Management of Pre-Operative MRSA Nasal Swab Positive Patients
For patients with a positive pre-operative MRSA nasal swab, decolonization with intranasal mupirocin 2% ointment twice daily for 5 days combined with chlorhexidine gluconate body wash is strongly recommended, especially before cardiac and orthopedic surgeries. 1, 2
Decolonization Protocol
Standard Regimen
- Apply mupirocin 2% nasal ointment to both anterior nares twice daily for 5 days 1, 2
- Use chlorhexidine gluconate 4% soap for daily full-body washing during the 5-day treatment period 2, 3
- Complete decolonization 1-2 weeks before surgery when possible 1, 2
- For elective surgeries, consider postponing the procedure to complete decolonization if feasible and safe 1
Timing Considerations
- Decolonization should be performed and completed as close as possible to the operation (ideally 1-2 weeks before surgery) 1, 2
- Patients whose 5-day course is not completed preoperatively should complete it post-surgery 1
Surgical Antibiotic Prophylaxis Modification
- For MRSA carriers undergoing cardiac surgery, orthopedic surgery, or neurosurgery, add vancomycin to standard prophylaxis 1
- Combined interventions (decolonization plus targeted prophylaxis) are particularly important for MRSA carriers undergoing cardiac and orthopedic procedures 1
Effectiveness and Follow-up
- Decolonization protocols using intranasal mupirocin and chlorhexidine washes are effective at reducing MRSA colonization rates from approximately 4% to less than 0.5% 4, 3
- Consider repeat testing on the day of surgery to confirm successful decolonization, especially for high-risk procedures 4, 5
- Be aware that decolonization may not be persistent in approximately 30% of patients, necessitating repeat screening and decolonization for any subsequent procedures 5
Special Considerations
Mupirocin Resistance
- Monitor for potential mupirocin resistance, which is more common in MRSA (22.5%) than MSSA (3%) 6
- In settings with high mupirocin resistance rates, consider alternative agents such as intranasal povidone-iodine 6, 7
Environmental Measures
- Reinforce personal hygiene measures including frequent handwashing 2
- Clean high-touch surfaces in the home environment 2
- Consider evaluating household contacts for potential MRSA colonization in cases of recurrent infections 2
Rationale for Recommendation
The strong recommendation for decolonization is based on evidence showing that MRSA colonization significantly increases surgical site infection risk, particularly in cardiac and orthopedic surgeries 1. While one prospective study showed no benefits of MRSA screening alone without decolonization 1, multiple studies demonstrate that combining screening with decolonization effectively reduces MRSA colonization rates and subsequent infection risk 4, 3.
The European Society of Clinical Microbiology and Infectious Diseases/European Committee on Infection Control strongly recommends this approach for cardiac and orthopedic surgeries based on moderate certainty evidence 1, with conditional recommendations for other surgical procedures 1.