Pre-Operative Management for MRSA-Colonized Patient Before Bunion Surgery
This 26-year-old patient with positive MRSA nares colonization should undergo a 5-day decolonization protocol with intranasal mupirocin 2% twice daily combined with daily chlorhexidine gluconate 4% body wash, completed 1-2 weeks before the bunion surgery, and should receive vancomycin added to standard surgical prophylaxis on the day of surgery. 1
Decolonization Protocol
Start the decolonization regimen now to complete it before surgery:
- Intranasal mupirocin 2% ointment: Apply twice daily to both nostrils for 5 consecutive days 1
- Chlorhexidine gluconate 4% body wash: Daily full-body washing for 5 consecutive days 1, 2
- Timing: Complete this regimen 1-2 weeks before the scheduled surgery date, as decolonization should be performed as close as possible to the operation 1
The combination of mupirocin and chlorhexidine is more effective than mupirocin alone, with studies showing significant reductions in surgical site infections in orthopedic surgery patients 1. The 2024 European guidelines provide strong evidence specifically for orthopedic procedures, making this the gold standard approach 1.
Surgical Prophylaxis Modification
On the day of surgery, the patient requires modified antibiotic prophylaxis:
- Add vancomycin to the standard surgical prophylaxis regimen (typically a cephalosporin) 1
- Vancomycin dosing: 15 mg/kg administered as an infusion starting 1-2 hours before incision to ensure adequate tissue levels 3
- Continue standard prophylaxis: Do not replace the standard agent—vancomycin should be added, not substituted 1
The 2024 guidelines suggest adding vancomycin to standard prophylaxis for MRSA carriers undergoing orthopedic surgery, as this combined approach (decolonization plus targeted prophylaxis) shows the greatest reduction in surgical site infections 1.
Application Instructions for Chlorhexidine
For proper chlorhexidine body wash application: 2
- Wet the entire body with water
- Apply the chlorhexidine solution liberally to all skin surfaces
- Wash thoroughly for at least 2 minutes, paying attention to commonly colonized areas (axillae, groin, perineum)
- Rinse thoroughly with water
- Dry with a clean towel
- Repeat daily for 5 consecutive days
Important Caveats
Decolonization persistence is limited: Studies show that approximately 30% of patients become recolonized within 5-7 months after decolonization 4. Since your patient's surgery is only 9 days away, timing is appropriate, but if the surgery were delayed significantly, repeat screening and decolonization would be necessary 4, 5.
Completion is critical: If the 5-day decolonization course cannot be completed before surgery due to timing constraints, the patient should complete the remaining days postoperatively 1. However, with 9 days until surgery, there is adequate time to complete the full protocol before the procedure.
Mupirocin resistance monitoring: While mupirocin resistance exists, it remains relatively uncommon (0.6% in large studies), and mupirocin remains the gold standard for nasal decolonization 1, 6. No alternative agent has superior evidence for MRSA decolonization in the surgical setting 6, 7.
Post-Operative Considerations
Enhanced surveillance for surgical site infection:
- Monitor the surgical site closely starting 48 hours postoperatively 3
- Maintain a low threshold for obtaining wound cultures if any signs of infection develop (erythema, warmth, drainage, dehiscence) 3
- Any suspected infection should be treated empirically with MRSA-active antibiotics given the documented colonization history 3