Answering your questions about resistance rates, compliance, and antiseptic nares decolonization.
The administration of a nasal decolonization agent before surgery is an inexpensive preventative intervention for surgical site infections (SSIs). The nares are a common site for colonization with Staphylococcus aureus. Outpatient facilities have the opportunity to plan ahead with their patients for the most reliable and effective nasal decolonization regimen. Marc-Oliver Wright, MT (ASCP), MS, CIC, FAPIC, Clinical Science Liaison, Central Region, PDI, answers the most common question about pre-operative nasal decolonization.
Question: What’s wrong with what I am doing now? My practice group already performs nasal decolonization pre-operatively. We give the patient a prescription for mupirocin ointment to be applied to the nares twice daily for 5 days prior to surgery. We do this for all of our patients and have done so for the last 5 years. What is wrong with that?
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Marc-Oliver Wright responds: Congratulations! By decolonizing pre-operatively, your practice has already adopted recommended best practices for preventing surgical site infections in colonized patients. With a reported 85% DNA match between Staphylococcus aureus in the nares and Staphylococcus aureus wound infections and an associated 9-fold higher risk of infection, decolonization is certainly the way to go. However, with mupirocin there are a couple of things you might want to consider. Here are a few important ones to think about:
Did They Do It? Decolonization with mupirocin requires the patient to self-apply an ointment to their anterior nares a couple of times a day for 5 days leading up to their procedure. Activities of daily living (ADLs) including self-care activities such as getting dressed, bathing, homemaking and leisure are going to vary from patient to patient. The patient is going to have to remember and be able to apply the ointment as prescribed. They also need to be able to afford the out-of-pocket expense of the prescription. In one study, 54% of surveyed respondents said it was too expensive and 19% of the respondents refused to use mupirocin (Bosco et al)1 Even asking the patient on the day of surgery if they used mupirocin is no guarantee that they did. Just ask any dental hygienist how often the patient’s response to a question about flossing matches up with what they actually see!
Antibiotics → Antibiotic Resistance Mupirocin was released to the market in 1985 and by 1987, resistance among S. aureus strains was already reported. In 2019, resistance rates for MRSA were reported as high as 12.6% in California patients2 and rates of resistance grew with increased use. In fact, when one hospital used mupirocin to decolonize patients, resistance increased from 2.7% to 65% in four short years.3 Many screening programs do not check for mupirocin resistance and if the isolate is resistant, decolonization will fail.
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Mupirocin Compliance Does Not Guarantee Success If patients are instructed and encouraged to complete mupirocin decolonization pre-operatively, and even if all the isolates are susceptible to the antibiotic, it does not mean that the treatment works. In 2020, researchers reported on their experience trying to decolonize cardiac surgery patients pre-operatively.4 Notably, they missed 32% of their patients because the procedure was emergent, and a single dose of mupirocin does not prevent SSIs. They screened 286 patients, 73 of whom were positive for susceptible strains and prescribed a decolonization regimen. On the day of surgery, they screened all of the patients again and of those 73 patients, 19 (26%) were still positive, 10% of whom developed mediastinitis surgical site infections. Additionally, patients who tested negative the first time tested positive on the day of surgery as well.
Summary Antibiotics for nares decolonization require sequential days of application for patients, which may be difficult for some patients. Some patients find the cost of mupirocin financially burdensome. Antibiotics do not work when the isolates are resistant and increased use increases resistance rates. Even when the isolates are susceptible, the regimen can fail more than a quarter of the time. PDI’s Profend® swabs provide single pre-operative applications for antiseptic nares decolonization, performed by the clinician, providing assurance of compliance and no demonstrable antibiotic resistance.
Note: For more information, go to https://pdihc.com/defendwithprofend/
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