THIS WEEK'S ARTICLES
Upcoming Webinars to Advise Facilities on Creating Effective Nasal Decolonization Protocols
AORN and PDI will team to offer continuing education events on June 8 and 17.
Eight out of every 10 cases of Staphylococcus aureus-related surgical site infections (SSIs) are caused by the patient's own bacteria. S. aureus is present in the nose and on the skin of nearly one third of the population, and those people are two-to-nine-times more likely to develop an SSI. It's apparent that it is critical to decolonize patients of the bacterial load in their nares and on their body as part of a larger SSI-prevention strategy.
If you'd like to learn more about how to implement a preoperative nasal decolonization protocol at your facility, two upcoming virtual forums titled "Who NOSE the New Guideline Best?" sponsored by PDI Healthcare and supported by the AORN Foundation can help. The live webinars will include a review of AORN's recently updated Preoperative Patient Skin Antisepsis Guideline and a Q&A with presenters Karen deKay, MSN, RN, CNOR, CIC, AORN's perioperative practice specialist and lead author of the Preoperative Patient Skin Antisepsis Guideline, and PDI clinical science liaisons Deva Rea, MPH, BSN, RN, CIC, and Marc-Oliver Wright, MT (ASCP), MS, CIC, FAPIC.
The goal of the webinars is for attendees to better understand the significant role nasal decolonization plays in SSI prevention, gain the knowledge to discuss recommended protocols with colleagues, and help leadership outline a strategy best-suited for an individual facility: a universal approach that decolonizes all patients, a targeted approach that screens and tests patients for S. aureus before decolonization or a blended approach.
The continuing education events will be held Tuesday, June 8 at 1 p.m. ET and Thursday, June 17 at 5 p.m. ET. Click here to register for the June 8 forum; click here to register for the June 17 forum.
Nasal Decolonization by the Numbers
Facilities embrace nasal decolonization in a variety of ways and for a variety of reasons.
Nearly half of outpatient surgical facilities surveyed by Outpatient Surgery Magazine routinely swab patients with easy-to-apply nasal decolonization products. Of those, 56% use a povidone-iodine product.
Respondents said the practice is inexpensive, ranging from 10 cents to $12 per patient. A third of the facilities that responded only decolonize patients who are getting joint procedures, while 19% use it on all patients. A smaller percentage of facilities swab patients for certain other procedures, such as spine or cardiac surgeries, while others only decolonize if patients have tested positive for methicillin-resistant or methicillin-sensitive Staphylococcus aureus.
Fifty-eight percent of those surveyed said a nurse administers the product via nasal swabbing just before surgery; 10% have patients self-administer upon admission to the facility; and 6% have patients self-administer at home.
Most respondents cited patient education as the key to successfully incorporating nasal decolonization into a facility’s larger infection prevention program. Multiple facilities suggested providers should be enthusiastic when explaining the benefits of nasal decolonization to patients, and to emphasize that the staff is taking active steps to keep them safe from potential infections. The respondents noted that hesitant patients should understand they could be asymptomatic and still have S. aureus, and that the bacteria are problematic during a surgery.
Lisa Zerby, MN, RN, CNOR, a perioperative services educator at Highline Medical Center in Burien, Wash., suggests a four-part process:
- Explain why it’s being done (to reduce nasal bacteria)
- Explain how nasal decolonization will reduce the bacteria’s seeding into the surgical incision, which could cause a surgical site infection
- Answer any and all patient questions
- Provide instructions on how the patients should apply the antiseptic or explain how the nurses will performing the swabbing.
Jeri Culbertson, RN, BSN, CIC, director of infection control and sterile processing at Black Hills Surgery Center in Rapid City, S.D., suggests direct observation of staff who are performing the swabbing to ensure it is being administered correctly, and to have conversations with staff afterward if anything needs clarification. Suggestions from others who took the survey included incorporating the swabbing into the normal pre-op process, such as immediately after IV starts. Others noted that if you decide on a targeted approach in which only some patients will receive nasal antiseptics, make sure the patient criteria are clear and easy to determine.
