Management of Nasal Staph Aureus Carriage in Operating Room Personnel
Both the surgeon and nurse should undergo immediate decolonization with mupirocin 2% nasal ointment twice daily for 5 days, combined with chlorhexidine gluconate soap (40 mg/mL) for body washing, and should be temporarily removed from patient care until decolonization is completed and confirmed by negative screening cultures 1.
Rationale and Evidence Base
The 2024 European guidelines provide the framework for this recommendation, emphasizing that decolonization with mupirocin with or without chlorhexidine is effective for both MSSA and MRSA carriers before surgery 1. While these guidelines focus on patient decolonization, the same principles apply to healthcare workers who pose transmission risks.
Why Healthcare Worker Screening and Decolonization Matters
Healthcare workers have a 5% MRSA carriage rate (higher than the general population's 2%), and documented outbreaks have occurred from colonized surgical personnel 2. A compelling 2019 case series demonstrated that a single surgeon's nasal and hand MRSA carriage caused an outbreak of surgical site infections, with the surgeon as second assistant being the only significant risk factor (hazard ratio 25.088) after propensity score matching 3. This underscores that standard infection control measures alone are insufficient when personnel are colonized.
Specific Decolonization Protocol
For the affected personnel:
- Mupirocin 2% nasal ointment: Apply twice daily to both anterior nares for 5 consecutive days 1
- Chlorhexidine gluconate 4% soap: Daily body washing during the 5-day decolonization period 1
- Timing: Complete decolonization before returning to the operating room 1
- Verification: Post-decolonization screening cultures to confirm clearance (success rates approach 90%) 2
Work Restrictions
Healthcare workers colonized with S. aureus, particularly MRSA, should be assigned to non-patient contact areas during active colonization and decolonization 2. This is critical because:
- Provider hands and patient skin are confirmed sources of transmission 4
- Certain high-risk strains (like ST 5) show hypertransmissibility with 6.67-fold increased transmission risk 4
- Surgical masks alone are insufficient to prevent transmission from nasal carriers 5
Common Pitfalls to Avoid
Do not allow these personnel to continue operating during decolonization. The evidence shows direct transmission from colonized surgeons to patients despite standard infection control measures 3. The within-case mode of transmission (during the surgical procedure itself) is the primary route 4.
Do not assume one decolonization course is permanent. Implement ongoing surveillance screening for operating room personnel, as recolonization can occur 2, 6. The literature supports regular screening programs for surgical staff, not just outbreak-triggered responses 2.
Monitor for mupirocin resistance in your institution, as policies should include surveillance of resistance patterns in colonizing isolates 1.
Additional Infection Control Measures
Beyond decolonization:
- Reinforce hand hygiene compliance, as provider hands are documented transmission vectors 4
- Ensure proper surgical mask use, though recognize this is insufficient as sole prevention 5
- Implement active surveillance screening protocols for all operating room personnel 2
- Establish economic and healthcare safety nets for affected workers to encourage reporting and compliance 2
The evidence strongly supports proactive decolonization rather than reactive measures only after infections occur, as absence of infections does not mean absence of transmission 2.