Treating S. aureus
Despite evidence based infection prevention practices, surgical site infection remains a frequent and often preventable clinical problem associated with increased mortality and healthcare costs.1 S. aureus is the leading cause of surgical site infections and nearly half of these infections are caused by methicillin-resistant Staphylococcus aureus (MRSA).2 Addressing surgical site infection modifiable risk factors such as bacterial colonization with S. aureus is an essential component of surgical site infection prevention and skin preparation is a routine aspect of surgical care. Nasal colonization is also a well documented risk factor for infection.3,4 However, addressing the surgical site infection risk factor of nasal colonization with S. aureus may sometimes be overlooked.
Treating S. aureus colonization on the skin and in the nares has demonstrated to improve outcomes in surgical patients. In fact, several studies have shown the benefit of this approach.8,9 This strategy is also discussed and proposed in evidence based guidelines and recommended practices,1, 5-7 particularly for high risk procedures.
The treatment of choice to address nasal colonization with S. aureus has been a topical antibiotic dosing regimen (mupirocin calcium, 2%) applied to the nares. This approach has been utilized for decades14 and its effect on surgical site infection outcomes has been demonstrated in two systematic reviews.10,11 Other randomized controlled studies have failed to demonstrate a significant reduction in surgical site infections.12,13 Challenges associated with this approach may pose barriers to effective risk reduction.
There is increasing evidence of resistance and treatment failure associated with the use of mupirocin.15, 16 Due to antibiotic resistance, mupirocin is not recommended without active surveillance and identification of S. aureus carriers.1 There is no standardized protocol for screening specific patient populations. In addition, screening will not identify all carriers, which may leave some patients at risk. In fact, MRSA detection from nasal swabs by culture is only 48-66% sensitive 17,18 and by rapid PCR test 62% sensitive.17 Therefore, screen and treat protocols may be ineffective for S. aureus carriers who are not identified.
Treatment failure can occur due to an incomplete dosing regimen or patient noncompliance.20 The recommended dosing for mupirocin is twice daily for five days.19 This can be difficult to complete prior to certain non-elective procedures. Decolonization efficacy is dose dependent12 and outpatient compliance rates of 62-86% to a preoperative intranasal mupirocin dosing regimen have been reported.20, 21 Treatment failure, mupirocin resistance and challenges associated with the screen and treat decolonization approach led to the need for an alternative solution to help reduce the risk of S. aureus surgical site infection due to nasal colonization.
Addressing the Challenges
To address these challenges, a novel antisepsis strategy for reducing bacterial colonization in the nose has been developed. The evidence is mounting for this safe and effective alternate approach to help reduce the risk of surgical site infection. 3M™ Skin and Nasal Antiseptic (povidone-iodine solution 5% w/w (0.5% available iodine)USP) Patient Preoperative Skin Preparation was specially formulated to address the rising concern of surgical site infections associated with bacteria in the nares and to address the challenges associated with traditional decolonization strategies. The proprietary formula demonstrates broad spectrum bactericidal activity22,23 and no resistance has been shown (in vitro*).24 Because it is an antiseptic and not an antibiotic, potentially fewer concerns for long-term resistance may be advantageous for standardization of the preoperative process and treating all patients. This horizontal treatment approach to reducing nasal colonization as part of a comprehensive preoperative protocol has been effective in helping to reduce the risk of surgical site infections in several quasi-experimental studies 25-28 and may lead to cost savings.25,27
*Clinical significance of in vitro data is unknown
A simple, one-time directly observed preoperative application ensures patient compliance.21 It may also be an effective “just in time” therapy when the duration of a decolonization regimen is undesirable, impractical or impossible to complete. The use of 3M™ Skin and Nasal Antiseptic has consistently and repeatedly been effective in helping to reduce the risk of surgical site infection when used as part of a multifaceted infection prevention approach.21, 25-30 It has helped to reduce S. aureus infection rates below those in studies in which mupirocin was used as the treatment of choice.21,28 Furthermore, in a prospective randomized trial versus mupirocin in an orthopedic population, there was a significant reduction of deep S. aureus infections in the Skin and Nasal Antiseptic group. This group was also associated with significantly fewer adverse events.21
This approach provides a simple, standardized solution to address the risk factor of nasal colonization with S. aureus and ameliorates many of the challenges associated with the conventional approach. It is an innovative, safe and effective strategy to help reduce the risk of surgical site infections.