Evaluating the Evidence for Decolonization
Milestones in the debate about ideal protocols as bacterial migration is an ongoing and unsurprising phenomenon.
In the summer of 1980, Bryan and colleagues at Richland Memorial Hospital and the University of South Carolina reported the results of a survey of 113 of the United States' largest hospitals.1 They had asked infection control programs how they would handle a theoretical outbreak of Staphylococcus species infections in their nursery or neonatal intensive care unit. Specifically, they asked if they would screen healthcare workers for Staphylococcus nares colonization (Yes= 70.8%), and if positive would they prescribe antibiotic ointment for their staff while awaiting bacteriophage typing results (Yes=39.8%).1
Four years later, Bartzokas and colleagues at the Royal Liverpool Hospital described stopping an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) through their vascular surgery unit by regular whole body bathing with a 2% triclosan, which the authors suggested "should be more effective than treatment of selected carriage sites only."2
By 1996, John Boyce warned us to proceed with caution noting that since the 1940s more than 50 different Staphylococcus decolonization regimens had been evaluated, and that the majority were either not effective, fraught with side effects and/or lead to the development of resistance against agents used. Twenty-five years later, the debate over ideal protocols is ongoing.3
Decolonization beyond the nares
Leonard Mermel described in detail the various anatomical sites and combinations thereof where MRSA could be recovered from colonized individuals. While the nares predominated all other sites (48/53), most (40/53) patients also had the organism recovered from the groin, axilla or perineum.4 A larger study of 3,464 patients including blood donors, dental patients, healthcare workers and hospitalized patients revealed that only 32% of Staphylococcus aureus carriers were exclusively colonized in the nares.5
Even if colonization starts in the nares, it surely doesn't stay there. In a 2015 study, researchers showed that medical students touched their face on average 23 times each hour, nearly half of which involved mucous membranes, a third of which involved the nose.6 Bacterial migration across various anatomical sites is an ongoing and an unsurprising phenomenon.
Evaluating the evidence
The validity of any study's results is contingent on a solid foundation of principles described in the "Methods" section and the reader should review these carefully – fallible methods can net unreliable results. In recent years, there have been a handful of studies assessing the efficacy and duration of S. aureus decolonization. A key consideration in reviewing these studies is their method of decolonization.
Is their use of a nasal decolonizing agent in alignment with manufacturer's instructions? Did their regimen include concurrent chlorhexidine (or similar) bathing (at a minimum) or antiseptic oral rinse? For example, in a recent randomized controlled clinical trial, researchers attempted to assess the degree of antiseptic suppression of MRSA via antiseptic nares decolonization alone, despite the fact that 90% of the study participants were colonized at other anatomical locations in addition to the nares.7
If Staphylococcus aureus colonization is known to be concurrent in multiple anatomical locations and their migration between locations is aided by human behavior, then studies that assess decolonization protocols cannot be limited to the nares alone.
There are many unresolved questions regarding decolonization. Which patients? How best to prevent pathogen resistance? Do we test and treat? While the perfect protocol to achieve decolonization may still be unresolved, looking beyond the end of our nose is critical when attempting to answer these questions.
Note: This article appeared in a blog by Marc-Oliver Wright, MT(ASCP), MS, CIC, FAPIC on https://pdihc.com.
1. Bryan CS, Wilson RS, Meade P, et al: Topical antibiotic ointments for staphylococcal nasal carriers: Survey of current practices and comparison of bacitracin and vancomycin ointments. Infect Control 1980; 1:153-156.
2. Bartzokas CA, Paton JH, Gibson MF, Graham F, McLoughlin GA, Croton RS. Control and eradication of methicillin-resistant Staphylococcus aureus on a surgical unit. N Engl J Med. 1984 Nov 29;311(22):1422-5. doi: 10.1056/NEJM198411293112207. PMID: 6567778.
3. Boyce, J. (1996). Preventing Staphylococcal Infections by Eradicating Nasal Carriage of Staphylococcus aureus: Proceeding With Caution. Infection Control & Hospital Epidemiology, 17(12), 775-779. doi:10.1017/S0195941700003441
4. Mermel LA, Cartony JM, Covington P, Maxey G, Morse D. Methicillin-resistant Staphylococcus aureus colonization at different body sites: a prospective, quantitative analysis. J Clin Microbiol. 2011;49(3):1119-1121. doi:10.1128/JCM.02601-10.
