorhexidine when it comes to preventing S. aureus deep SSIs after arthroplasties and spine fusion surgeries.