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Home E-Weekly October 1, 2020

Sniffing Out COVID-19 in the Nares

Published: October 1, 2020

Nasal decolonization protocols take on added importance during the pandemic.

Pre-op nasal decolonization has risen to prominence over the last decade largely due to the risk of the presence of Methicillin-resistant Staphylococcus aureus (MRSA). Now COVID-19 has placed increased focus on treating the nares of every patient before surgery.

Randy Loftus, MD, a professor of anesthesiology at the University of Iowa in Iowa City, views nasal decolonization as a vital component of a multifaceted approach to prevent transmission of COVID-19 in surgical settings. The current reality, he says, is that every patient should be functionally treated as a carrier of COVID-19, both due to the virus' high asymptomatic rate and continuing issues with testing effectiveness. The nares are a transient base for the virus. The viral load is initially higher in the nasal or oral pharynx before moving to the lower respiratory tract after seven days of infection, according to Dr. Loftus, who with colleagues has studied the epidemiology of disease transmission in the perioperative space for 14 years.

"The modeling we've done on disease transmission has been largely about the behavior of clinicians — it relates to compliance with basic preventative measures," he explains. "Nasal decolonization is currently applied to a subset of patients — primarily those undergoing joint replacements — but the evidence for surgical site infection prevention suggests its use should be more widespread."

The good news, of course, is that COVID-19 is an enveloped virus that's inactivated with brief exposure to agents like isopropyl alcohol, chlorhexidine and low concentrations of povidone iodine, which are typically used in prepping the nares and skin for surgery. "Timely use of these agents, based on our knowledge of the epidemiology of transmission of other infectious organisms like S. aureus, creates an evidence-based defense strategy against COVID-19," says Dr. Loftus. He adds that decolonizing the nares isn't just for the protection of OR staff or the patient undergoing surgery. Because of the ease with which the virus can contaminate and transmit within a closed environment, it's also for the good of patients who will subsequently populate ORs.

"COVID-19 should serve as a wake-up call," says Dr. Loftus. "We need to pay attention to limiting transmission by universally applying evidence-based measures, including nasal decolonization. It's through that approach that we'll control the spread of bacteria and viruses, reduce infections and dramatically improve patient outcomes.

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