What is the recommended treatment for a partner with a positive Methicillin-resistant Staphylococcus aureus (MRSA) swab?

Management of Partner with Positive MRSA Swab

For an asymptomatic partner with a positive MRSA nasal swab, no treatment is routinely recommended unless there is a history of recurrent skin infections or ongoing household transmission. 1

Initial Assessment

Determine whether the partner requires decolonization based on:

• History of recurrent MRSA skin and soft tissue infections (defined as ≥2 discrete episodes at different sites over 6 months) despite optimizing wound care and hygiene 2
• Ongoing transmission among household members despite implementing hygiene measures 2
• Upcoming high-risk procedures (e.g., surgery with prosthetic implants) where MRSA infection would be catastrophic 3

If none of these criteria are met, proceed with hygiene measures only and do not pursue decolonization. 1

Hygiene Measures for All MRSA Carriers (Symptomatic or Not)

These should be implemented regardless of whether decolonization is pursued:

Personal Hygiene

• Maintain regular bathing with soap and water 2, 1
• Clean hands frequently with soap and water or alcohol-based hand sanitizer, especially after touching potentially contaminated items 2, 1
• Keep any draining wounds covered with clean, dry bandages 2
• Avoid sharing personal items including razors, linens, and towels that contact skin 2

Environmental Hygiene

• Focus cleaning on high-touch surfaces (counters, doorknobs, bathtubs, toilet seats) that contact bare skin 2
• Use commercially available cleaners according to label instructions for routine surface cleaning 2

Decolonization Protocol (When Indicated)

If decolonization criteria are met, implement the following combined approach:

Nasal Decolonization

• Mupirocin 2% ointment applied to both anterior nares twice daily for 5-10 days 2, 1

Body Decolonization (Choose One)

• Chlorhexidine gluconate 2-4% body wash daily for 5-14 days 1, 4, OR
• Dilute bleach baths: 1 teaspoon per gallon of water (¼ cup per ¼ tub or 13 gallons) for 15 minutes twice weekly for 3 months 2

Oral Rinse (Optional Addition)

• Chlorhexidine mouthwash can be added to the regimen, particularly if there is throat colonization 4, 5

Important caveat: The IDSA guidelines note that while decolonization strategies are frequently employed, there are no published data definitively proving efficacy in preventing recurrent MRSA skin infections in the community setting. 2 However, a high-quality 2019 RCT demonstrated that postdischarge decolonization with chlorhexidine and mupirocin led to a 30% lower risk of MRSA infection compared to education alone (hazard ratio 0.70,95% CI 0.52-0.96, P=0.03). 4 This represents the strongest evidence supporting decolonization and should guide practice when decolonization is indicated.

Oral Antimicrobials (Rarely Indicated)

Oral antibiotics are NOT routinely recommended for decolonization. 2 They should only be considered if:

• Infections continue despite topical decolonization measures AND hygiene optimization 2
• If prescribed, use a rifampin-based combination (with TMP-SMX or doxycycline) for 5-10 days to minimize resistance development 2

The evidence shows no benefit of oral antibiotics for MRSA eradication compared to placebo or topical antibiotics, and they carry risks of adverse events and resistance development. 2

Monitoring and Follow-Up

• Screening cultures prior to decolonization are NOT routinely needed if at least one prior infection was documented as MRSA 2, 1
• Surveillance cultures following decolonization are NOT routinely recommended in the absence of active infection 2, 1
• Evaluate symptomatic household contacts for possible MRSA infection 1

Critical Pitfalls to Avoid

• Do not use hexachlorophene in infants <2 months of age due to risk of neurological complications 2, 3
• Ensure adequate dilution of bleach baths to prevent skin irritation; provide clear written instructions 2
• Recognize that decolonization provides only temporary clearance with recolonization often occurring after discontinuation 2, 1
• Do not rely on mupirocin monotherapy if colonization involves multiple body sites beyond the nares, as effectiveness is limited 6
• Reinforce that hygiene measures must continue indefinitely, even after successful decolonization 2

Household Transmission Considerations

When household transmission is suspected:

• Implement personal and environmental hygiene measures for ALL household members 2
• Evaluate all symptomatic contacts for evidence of S. aureus infection 2, 1
• Consider decolonization of asymptomatic household contacts only if ongoing transmission persists despite hygiene measures 1