The Keys to Nasal Decolonization Implementation

Explaining the ‘why’ behind this intrusive but simple infection prevention intervention gets patients happily complying.

The practice of nasal decolonization — the application of a topical bactericidal agent in the nares to help prevent infection — should seem familiar to patients who had been regularly swabbing their nostrils to test for COVID-19 at home.

But are they resistant to the proposition of nasal decolonization before surgery? If so, why? And how can clinicians help them overcome their concerns? We spoke with three industry experts about the importance of implementing this proven tactic preoperatively (and possibly postoperatively), how to address patient resistance, and best practices in decolonization.

Easy and low-risk intervention

The Association of periOperative Registered Nurses (AORN) recently updated its guideline and recommends an interdisciplinary team be formed to determine the need to implement a preoperative decolonization program within the organization using a risk-based approach that includes local epidemiology, procedure-specific risk factors and patient risk factors when determining which approach (targeted, universal, blended) will be implemented.

“If you’re talking about ambulatory surgery, I would say that [nasal decolonization] should be a universal practice, and that’s because the evidence in the literature shows us that nasal decolonization works if the protocols are followed,” says Jennifer Bender, MPH, BSN, RN, CIC, a clinical science liaison with PDI Health*. She cites methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) as the standard targets of the procedure, as both can cause serious surgical site infections (SSIs).

Nasal decolonization, she says, is easy. “It’s a really low-risk intervention,” says Ms. Bender. “There aren’t a lot of side effects that can happen from treating with any of the agents, but studies show that about one in three people carry Staph aureus in their nose. Why wouldn’t you prevent those infections if you could?”

What causes these infections? Benjamin Galvan, MLS(ASCP), CIC, CPH, director, infection prevention with HCA Florida South Tampa Hospital, cites self-inoculation as a major culprit. “You can pick your nose and not wash your hands,” he says. “You can sneeze — really, anything that involves touching the nares. We don’t realize how many times we touch our noses every single day. Most of the time, we probably don’t use hand sanitizer after we do it. And the problem can occur because then you may be not only contaminating your hands, but you may be contaminating your environment with that bacteria. That opens the opportunity for additional risk of patients infecting themselves in their surgical wounds.”

Questions about the process

While opinions on the efficacy of nasal decolonization as a universal practice are mixed, Ms. Bender feels it has great value. “Nasal decolonization just makes sense when you look at the percentage of healthy adults that carry MRSA in their nares,” she says. When providers evaluate the various options for nasal decolonization, providers should consider a number of factors. “Are you writing a script that the person has to fill, or is it something you can stock and have your staff do easily and quickly?” says Ms. Bender. “If you’re choosing a product, is there data that shows the product is effective, and who were those data collected by? Is it something the manufacturer produced, or is it an independent third party? Is it peer-reviewed?”

While a proponent of nasal decolonization, Mr. Galvan feels many factors should be considered before performing it. “It really depends on the setting and your patient population,” he says. “What I see for decolonization is a focus more on high-risk patient populations for certain types of surgeries that are at greater risk of self-inoculation, like heart surgeries and orthopedic surgeries — cases that are at high risk of infection and of severe complications as a result. You need to weigh the risks and the costs of doing it with the types of procedures you’re doing in the patient population you’re serving.”

Povidone-iodine versus alcohol-based products

BEEN THERE, DONE THAT Because most patients have experienced COVID testing, the idea of a swab in their nostril isn’t quite as unexpected or scary as it might have once been.

A variety of products can be used for nasal decolonization. “Certain products have an antibiotic that kills the bacteria in the nares,” says Mr. Galvan. Mupirocin requires five days of treatment to be fully effective. “Other products like povidone-iodine are more of an ‘immediate kill,’ but you need to do it at a certain interval to keep the amount of bacteria low in the nares, daily or twice daily — it depends on the product,” he says. “It doesn’t have a long-term effect. The antibiotic treatment would have longer-term effect until the patient gets recolonized for whatever reason.”

At his facility, Mr. Galvan notes that pairing nasal decolonization with chlorhexidine gluconate (CHG) makes good sense because CHG helps to reduce the bacteria on the skin in general.

