April 21, 2021

Alternatives to the standard mupirocin treatment are beginning to gain traction.

ON THE NOSE It's generally agreed that preoperative nasal decolonization helps prevent SSIs, but the most effective method is still a matter of debate. (Note: Photo taken before the COVID-19 pandemic).

Nasal decolonization is a cost-effective way to reduce the risk of surgical site infections (SSIs), especially in patients undergoing joint replacement surgery. Infected joints can be expensive to treat and devastating for patients. The infection itself could be serious; the implant needs to be removed and replaced; and the end result might be suboptimal. That's why it's vital to employ nasal decolonization before surgery to treat Staphylococcus aureus (S. aureus) in the nares, a common cause of infection in joint replacement patients.

But which method should you use? There are currently three primary options from which to choose, all of which have some peer-reviewed data that indicates they're effective, says Edward Septimus, MD, an infectious disease specialist and professor of internal medicine at Texas A&M College of Medicine in Houston. Consider the following points when deciding which method to use for your patients:

• Mupirocin. The classic treatment involves testing the nares for the presence of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus aureus (MSSA) before patients arrive for surgery. If either organism is present, the patient applies mupirocin to the anterior nares two times a day for five days leading up to surgery, in conjunction with daily chlorhexidine bathing. The challenge with mupirocin is that it requires screening patients at least a week in advance of their procedures, and then patients need to strictly follow the application regimen at home. Widespread use also contributes to the increasing prevalence of mupirocin resistance.
• Povidone-iodine (PI). This topical antiseptic is applied in pre-op on the day of surgery — two applications in each nostril twice before the patient goes into the OR — so you don't need to worry about screening patients days in advance of their procedures. The evidence of PI's effectiveness in reducing SSIs is growing, and its simple application method makes it an appealing option in outpatient surgery settings.
• Alcohol-based antiseptic. This method is short in duration and therefore must be applied multiple times a day to lower colony counts in the nares. Although significant clinical evidence is lacking on the overall efficacy of alcohol-based nasal decolonization, it's a viable and convenient option for use on patients in pre-op.

"The problem right now is a lack of consensus on what the most effective and reliable nasal decolonization regimen actually is," says Dr. Septimus. "Given the limited peer-reviewed information on the true efficacy of the mupirocin alternatives, it's too early to say which is the best. The nasal decolonization picture will likely become clearer in the next couple of years."

Take a sneak peek at some of your colleagues' nasal decolonization strategies.

Credit: PDI Healthcare
INFECTIONS BEWARE Nasal decolonization can fight infections before they contaminate the surgical site.

Surgical professionals know that reducing surgical site infections (SSIs) is important, that a large percentage of Staphylococcus aureus bacteria resides in patients' noses and that nasal decolonization can help reduce the risk of SSIs. But which method is best to attack the pathogen, and once you pick a strategy, how do you implement it? Here are some success stories to help you decide what's best for your facility.

The Keck USC School of Medicine in Los Angeles published research that found that mupirocin applied twice a day and daily chlorhexidine showers for five days before surgery eradicated methicillin-resistant Staphylococcus aureus (MRSA) in colonized total joint patients. Screening patients for MRSA and methicillin-resistant Staphylococcus aureus (MSSA) and treating carriers with the topical antibiotic remains a common practice, but surgical professionals are opting for universal nasal decolonization of all patients on the day of surgery for added convenience and because of growing concerns about mupirocin resistance.

Several years ago, a nurse at the VA Portland Health Care System turned to pre-op nasal decolonization in an effort to lower the facility's rate of MRSA infections. Melissa S. Schmidt, MSN, RN, CNL, CPAN, CAPA, PACU, realized treating patients who had tested positive for MRSA one to four weeks before surgery with mupirocin nasal ointment and chlorhexidine showers had a major glitch: patients and surgeons weren't complying with the protocol. The facility therefore pivoted to having pre-op nurses administer povidone-iodine via nasal swabs to every patient within two hours of their surgeries. The two-minute, $14-per-patient application led to a zero SSI rate over an extended time after the switch was made.

Alcohol-based antiseptic treatments are easy to use, don't contribute to bacterial resistance and can be applied immediately before surgery. Marshall Medical Center, a 113-bed acute care hospital in Placerville, Calif., uses alcohol-based antiseptics on every surgical patient, not just those who test positive through screening, according to Nina Deatherage, RN, BSN, CIC, the infection control lead.

Nurses administer the alcohol-based antiseptic three times to patients within the hour before surgery. "It's like painting a wall," says Ms. Deatherage. "Three rolls and you know you have covered every spot."

Many researchers have concluded the treat-all and screen-and-treat strategies have nearly identical average cost-effectiveness ratios. A treat-all strategy is simpler to implement, but facilities with a high prevalence of mupirocin-resistant strains may prefer a screen-and-treat strategy. Regardless of the method, nasal decolonization has evolved into an important part of a multifaceted infection prevention strategy.

Nurses can play an important role in the application of an intranasal PI solution.

Credit: PDI Healthcare
Prior to patient application, a nurse holds a Profend® Nasal Decolonization swab.

Preoperative nasal decolonization of surgical patients with nasal povidone-iodine (PI) has the potential to reduce pathogenic organisms responsible for surgical site infections, according to a recent study.¹ The study evaluated the implementation feasibility, fidelity and acceptability of intranasal PI solution application by surgical nurses using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework. It yielded some interesting results that indicate that nurses can implement PI.

