Making the Case for Nasal Decolonization


Universal application of this proven protocol is a powerful weapon in the fight against surgical site infections.

If you’re one of the many facilities leaders wrestling with trying to decide which patients should undergo nasal decolonization before their procedures, you might be asking the wrong question. Instead of focusing your time and resources on pinpointing the most appropriate patient demographic, perhaps focus on convincing your staff to implement a standardized nasal decolonization protocol.

“Around 30% of the general patient population walk into your facility colonized with Staphylococcus aureus (S. aureus) in their nares,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, a clinical instructor in the division of infectious diseases at University of North Carolina’s School of Medicine in Chapel Hill. “When you consider that 70% to 80% of surgical site infections (SSIs) are caused by strains of S. aureus in patients’ own noses, universal nasal decolonization is a worthwhile endeavor.”

In other words, the fundamental question surrounding the practice given the overwhelming data on its effectiveness really should be: Why wouldn’t you decolonize all your patients?

Convenient options

METHOD NURSING Providers should try nasal decolonization products on themselves before deciding which one patients would prefer.  |  Pamela Bevelhymer

Infection control experts beleive nasal decolonization should be a standard part of a robust, comprehensive SSI prevention bundle — and for good reason. “The nose is pretty well known to be colonized with MRSA,” says Peter B. Graves, BSN, RN, CNOR, an independent consultant, speaker and writer who focuses on infection-prevention and evidence-based best practices in the OR. 

While most facilities tend to start small with their decolonization efforts — with a certain department or patient demographic serving as the pilot group — it generally isn’t the most effective tact to take. “Many surgical leaders will say, ‘I have so much going on, I can’t even think about launching a facility-wide program. Maybe, I’ll try it in one unit first,’” says Ms. Hoffmann.

She says facilities that want to begin by decolonizing a small group of patients before expanding the program are missing out on a tremendous opportunity to prevent infections and, subsequently, readmissions. “If you’re not decolonizing the 30% of the patient population that comes in with S. aureus, they’ll undergo surgery and have eight times the likelihood of being readmitted for a related infection,” she says.

If the research clearly indicates that nasal decolonization can reduce the likelihood of infection, why even bother with a piecemeal approach to the protocol in the first place?

When it comes to the products available for nasal decolonization, you’re essentially choosing from three main categories: a povidone-iodine swab, an alcohol-based antiseptic and the topical antibiotic mupirocin. While there are a variety of factors — cost, clinician preference, patient acceptance — that will undoubtedly impact your facility’s decision, Mr. Graves and Ms. Hoffmann can’t stress enough the importance of the convenience factor, from both the staff and clinician standpoint.

Ms. Hoffmann, who says having an infection preventionist on the product evaluation committee is a must, notes that povidone-iodine, mupirocin and alcohol-based nasal antiseptics all have proven capabilities to decrease S. aureus colonization in the nares, so what you really need to consider is whether your end-users like using the product. “One of the keys of effectiveness is satisfaction among patients and healthcare providers,” she says.

Will members of your staff use the product on every patient, or will they push back against incorporating another step into their preoperative care routines? How long does the treatment take to perform? Is it pleasant for patients? “If patients don’t like the product, providers aren’t going to want to use it,” says Ms. Hoffman.

She points to treatments with mupirocin as an example of how the lack of convenience in a nasal decolonization protocol can ultimately derail the entire effort. “Mupirocin is applied to each nostril twice a day for five days before surgery,” she says. “It relies on patients to be compliant with the regimen, and we know that’s a serious concern.” Universal use also increases concerns of patients developing mupirocin resistance, a separate but serious issue. On the other hand, povidone-iodine and alcohol-based antiseptics are effective immediately and can be applied to patients in pre-op on the day of surgery.

Like Ms. Hoffman, Mr. Graves believes patient satisfaction is paramount when it comes to the use of a nasal colonization product. What’s more, he believes the only surefire way to find out whether your patients will tolerate these products is to try them out on yourself. “Years ago, I attended a lecture where a busy bariatric surgeon said he tried all available nasal decolonization products,” he says. “I think this is a sage approach, and I think we owe it to our patients.”

As Mr. Graves points out, one of two things is going to happen. “You’re going to find you don’t prefer it for whatever reason or you’re going to find it appealing,” he says. “Historically, if you like something you’re more likely to continue using it, and that’s important because nasal decolonization isn’t a single episode or a one-off thing.”

In most cases, finding the right product will be a straightforward endeavor that’s decided during the evaluation stage. But what if the decision isn’t so cut and dried? Do your due diligence and be sure to dig a little deeper into each option. “I always encourage decisionmakers to go to the product manufacturers’ websites and read all of their studies  — not the marketing materials  — but the actual clinical research,” says Mr. Graves.

You also want to select a vendor you can trust to be responsive and hands-on when it comes to training your staff, says Ms. Hoffmann. “There are so many demands on infection preventionists right now, so you really have to find a company that will do data analysis with education and ongoing training,” she says. “You have to look into what kind of company support you’re going to get from the product you choose.”


Reducing the counts

EXPERT OPINION Facilities should always have an infection preventionist involved in evaluating decolonization agents.

Regardless of which type of nasal decolonization product or protocol you employ, develop a standardized method to apply it consistently in order to effectively reduce each patient’s risk of suffering an SSI. “You’re never going to render the nose sterile, but you can reduce the microbial counts — and that’s critical,” says Mr. Graves.

Ultimately, nasal decolonization should be viewed as the continuation of a comprehensive infection prevention bundle — not a protocol that occurs in a vacuum. “You need to make sure you’re able to decolonize the patient, not just the nose,” says Mr. Graves.

These efforts should include preoperative bathing, proper hand hygiene and all other standard SSI-prevention practices. “Nasal decolonization is one aspect of the entire process of rendering the patient as clean as possible before surgery,” says Mr. Graves. 

S. aureus remains the top cause of healthcare-acquired infections and SSIs, or as Ms. Hoffmann puts it, “enemy number one.” Nasal decolonization eliminates the reservoir for S. aureus in patients’ nares, making it a battle-tested weapon you should use to fight that enemy. OSM

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