Answers for Those Pressing Nasal Decolonization Questions

Universal or targeted? Which agent to use? Recent studies can help.

Should facilities screen all patients for Staphylococcus aureus, or just some? Should they decolonize all patients without screening first? Do they need a nasal decolonization program at all? If they do, which agent should they use — mupirocin, povidone-iodine, alcohol-based antiseptics, or even photodynamic therapy?

ASCs couldn’t pick a better time than right now to review their decolonization processes, as multiple studies have been published over the last 12 months that can help facilities decide how to screen and/or treat patients and which agents might be most clinically and financially effective.

The most common approach is to screen high-risk patients for S. aureus and treat those who test positively. The Association of periOperative Registered Nurses (AORN), however, advocates for a universal nasal decolonization approach for all surgical patients, no matter the setting.

“I agree with AORN,” says Karen Hoffman, RN, MS, CIC, FSHEA, FAPIC, clinical instructor at the University of North Carolina School of Medicine in Chapel Hill and a past president of the Association for Professionals in Infection Control and Epidemiology (APIC). “Every patient is at risk. Obviously, some are more at risk than others, but universal nasal decolonization has been demonstrated in a number of studies to provide both greater overall infection reduction and, as a result, lower costs due to the prevention of SSIs.”

Consider that about 30% of the population are methicillin-resistant S. aureus (MRSA) carriers, and it’s almost certainly higher among healthcare professionals who are exposed to bacteria day in, day out. People don’t know they have it. The nares are the main reservoirs for S. aureus and other pathogens that lead to roughly 80% of healthcare associated infections (HAIs) and 80% of bacteria found on skin expelled from the nose.

Marc-Oliver Wright, MT (ASCP), MS, CIC, FAPIC, a clinical science liaison for PDI and former infection preventionist and infection prevention quality health system director, understands the differences between processes in a hospital-based setting versus those in an ASC. In many cases, there are significant differences between patients who undergo surgical procedures in an ambulatory setting and those who receive care as an inpatient. Mr. Wright says there’s no denying that a healthy, 49-year-old female knee-replacement patient with a healthy BMI who runs marathons and has no comorbidities is markedly different from a diabetic patient in their mid-60s with a BMI in the 40s who has multiple comorbidities and has been a lifelong smoker.

Still, both patients have one risk in common: They both likely have colonization of bacteria in their nose. “Colonization is ubiquitous,” says Mr. Wright. “As highly individualized as ASC patients — or any patients — may be, no one has germ-free nares.”

What’s more, the vast amount of research on nasal decolonization that is available focuses only on S. aureus. “There are a few reasons for that,” says Mr. Wright. “For one, it’s one of the most common organisms found in the nares — it’s present in roughly 30% to 33% of adults at any point in time. When it migrates from colonization to cause an infection, it’s nasty, and it’s something you want to avoid at all costs.”

HOW TO Use best practices to swab patients’ nares to get optimal results.

As awful as S. aureus infections can be, there are other organisms living rent-free in your patients’ nares, and Mr. Wright believes providers should treat these potentially infection-causing organisms in the nose the same way they do for the skin — with a universal approach to nasal decolonization. “I would be very surprised to go into an orthopedic ASC and not see either bottles of chlorhexidine gluconate (CHG) soap or packets of CHG wipes,” he says. “Why not the nose? As a provider, you can decolonize more sufficiently by suppressing the organisms in the nares with a universal approach, just like you did on their skin with a CHG treatment.”

While Mr. Wright understands there are reasons a universal approach for ambulatory patients wouldn’t work with say, mupirocin, he points out that facilities do have options that should translate naturally into their workflows. “Nasal antiseptics can be applied by the patient or the clinician, and they more or less kill everything,” he says. “You apply one hour prior to surgery, and you’ve effectively suppressed the organisms — not just S. aureus — in the nares during the highest risk period.”

Mr. Wright offers a tip to make decolonization seamlessly fit into already well-established protocols: Put your nasal decolonization kit right next to your CHG cloths. “That way, when you explain to the patient what the next step is, it’s all part of the same conversation that goes something like, ‘We are going to use these CHG cloths to get rid of the organisms on your skin, and by the way, we’re also going to put these small Q-tips with a nasal antiseptic inside your nares to do the exact same thing and ultimately reduce your risk for anything less than a full, speedy and infection-free recovery.”

Here’s a rundown of what recent studies say:

• A cohort study published in JAMA Network examined the cost-effectiveness of universal vs. targeted CHG bathing and nasal decolonization in preventing hospital-onset bactermia and fungemia (HOB) among surgical and nonsurgical hospital patients.

Targeted nasal decolonization was administered only to patients with medical devices such as central venous catheters, midline catheters and lumbar drains. Researchers factored in upstream costs for bathing and nasal decolonization, as well as downstream costs associated with HOB. “Targeted bathing was cost-effective under a broad range of scenarios for both the hospital system and payor decision-makers,” says the study. “Universal decolonization was cost-effective in some scenarios, such as in specific units where many patients have medical devices or if it were difficult to implement a targeted approach.”

Is povidone-iodine superior to mupirocin?

Mupirocin is proven to reduce the risk of hospitalizations for bloodstream infections.

“ASCs couldn’t pick a better time than right now to review their decolonization processes.”

But the ongoing emergence of mupirocin resistance is spurring the use of povidone-iodine, which boasts a broad range of antimicrobial activity and no noted resistance.

Don’t sleep on alcohol-based antiseptics!

Last but not least, a meta-analysis by Ms. Hoffman and her colleagues found alcohol-based antiseptics (ABAs) are viable nasal decolonization alternatives to mupirocin and iodophors such as povidone-iodine in reducing all-cause SSIs.

They saw statistically significant positive effects in more than 16,000 patients who received mupirocin, iodophors or ABAs. Ms. Hoffman noticed that hospitals had been reporting excellent results using ABAs for prevention of SSIs, but the lack of a multicenter study was preventing wider adoption.

“Studies show that ABAs can achieve a 99.99% reduction of all gram-positive, gram-negative and Candida species in fewer than 60 seconds,” she says. “There are several viable antiseptic alternatives to antibiotics and antibiotic stewardship suggests we should choose that path.”

The meta-analysis, published in the October 2024 edition of the American Journal of Infection Control, reviewed seven SSI-prevention studies and showed that alcohol-based nasal antiseptics were effective when used as a replacement for both mupirocin and iodophor nasal decolonization.

All seven studies included the continued use of CHG wipes for pre-op bathing during the study.

The hospital patients studied included those receiving surgeries. Ms. Hoffman, a consultant for ABA manufacturer Global Life Technologies, stresses that other nasal decolonization agents are reasonable choices for the wide range of surgical candidates and procedures handled by ASCs.

She remains steadfast about universal decolonization protocols. “All surgical patients should be decolonized regardless of the agent used,” she says. OSM