Would you treat a patient with high nasal colonization of Staphylococcus aureus (Staph A)?

Management of High Nasal Colonization of Staphylococcus aureus

Asymptomatic Staphylococcus aureus nasal colonization should not be treated unless there is a history of recurrent skin infections or ongoing household transmission.

When to Consider Treatment for Nasal Staph A Colonization

• Decolonization therapy is not routinely recommended for asymptomatic patients with positive Staphylococcus aureus nasal swabs 1
• Treatment should only be considered in the following specific situations:
  • Patients with recurrent Staphylococcus aureus skin and soft tissue infections (SSTIs) despite optimizing wound care and hygiene measures 2, 1
  • When there is ongoing transmission among household members or other close contacts despite optimizing hygiene measures 2
  • Patients at high risk for surgical site infections, particularly those undergoing certain surgical procedures 3

Recommended Decolonization Protocol When Treatment is Indicated

• Nasal decolonization with mupirocin 2% ointment applied to both anterior nares twice daily for 5-10 days 2, 1
• Consider adding topical body decolonization with:
  • Chlorhexidine gluconate (CHG) body wash daily for 5-14 days, or
  • Dilute bleach baths (1 teaspoon per gallon of water for 15 minutes twice weekly) 2, 1

Important Hygiene Measures for All Carriers

• Keep draining wounds covered with clean, dry bandages 2
• Maintain good personal hygiene with regular bathing 1
• Clean hands frequently with soap and water or alcohol-based hand sanitizer 2
• Avoid sharing personal items (razors, linens, towels) that contact skin 2
• Focus cleaning efforts on high-touch surfaces using commercially available cleaners 2

Household Contact Management

• Evaluate symptomatic contacts for evidence of Staphylococcus aureus infection and treat accordingly 2
• Consider nasal and topical body decolonization of asymptomatic household contacts if there is ongoing transmission 2, 1

Monitoring and Follow-up

• Routine surveillance cultures following decolonization are not recommended in the absence of active infection 2, 1
• Be aware that decolonization may only provide temporary clearance, with recolonization occurring after discontinuation 2, 4

Special Considerations

• Age is a risk factor for subsequent infection in colonized patients, with those over 40 years having higher risk 5
• MRSA carriers have a significantly higher risk of subsequent infection compared to MSSA carriers, especially in younger patients 5
• Patients with a prior history of Staphylococcus aureus positive cultures are at higher risk for subsequent infection 5

Potential Pitfalls

• Mupirocin resistance is increasing, which may reduce effectiveness of decolonization strategies 4
• Hexachlorophene should not be used in infants under 2 months of age due to risk of neurological complications 2
• Decolonization without addressing underlying risk factors or environmental contamination may lead to early recolonization 2, 4