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Archive October 2020 XXI, No. 10

Understanding Your Nasal Decolonization Choices

Treating the nares is a vital component of a multifaceted SSI prevention approach.

Edward Septimus

Edward Septimus, MD


JUST A DAB Using povidone-iodine as a nasal decolonization agent allows you to eliminate the several days of at-home patient compliance associated with mupirocin.

Surgical site infections (SSIs) are expensive adverse events for surgical facilities, especially with procedures like total joint replacements and complex spine cases. While SSI risk is very low, complications are devastating for everyone involved. An implant infection is quite significant because typically the implant must be removed, so it becomes a costly multiple-stage procedure and the patient may not emerge with a good result. It's important, then, to realize that the simple administration of nasal decolonization before surgery is an extremely inexpensive preventative intervention. If the patient is colonized with S. aureus, the nares are far and away the most common site.

The problem right now is a lack of consensus on what the most effective and reliable nasal decolonization regimen actually is. Four major buckets of therapies enjoy at least some peer-reviewed data to suggest potential efficacy and use. Mupirocin is the traditional treatment. Nasal povidone-iodine (PI) is a distant second in terms of number of publications, followed by nasal alcohol-based preps and photodynamic therapy. Given the limited peer-reviewed information on the true efficacy of the mupirocin alternatives, it's too early to say which is the best. Here, we'll take a closer look at all four in the hopes of better informing your facility's nasal decolonization regimen.

Remember, as an outpatient facility, you possess an advantage: procedures are elective. That means you have the ability to plan ahead for each patient's nasal decolonization — a process that can take several days to complete before surgery.

  • Mupirocin. For procedures that involve high risk for S. aureus infections — primarily when implants are inserted ­— the classic treatment with the highest volume of supporting literature has been to swab the nares preoperatively for MRSA and MSSA (which has received less attention recently than MRSA, but is making an alarming comeback). If either organism is present in the nares, a clinician or the patient applies mupirocin to the anterior nares two times a day for five days, in conjunction with daily chlorhexidine bathing, ending the day before the procedure.
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