Despite tremendous advancements in surgical practice, surgical site infection (SSI) remains a major challenge in healthcare, affecting approximately 500,000 patients annually in the United States.² According to the study, surgical site infections (SSIs) are associated with prolonged hospital stays and the need for antibiotic therapies that are frequently not only complex and lengthy, but potentially toxic.³ Nasal carriage of Staphylococcus aureus is found in approximately 30% of patients ^5,6 and greatly increases the risk of SSI.³

To mitigate the risk of S. aureus SSIs, current evidence-based guidelines recommend decolonization of patients through the application of nasal mupirocin twice daily in the five days preceding surgery. Unfortunately, significant drawbacks are associated with this preventive measure, including the potential for an emergence of staphylococcal resistance to mupirocin^7.8 and mupirocin related adverse reactions.⁹

Add to that the out-of-pocket cost of the drug and the inconvenience of having to apply mupirocin ointment multiple days prior to surgery and patient compliance becomes difficult, according to the study. An alternative, cost-effective, safe nasal antimicrobial decolonizing agent – not reliant on patients for implementation – has been identified as an urgent need. Intranasal povidone iodine solution (PI) appears to be a promising alternative to mupirocin as an immediate preoperative option for the day of surgery.

According to the study, "Intranasal PI has broad-spectrum antibacterial activity, including against methicillin-susceptible and resistant S. aureus and Pseudomonas.¹⁰ PI is rapidly bactericidal in vitro (within 15 to 20 seconds) with effects on skin lasting for 12 to 14 hours after application, a feature that provides microbial suppression in the immediate postoperative period.^11,12 Unlike mupirocin that needs to be applied by the patient five days prior to surgery, intranasal PI solution can be applied by a nurse one hour before the procedure."

To date, several studies evaluating intranasal PI solution have demonstrated its effectiveness in reducing SSI.^5,13,14 Patients also seem to like this solution, so it is not surprising that hospitals are increasingly interested in implementing PI to reduce surgical site infections among surgical patients.

In the study, ambulatory nurses were involved with the PI and administered it to patients prior to surgery. They reported that "the PI implementation process was easy and quick once they had received appropriate information and training and not as complicated or time consuming as they may have initially expected." Generally, all the nurse who were studied in the ambulatory setting supported the idea of incorporating this process into the pre-surgical workflow PI implementation to reduce SSI.

Communication about policies is important for compliance and effectiveness.

A recent real-world study shows putting a pre-op nasal povidone-iodine (PI) application protocol into practice is feasible and acceptable among surgical staff and patients.

The study's authors interviewed 15 pre- and post-op nurses who worked at a health system's surgery center and a hospital's surgical department about their experiences with the facilities' nasal PI protocols. The nurses said administering PI was quick and easy when they received appropriate information and training about the application process. You can read more about their insights in the complete study, which was published online in PLOS One.

However, the nurses also voiced concerns over ineffective communication about the application policies and the lack of systematic administration protocols. Based on the feedback, the research team collaborated with the nurses to develop a written implementation policy and trained the staff to follow the protocol correctly and consistently to ensure compliance.

Nasia Safdar, MD, PhD, co-author of the study and a professor of infectious disease at the University of Wisconsin School of Medicine and Public Health in Madison, believes any quality improvement program should be monitored closely and include feedback from frontline staff on the feasibility of the new protocols. "We were surprised by the challenges in implementation that the nurses shared, which is an important reminder that even a seemingly simple intervention has a number of parts that need to be communicated and connected to ensure success," she says.

The researchers say creating an effective PI nasal decolonization program requires involvement from leadership, dedicated time for training and the involvement of frontline nurses in the development of the administration protocol. "Povidone-iodine shows promise as an immediate preoperative option on the day of surgery," says Dr. Safdar. "We've found that paying attention to how the intervention is implemented is critically important."

Efforts to control nostril microbiome can help decrease the rate of SSIs.

Perioperative teams always pay close attention to prepping the skin around surgical sites before surgery. They should also focus on treating the nares with antiseptics in order to reduce the risk of post-op infections, says Richard Wenzel, MD, MSc, emeritus chairman and professor of the Department of Internal Medicine at Virginia Commonwealth University (VCU) Medical Center in Richmond.

"There's an increasing body of evidence that shows a 'normal' microbiome in the nares protects against infections," explains Dr. Wenzel. "Skin flora at the incision site and in the nares are sometimes related — a particular staphylococcal strain on the skin is often also found in the nose. Eliminating potential pathogens at both sites will reduce SSIs."

The carriage of Staphylococcus aureus (S. aureus) in the nares is a marker and risk factor for SSIs, points out Dr. Wenzel, who says current data suggest the nares may also be the reservoir and risk factor for coagulase-negative staphylococci and gram-negative rod SSIs.

Dr. Wenzel believes surgical professionals should continue to study how organisms in the nares impact SSIs, and perhaps apply a topical agent to the nares before and after surgery. "It's reasonable to use a broad-spectrum nasal antiseptic preoperatively and for a week postoperatively to minimize the risk of SSIs," he says, "especially for procedures with a high consequence of infection, such as joint replacements."