Methicillin-resistant Staphylococcus aureus (MRSA) is one of the major causes of surgical site infections, but many facilities don't identify and treat carriers. With more complex procedures moving to the outpatient arena, it's critical that you prevent the spread of MRSA by applying topical antibiotics or antiseptics to the noses of patients before they step foot in your ORs.

• Screen and treat. One of the key parts of MRSA prevention protocols is screening for those infected or carrying the pathogen and decolonizing those who are, says Kevin T. Kavanagh, MD, MS, FACS, a healthcare policy researcher and patient safety advocate based in Lexington, Ky. "Some providers think this protocol should only be applied to certain patient groups — those undergoing joint replacements, for example — but by performing this surveillance on all patients, you are much more likely to prevent the ?spread ?of MRSA in your facility."

Patients are tested for the presence of pathogenic bacteria in the nasal ?cavity with a simple culture or with rapid molecular ?testing. A culture will help to reduce the cost of the surveillance process, but it takes several days to get results, says Dr. Kavanagh. Patients who are infected with MRSA or are carriers of the pathogen should ?undergo decolonization. This involves using an intranasal antibiotic, often mupirocin, ?2 to 3 times daily.

Most ?decolonization protocols ?also require daily bathing with an antiseptic solution for 5 days. MRSA positive patients ?should have ?at least one negative culture before undergoing surgery.

Screening and treating must be done well in advance of surgery, so get your surgeons invested in the process, suggests Dr. Kavanagh. "Make it part of your facility's written protocol that all patients who are scheduled to undergo surgery must be tested ?before the day of surgery," he adds. "Ideally, this can be done at pre-op visits to surgeons' offices."

There are several reasons to avoid treating all patients as if they have MRSA, says Dr. Kavanagh. First, the type of prophylactic antibiotic given will vary depending upon the MRSA carrier's state. Second, intranasal antibiotics, along with certain antiseptics, can promote bacterial resistance in the targeted pathogen and other organisms. Unnecessary antibiotics also impact the patient's microbiome. Though it's added work, it's truly best to first test the patient and treat only when necessary.

• Nasal decolonization. Nasal sanitizing swabs promise to help reduce the number of pathogens in a patient's nose without the risk of antibiotic use. Pre-op nurses use the swabs to apply an alcohol-based antiseptic to patients' nostrils just before they enter the OR. A study published in the American Journal of Infection Control (osmag.net/9dBXvS) tested the efficacy of an alcohol-based nasal antiseptic to prevent MRSA infection in 673 patients who underwent outpatient spine surgery and who did not receive mupirocin as part of a prevention protocol. Applying the nasal antiseptic in pre-op resulted in a significant reduction in S. aureus SSIs over the 15-month study.

A povidone-iodine solution can also be applied to patients' nostrils with a pre-moistened swab. One swab is rotated 4 times in each nostril for 30 seconds. A study in the Journal of Arthroplasty showed the povidone-iodine solution effectively eliminated nasal S. ?aureus in over two-thirds of 429 joint replacement patients (osmag.net/UX2Sna).

Screening and treating has been proven to reduce SSI rates and is routine practice in many facilities, but it's labor-intensive and challenges antibiotic stewardship protocols. Nasal decolonization might be a more practical approach.

More is needed

When possible, patients with MRSA infections or those who are carriers should be operated on at the end of your schedule, suggests Dr. Kavanagh. "This way," he explains, "the patient is the last case and staff can take the time to perform a thorough terminal cleaning."

There are also additional items on the market that ?may ?aid in disinfecting rooms at the end of the day, such as robots that employ ultraviolet light or hydrogen peroxide vapor. Remember that these technologies are not effective if debris or thick biofilm remain on surfaces. Therefore, make sure you're using these new technologies in addition to, not in place of, a thorough cleaning and scrubbing of the OR.

Ultimately, incorporating ?multiple ?interventions ?— pre-op showering, surface disinfection and proper hand hygiene — is key to a successful MRSA prevention protocol, says Dr. Kavanagh. He points out that many of these practices are ?also ?required to prevent the spread of several known pathogens like ?C. diff ?(although screening ?is not currently recommended, carriers do contribute to transmission) ?and CRE, the latter being poised to become a significant worry in the healthcare setting.

The best infection control practices include several layers of preventative measures, according to Dr. Kavanagh, who adds, "Once you have ?effective ?protocols in place, you'll be better prepared to deal with all of the dangerous pathogens that threaten your patients and staff." OSM