What is the recommended treatment for decolonization of Methicillin-resistant Staphylococcus aureus (MRSA)?

MRSA Decolonization Treatment Protocol

The recommended treatment for decolonization of Methicillin-resistant Staphylococcus aureus (MRSA) is intranasal mupirocin 2% ointment applied twice daily for 5 days combined with chlorhexidine gluconate body washes. 1, 2

Primary Decolonization Regimen

• Apply mupirocin 2% ointment to both anterior nares twice daily for 5-10 days 1, 3
• Use chlorhexidine gluconate 4% soap for daily full-body washing during the 5-day treatment period 2, 4
• For optimal results, complete the full course of treatment without interruption 1
• This combination has shown superior efficacy compared to either agent alone 5

Indications for Decolonization

• Patients with recurrent MRSA skin and soft tissue infections despite optimized wound care and hygiene 1, 3
• Patients scheduled for high-risk surgeries, particularly cardiothoracic and orthopedic procedures 1
• Situations with ongoing MRSA transmission among household members or close contacts 3
• Patients being discharged from healthcare facilities with known MRSA colonization 5

Enhanced Decolonization for Persistent Cases

• For difficult-to-eradicate cases, consider adding diluted bleach baths:
  • Concentration: 1 teaspoon bleach per gallon of water (or 1/4 cup per 1/4 tub) 1
  • Duration: 15 minutes twice weekly for up to 3 months 1, 3
• For persistent extra-nasal colonization, systemic antibiotics may be considered:
  • Rifampin-based combination therapy (with TMP-SMX or doxycycline) for 5-10 days 1, 6
  • Note: Oral antimicrobials should be reserved for cases that fail topical therapy due to risk of resistance development 1, 7

Special Considerations

• Mupirocin resistance is emerging (up to 22.5% in some MRSA strains), so consider susceptibility testing in recurrent cases 8
• Alternative agents for nasal decolonization when mupirocin resistance is present:
  • Povidone-iodine nasal antiseptic 8, 4
  • Alcohol-based nasal antiseptics 4
• Hexachlorophene should not be used in infants under 2 months of age due to risk of neurological complications 1, 3
• For surgical patients, decolonization should be completed 1-2 weeks before the procedure 1

Environmental and Hygiene Measures

• Keep draining wounds covered with clean, dry bandages 1, 2
• Avoid sharing personal items that may contact skin (towels, razors, clothing) 2, 3
• Clean high-touch surfaces in the home environment with standard cleaning products 3
• Wash hands frequently, particularly after touching potentially infected areas 1, 3
• Evaluate household contacts for evidence of MRSA infection or colonization 1, 2

Monitoring and Follow-up

• Routine surveillance cultures following decolonization are not recommended in the absence of active infection 3
• For patients with recurrent infections despite decolonization, consider:
  • Evaluating for persistent colonization sites (throat, perianal area) 6
  • Assessing for mupirocin resistance 8
  • Implementing a maintenance regimen (e.g., mupirocin for 5 days monthly) for high-risk patients 9

The evidence strongly supports that proper implementation of this decolonization protocol can reduce MRSA infection risk by approximately 30%, with fully adherent patients experiencing up to 44% fewer MRSA infections compared to hygiene education alone 5.