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Introduction ⬇

Patients who are colonized with a pathogen carry the pathogen on a body surface, such as the skin, mouth, nose, intestines, or airway, without actually having the disease. Infection occurs when the pathogen invades the body, causing the disease. The process of decolonization can prevent the pathogen from causing infection. It’s believed that patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) are a major source of MRSA being introduced into health care facilities. 1

Research shows that nasal carriage increases the risk of bacteremia and other infections caused by the pathogen, including surgical site infections. 1 Moreover, it’s the most common indication for total knee arthroplasty revision and the third most common indication in total hip arthroplasty revision. 2 Nasal decolonization strategies have proven effective in reducing not only S. aureus colonization but also S. aureus surgical site infections. 3 Guidelines recommend nasal decolonization for patients undergoing high-risk surgeries, including orthopedic surgery, cardiothoracic surgery, and neurosurgery. 4,5 Universal decolonization in intensive care units has also been effective in reducing bloodstream infections. 6

Mupirocin, administered to the nares twice a day for 5 days preoperatively, has become the gold standard topical antibacterial agent for nasal decolonization. It’s effective against staphylococci and many gram-negative bacteria. 3 Povidone-iodine and alcohol can also be used. 7 Povidone-iodine has a broad spectrum of activity against many gram-positive organisms, including methicillin-susceptible S. aureus, MRSA, and many gram-negative organisms. 8 It has some advantages over mupirocin in that it’s bactericidal within 10 to 20 seconds, and there’s no evidence that bacteria can develop resistance to it; however, mupirocin has a more persistent bactericidal effect than povidone-iodine. 3 Alcohol has activity against a wide range of gram-positive and gram-negative bacteria, including such resistant organisms as MRSA. It’s rapidly bactericidal but has almost no residual bactericidal effects after application.

Equipment ⬆ ⬇

Equipment

Prescribed decolonization agent (mupirocin 2% ointment, povidone-iodine 10% swab stick, alcohol 62%) • gloves • tissues • Optional: gown, cotton-tipped swab.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order.
  • Review the patient’s medical record for history of colonization with a resistant organism and allergies to the prescribed decolonization agent or its ingredients.
  • Gather the necessary equipment and supplies.
  • Perform hand hygiene. 9,10,11,12,13,14
  • Put on gloves and, as needed, other personal protective equipment to comply with standard precautions.15,16,17
  • Confirm the patient’s identity using at least two patient identifiers. 18
  • Provide privacy. 19,20,21,22
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.23
  • Ask the patient to tilt the head back to gain access to the nares.
  • Clean the inside of both nostrils with a tissue, including the inside tips of the nostrils. Discard the tissue in an appropriate receptacle. 24,25

For Decolonization With Mupirocin

  • Apply one-half of the mupirocin nasal ointment from a single-use tube into one nostril and the other half into the other nostril. 26

NURSING ALERT Avoid contact between mupirocin nasal ointment and the patient’s eyes. If accidental contact occurs, rinse well with water to prevent burning and tearing.26

  • Close the nostrils by pressing together and releasing the sides of the nose repetitively for about 1 minute to spread the ointment throughout the nares.26
  • Discard the tube after use; don’t reuse. 26
  • Apply the ointment twice daily (morning and night) for 5 days, as ordered. 26
  • Avoid concurrent administration of any other intranasal products during the treatment period. 26
  • Monitor the patient for such adverse effects as headache, rhinitis, pharyngitis, respiratory disorders, taste perversion, burning, stinging, cough, and pruritus. 3,26

For Decolonization With a Povidone-Iodine Swab Stick

  • Hold the applicator tube between the thumb and forefinger with the tube in a vertical position with the tip or handle up. Tap the swab stick gently against a firm surface to push any excess solution to the bottom of the swab stick tube.25
  • Place the thumb and forefinger of the other hand at the base of the handle or tip (thumb-to-thumb).25
  • Bend and snap the swab stick away from yourself at the score line. 25
  • Bend and snap the swab stick in the opposite direction to disconnect the swab stick.25
  • Remove the swab stick from the tube and discard the tube in an appropriate receptacle. 25 Don’t place the swab stick back into the tube, because the swab stick is presaturated with the correct volume of solution at the time of removal from the tube.25
  • Insert the swab stick comfortably into one nostril. 25
  • For a total of 15 seconds, rotate the swab stick around the circumference of the nostril. Then rotate the swab stick in the anterior nares for a least six complete revolutions, applying slight pressure and covering all surfaces. Repeat the procedure in the same nostril, using a new swab stick. 25
  • Complete the swab insertion two times in the other nostril. 25
  • If the solution drips from the nose, wipe it gently with a tissue; don’t allow the patient to blow the nose. 25
  • Discard the swab sticks in an appropriate receptacle. 25

