The Importance of Keeping Noses Clean

Considering the astronomical costs associated with even a single surgical site infection (SSI), it makes sense to take every possible precaution to mitigate the risks. But one safeguard that doesn’t always get the attention it deserves is nasal decolonization. The nose is a primary reservoir for Staphylococcus aureus (S. aureus), and a lack of nasal hygiene increases the risk of SSIs in patients. There’s a wealth of research reporting the effectiveness of a consistently followed nasal decolonization program in decreasing post-op infection risk. 

This extra level of protection should be standard practice at your facility because the safest approach is universal nasal decolonization of your surgical patients. 

Before putting a nasal decolonization regimen in place, you must first select a method to use. There are currently three main choices:

• povidone-iodine (PI) nasal antiseptic
• alcohol-based nasal antiseptic 
• mupirocin antibiotic ointment

While you can make a case for any of these options, I advise against the use of mupirocin for several reasons. The most significant is the ongoing development of mupirocin-resistant bacteria, including methicillin-resistant S. aureus (MRSA). Antiseptics do not contribute to the development of antibiotic-resistant bacteria. There’s also the convenience factor — for both patients and facilities. Mupirocin isn’t pleasant for patients, and it takes five days before it reaches full efficacy. Because full effectiveness isn’t reached immediately with mupirocin the way it is for antiseptics, you run the risk of limited efficacy due to non-compliance among those who are asked to self-apply. From the facility’s perspective, a downside to mupirocin is that it’s typically used in a targeted decolonization program where patients are first screened for MRSA and then prescribed mupirocin if they test positive. This is a logistically challenging and costly process.

Plus, the screening doesn’t identify patients who are colonized with methicillin-susceptible S. aureus (MSSA), a causative pathogen for SSIs. Because of this, many facilities opt for applying nasal antiseptics in pre-op that immediately eliminate MRSA and MSSA and avoid having to manage the burden of screening and treating carriers leading up to surgery.

Nasal antiseptics are packaged in ampules or ready-to-use swab sticks and are applied directly in the nares according to the specific product’s instruction for use. PI is applied to the nares before surgery with four swab sticks. Alcohol-based nasal antiseptics are applied preoperatively with cotton-tipped ampules. Although I haven’t heard of any facilities using PI products postoperatively, some hospitals that use alcohol-based antiseptics have extended the application to several days post-op following both inpatient and outpatient procedures.

The nasal decolonization method you choose should be supported by clear, compelling data from peer-reviewed studies. Clinical evidence demonstrates the efficacy of alcohol-based products (osmag.net/sbwna4) and PI antiseptics (osmag.net/dyx5xb). Your infection preventionists and perioperative managers should lead the charge in introducing evidence-based products. But it’s critical to get the frontline staff engaged in the process, as well. Keep in mind that not all of the nasal decolonizing agents on the market are backed by peer-reviewed clinical studies. There are unproven products out there, so making the selection of your facility’s method contingent upon peer-reviewed research supporting both its safety and efficacy is a good minimum requirement.

Once the efficacy has been established, a formal product evaluation is the next logical step. Start small — perhaps with patients scheduled for one type of procedure. This will help work out any challenges in your facility’s unique workflow. You should also gauge staff and patient satisfaction with the product and application process.

The latter is key. The closer to the application you are when gathering feedback, the more accurate the patients’ responses are likely to be. This doesn’t need to be a big, formal survey. It can be done when you’re explaining to patients how the nasal decolonization product will be applied and why it’s being done. After application, simply ask patients for their immediate feedback: How did that feel? Is it uncomfortable in any way? Is the scent pleasant? What are your initial reactions to this product and process?

The nasal decolonization product you choose should be supported by clear, compelling data from peer-reviewed studies.
— Sue Barnes, RN, BSN, CIC, FAPIC

You can apply this informal line of questioning to staff, too. While trialing products, ask your team what they like or dislike about the antiseptic, whether it’s a simple process or something that’s likely to impact workflow. On the vendor side, you want to work with a company that offers all the support needed to get a nasal decolonization program off the ground. This would include staff training (initial and ongoing) and compliance tracking. They should also be able to assist with development of a business case proposal if one is needed to sell the benefits of the program to your facility’s leaders or owners.

I’ve been a proponent of nasal sanitizing or decolonization for decades, but it wasn’t until the last few years that I saw firsthand just how effective this simple tactic could be. Before the pandemic, I’d wind up sick every time I set foot on an airplane. Without fail, two to three days hours after the flight, I’d develop a cough, a sore throat, congestion or fever. Then, about five years ago, I began using an alcohol-based nasal antiseptic prior flying, and I didn’t experience a single respiratory-related infection after traveling. 

When this pandemic ends, I won’t fly again without my nasal antiseptic. I see it as an extra layer of protection — like an internal mask or hand hygiene for the nose — that can make the difference between an enjoyable, relaxing vacation or a miserable experience. Of course, the stakes are much higher for surgical patients. With the ample evidence that’s out there supporting the efficacy of nasal decolonization in reducing bacterial infections, you owe it to your patients to make this infection control practice a priority. OSM