Do you recommend a decolonization program for Methicillin-resistant Staphylococcus aureus (MRSA) infection?

MRSA Decolonization Program Recommendations

Decolonization with mupirocin nasal ointment and chlorhexidine body wash is recommended for MRSA carriers, especially before high-risk surgeries and for patients with recurrent MRSA infections. 1

Evidence-Based Decolonization Protocol

When to Consider Decolonization

• Decolonization is recommended for MRSA carriers before cardiac and orthopedic surgery (strong recommendation, moderate certainty of evidence) 1
• Decolonization should be considered for patients with recurrent MRSA skin and soft tissue infections despite optimizing wound care and hygiene measures 1
• Decolonization may be appropriate when ongoing MRSA transmission is occurring among household members or close contacts 1

Standard Decolonization Regimen

• Intranasal mupirocin 2% ointment applied twice daily for 5-10 days 1, 2
• Chlorhexidine gluconate (4%) body wash or soap for daily bathing during the treatment period 1, 3
• For comprehensive decolonization, both components should be used simultaneously 4

Implementation Considerations

• Decolonization should be performed and completed as close as possible to surgery (ideally 1-2 weeks before the procedure) 1
• For elective surgeries, consider postponing the procedure to complete decolonization if feasible 1
• Screening for MRSA before decolonization is recommended for high-risk surgeries but may not be necessary for patients with documented prior MRSA infection 1

Effectiveness and Outcomes

Clinical Impact

• Decolonization reduces the risk of MRSA infection by approximately 30% compared to education alone 4
• The number needed to treat to prevent one MRSA infection is approximately 30 patients 4
• Successful decolonization significantly reduces MRSA infection rates (0% vs 4.3% in decolonized vs non-decolonized patients) 5

Success Rates and Factors

• Overall success rates for MRSA decolonization range from 39-87% depending on protocol adherence and patient factors 5, 6
• Multiple decolonization cycles may be required, with an average of 2.1 cycles needed for successful decolonization 6
• Patients with MRSA-positive skin alterations (wounds, entry sites) have lower decolonization success rates (22%) compared to those with MRSA-negative skin alterations (50%) 7

Special Considerations

Extended Decolonization

• For patients with short hospital stays, continuing decolonization after discharge in the domestic setting significantly improves success rates (47% vs 12%) 7
• Integrated MRSA management extending beyond hospitalization is particularly important since successful decolonization typically requires up to 22 days of treatment 7

Resistance Concerns

• Close monitoring for mupirocin and chlorhexidine resistance is warranted with widespread use of decolonization protocols 8
• Universal decolonization without screening should be applied cautiously as it may lead to mupirocin resistance 1

Additional Measures

• Focus cleaning efforts on high-touch surfaces that may contact bare skin 1
• Personal and environmental hygiene measures should be reinforced in the patient and contacts 1
• Symptomatic contacts should be evaluated and treated for potential MRSA infection 1

Algorithm for MRSA Decolonization Decision-Making

1. Identify candidates for decolonization:

   • Patients scheduled for cardiac or orthopedic surgery 1
   • Patients with recurrent MRSA infections 1
   • Patients in settings with ongoing MRSA transmission 1

2. Implement appropriate screening:

   • Screen high-risk surgical patients according to local epidemiology 1
   • Consider rapid screening methods to obtain timely results 1

3. Apply decolonization protocol:

   • Mupirocin 2% nasal ointment twice daily for 5-10 days 1, 2
   • Daily chlorhexidine gluconate body wash 1, 3
   • Continue treatment for full course, extending to post-discharge if necessary 7

4. Monitor effectiveness:

   • Consider follow-up cultures only if clinically indicated (not routine surveillance) 1
   • Be prepared to repeat decolonization if needed, as multiple cycles may be required 6

MRSA decolonization is an effective strategy for reducing infection risk, particularly in surgical patients and those with recurrent infections, but requires careful implementation and monitoring to maximize success and minimize resistance development.