For Decolonization With Alcohol Using an Ampule

  • Holding the ampule by the cardboard sleeve, shake it for 4 to 5 seconds until the solution becomes emulsified. 27
  • Remove the ampule from the cardboard sleeve to expose the swab’s tip. 27
  • Reinsert the ampule into the cardboard sleeve with the swab’s tip exposed. Avoid touching the swab tip with your fingers. 27
  • Hold the ampule by the cardboard sleeve and press firmly near the middle, at the blue dot, to crush the ampule.27
  • Pointing the swab tip downward, squeeze the ampule to saturate the swab tip.27
  • Insert the swab tip into the right nostril, to a distance no deeper than the tip of the swab. 27
  • While applying moderate pressure, swab the right nostril six times clockwise and then six times counterclockwise. Make sure to swab the inside front pocket of the right nostril. 27
  • Turn the swab upside down, and then squeeze the ampule gently and repeatedly to resaturate the swab tip.27
  • Repeat the application in the left nostril. 27
  • Discard the ampule and sleeve in an appropriate receptacle. 27
  • Repeat the application in both nostrils using all three ampules in the pack, within 1 hour before surgery. 27

For Decolonization With Alcohol Using a Cotton-Tipped Swab

  • Shake the multidose bottle well and then remove the cap. 28
  • Apply four drops of alcohol solution onto the tip of a cotton-tipped swab. 28
  • Insert the swab tip into the patient’s right nostril to a distance no deeper than the tip of the swab. 28
  • While applying moderate pressure, swab the right nostril six times clockwise and then six times counterclockwise. Make sure to swab all surfaces of the nostril, including the inside tip of the nostril. 28
  • Resaturate the swab tip of the cotton-tipped swab by applying two drops of alcohol solution. 28
  • Repeat the application in the left nostril. 28
  • Discard the cotton-tipped swab in an appropriate receptacle.

Completing the Procedure

  • Remove and discard your gloves and, if worn, other personal protective equipment.
  • Perform hand hygiene. 9,10,11,12,13,14
  • Document the procedure. 29,30,31,32

Special Considerations ⬆ ⬇

Special considerations
  • Data are insufficient to recommend mupirocin nasal ointment for general prophylaxis of an infection in any patient population. 2

Complications ⬆ ⬇

Complications

Improper technique can result in continued colonization, increasing the risk of infection. Another potential complication is allergic reaction to the prescribed decolonization agent.

Documentation ⬆ ⬇

Documentation

Document the decolonization agent’s name and strength and the date and time of administration. Include the route and site you used, such as the right and left nares. Record any adverse reactions to the prescribed agent, the date and time you notified the practitioner, prescribed interventions, and the patient’s response to those interventions. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. Association of Professionals in Infection Control and Epidemiology (APIC). (2014). APIC text of infection control and epidemiology (4th ed.). Arlington, VA: APIC.
  2. Berríos-TorresS. I., et al. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA, 152(8), 784–791. https://jamanetwork.com/journals/jamasurgery/fullarticle/2623725?appId=scweb
  3. BrockJ. (2019). Nasal decolonization:

    Potential alternatives for SSI prevention

    . Infectious Diseases News, Julyhttps://www.healio.com/news/infectious-disease/20190702/nasal-decolonization-potential-mupirocin-alternatives-for-ssi-prevention.
  4. World Health Organization. (2016). Global guidelines for the prevention of surgical site infection. https://apps.who.int/iris/bitstream/handle/10665/250680/9789241549882-eng.pdf?sequence=8 (Level IV)
  5. Centers for Disease Control and Prevention. (2019). Strategies to prevent hospital-onset Staphylococcus aureus bloodstream infections in acute care facilities. https://www.cdc.gov/hai/prevent/staph-prevention-strategies.html
  6. HuangS. S., et al. (2013). Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine, 368, 2255–2265. (Level I)
  7. SeptimusE. J., & SchweizerM. L. (2016). Decolonization in prevention of health care-associated infections. Clinical Microbiology Reviews, 29, 201–222.
  8. GhaddaraH. A., et al. (2019). Efficacy of a povidone iodine preparation in reducing nasal methicillin-resistant Staphylococcus aureus in colonized patients. American Journal of Infection Control, 48, 456–459.
  9. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  10. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  11. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  12. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements:

    Interpretive guidelines & surveyor guidance-revision 20.0

    . Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  13. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  14. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  15. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  16. Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  17. SiegelJ. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
  18. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  19. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  20. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13 (c)(1)

    .
  21. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO® accreditation requirements:

    Interpretive guidelines & surveyor guidance-revision 20.0

    . Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  22. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  23. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  24. Global Life Technologies Corp. (2017). Nozin Nasal Sanitizer Popswab Ampule instructions for use. https://www.nozin.com/wp-content/uploads/Poster-Nozin-Daily-Decolonization-8x8_v66.x61666.pdf
  25. PDI. (2018). Profend nasal decolonization kit: General guidelines for use for nasal application. https://pdihc.com/wp-content/uploads/2018/09/PDI-Profend-IFU_05189933.pdf
  26. GlaxoSmithKline. (2017). Bactroban nasal ointment prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/050703s017lbl.pdf
  27. Global Life Technologies Corp. (2017). Pre-Op: Nozin Nasal Sanitizer preoperative pack instructions for use. https://www.nozin.com/wp-content/uploads/IFU_PreOp_Ampule_VF.x61666.pdf
  28. Global Life Technologies Corp. (2017). Nozin Nasal Sanitizer multidose 12mL bottle instructions for use. https://www.nozin.com/wp-content/uploads/IFU-POSTER-Multidose-Bottle-6x6-v56.x61666.pdf
  29. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  30. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24 (b)

    .
  31. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements:

    Interpretive guidelines & surveyor guidance-revision 20.0

    . Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  32. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)