5. Mertz D, Frei R, Periat N, et al. Exclusive Staphylococcus aureus Throat Carriage: At-Risk Populations. Arch Intern Med. 2009;169(2):172–178. doi:10.1001/archinternmed.2008.536
6. Kwok YL, Gralton J, McLaws ML. Face touching: a frequent habit that has implications for hand hygiene. Am J Infect Control. 2015 Feb;43(2):112-4. doi: 10.1016/j.ajic.2014.10.015. PMID: 25637115; PMCID: PMC7115329.
7. Ghaddara HA, Kumar JA, Cadnum JL, Ng-Wong YK, Donskey CJ. Efficacy of a povidone iodine preparation in reducing nasal methicillin-resistant Staphylococcus aureus in colonized patients. Am J Infect Control. 2020 Apr;48(4):456-459. doi: 10.1016/j.ajic.2019.09.014
The Dollars and Sense of Povidone-Iodine
Study projects savings of almost $75 per joint arthroplasty patient compared with a mupirocin protocol.
A study published in The Journal of Arthroplasty finds that using intranasal povidone-iodine to treat methicillin-resistant Staphylococcus aureus (MRSA) could save healthcare facilities money.
The study leveraged research that shows povidone-iodine antiseptic is equally as effective in reducing S. aureus as intranasal mupirocin is, but also potentially less expensive. It evaluated the incidence of MRSA colonization in a rural community-based population, gauged the infection rates within a mupirocin decolonization protocol and developed a cost-analysis model to compare how much treating patients costs with mupirocin versus povidone-iodine.
Researchers pored through more than four years of data points surrounding more than 5,000 total knee and hip arthroplasties performed at one institution, including how often MRSA decolonization took place, infection rates for patients who were not colonized, patients who underwent successful decolonization, and patients for whom decolonization was not successful. Using this information, the known costs of mupirocin, and infection-rate data for decolonization performed with povidone-iodine, the researchers developed a cost-comparison model.
Only 3.5% of patients tested positive for intranasal MRSA, and the SSI rate was well under one percent. All patients who suffered SSIs had initially tested negative for intranasal MRSA, so they were not part of the intranasal decolonization protocol. The model ultimately predicted that the use of povidone-iodine in place of mupirocin would achieve a potential savings of $74.72 per joint arthroplasty patient.
Three Factors Favor Povidone-Iodine Versus Mupirocin
It's less expensive, easier to administer and MRSA resistance is not an issue.
Povidone-iodine has emerged as an alternative to preoperative mupirocin-based intranasal decolonization regimens, especially for mupirocin-resistant methicillin-resistant Staphylococcus aureus (MRSA), according to a review in the journal Current Infectious Disease Reports.
The report says povidone-iodine appears to be well tolerated by patients. It also found that, in a randomized controlled trial, 5% nasal povidone-iodine solution was more effective for S. aureus decolonization during a four-hour interval than an off-the-shelf 10% povidone-iodine solution.
The researchers say 5% povidone-iodine appears to be effective in suppressing S. aureus growth in the immediate preoperative period, with the caveat that the effect isn't long-lasting, as 21% of patients tested in an orthopedic surgery study displayed positive S. aureus cultures four hours after administration and 59% did so 24 hours later.
The review highlights three big positives of povidone-iodine versus mupirocin: its lower price tag, the ability for either the patient or a nurse to administer it upon admission to the facility (unlike the more arduous multi-day, self-administered mupirocin pre-op protocol) and MRSA's growing resistance to mupirocin. "The studies to date, performed primarily in orthopedic surgery, suggest that effectiveness in SSI [surgical site infection] prevention is not significantly different between mupirocin and intranasal povidone-iodine," says the review.
The review, available in full here, suggests povidone-iodine should be used in conjunction with pre-op bathing with a chlorhexidine solution for best results.