Mupirocin has been used for many years, but requires a prescription and a high degree of patient compliance at home. Povidone-iodine and alcohol-based agents have entered the scene more recently and have gained adherents due to their relative ease of application compared with mupirocin. Povidone-iodine is recommended by the CDC, the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC). AORN endorses both povidone-iodine and alcohol.

In a recently released compendium, SHEA recommended nasal decolonization as an “additional approach” rather than an essential practice.

“The essential practices of the SHEA Compendium are really what you consider the basics of infection prevention — surveillance, a monitoring program, an annual risk assessment, cleaning and disinfection, hand hygiene education,” says Ms. Bender. “Everything you would do to prevent MRSA — active surveillance, testing, screening for colonization — is classified as an ‘additional approach.’ The quality of evidence varies when you look at those different interventions, but when you look at nasal decolonization under that additional approaches column, the qualities of evidence are all moderate to high; there are none that are low.”

“You have to look at the different products, what’s going to work for you and what people will do, and you have to work with your value analysis committee,” adds Marie Moss, MPH, RN, BSN, CIC, CPHQ, of the APIC Communications Committee. “It should be a multidisciplinary effort.”

The benefits of postoperative nasal decolonization

One point of contention in the discussion of nasal decolonization is whether it should be continued for patients after surgery.

“There’s a growing — I want to call it a ‘body of opinion,’ because there’s not really the literature yet — that [practitioners] should [continue nasal decolonization] until the wound has healed,” says Ms. Bender. “Depending on what you use, the nares can become recolonized quickly. As long as that wound is open and being exposed to any kind of fingers or dressing changes, you could technically still get an infection in that post-surgical period. I’d like to see decolonization continue until that wound is healed.”

“I think more people can recognize the benefit of doing it [post-surgery],” says Mr. Galvan. “It’s just making sure that you’re doing it correctly. You also need to be able to track it. Do you have a high infection rate? What types of infections are you seeing? Are you surveilling for infections in your surgical populations? Those details all play into the determination of whether decolonization would be appropriate for a particular setting.”

Overcoming patient resistance

Ms. Moss feels that patients’ experience with COVID-19 may help when they are met with the need to undergo nasal decolonization.

“It’s not difficult to teach it because it’s very similar to doing a COVID test,” she says. “You’re taking a swab stick and going clockwise for five rotations in each naris. In this case, it would be more than one swab. But it’s the kind of thing they’re familiar with from doing home COVID tests, so it’s not a big mountain to climb for patients to understand how to do it.”

Ms. Bender, however, speculates that patient discomfort with COVID-19 tests may make them apprehensive about nasal decolonization. “The COVID swab goes way up [into the nares],” she says. “When you’re doing a povidone-iodine swab, however, it’s right around the rim of the naris. It’s much more comfortable than a COVID test. It might take some explaining from the clinician to say, ‘This isn’t that; this is much more comfortable.’ They’re both pain-free, but decolonization is a simpler process.” Fear of the unknown or reluctance about undergoing yet another procedure before or after surgery may also contribute to patients’ reticence about nasal decolonization.

Mr. Galvan feels education is the key to overcoming such concerns. “If patients are taught or educated on the ‘why’ behind it, decolonization is a good way for them to feel more comfortable about getting surgery and feel safer,” he says. “If explained correctly, they can understand that the surgery center is helping reduce their risk of infection.”

Ms. Moss echoes these sentiments. “A lot of people still don’t want to get a COVID vaccine,” she says. “People aren’t as willing to say ‘yes’ to things, so patient education is paramount. It should be something that they should expect to have happen to them or that they do at home in the morning. It doesn’t have to be done in the OR or preoperatively on the day of surgery. When the patient is in for their presurgical evaluation, say, ‘I’d like you to do this. Here’s an instruction sheet. This is why we’re doing it. It’s important for you to prevent infection. It’s not harmful. You’ll have a tickle.’” OSM

*Editor’s Note: Jennifer Bender has disclosed her role with PDI Health, and her commentary is based solely on her expertise in the field of infection control.