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

MRSA Decolonization Protocol

For MRSA decolonization, use intranasal mupirocin 2% ointment twice daily for 5-10 days combined with daily chlorhexidine gluconate body washes for 5-14 days, reserving this approach for patients with recurrent skin infections despite hygiene measures or ongoing household transmission. 1

When to Consider Decolonization

Decolonization is not routinely recommended for simple MRSA colonization. 1 Reserve this intervention for specific clinical scenarios:

• Recurrent skin and soft tissue infections despite optimized wound care and hygiene measures 1
• Ongoing transmission among household members or close contacts despite hygiene interventions 1
• Pre-surgical patients with documented MRSA colonization, particularly for high-risk procedures 2

Do not pursue decolonization for asymptomatic colonization alone, as this promotes resistance without proven benefit in preventing community infections. 3, 4

Standard Decolonization Regimen

Nasal Component

• Mupirocin 2% ointment applied to both anterior nares twice daily for 5-10 days 1
• The 10-dose regimen (5 days, twice daily) is superior to shorter courses, maintaining decolonization for at least 4 weeks post-therapy 5
• Apply a pea-sized amount to each nostril and press nostrils together to distribute 3

Body Component (Choose One)

• Chlorhexidine gluconate 4% soap for daily full-body washing for 5-14 days 1, 6
  • OR
• Dilute bleach baths: 1 teaspoon per gallon of water (or ¼ cup per ¼ tub/13 gallons) for 15 minutes twice weekly for up to 3 months 1

The combination approach is more effective than nasal mupirocin alone. 7, 6

Enhanced Regimen for Treatment Failures

If initial decolonization fails or for difficult cases with multiple body sites colonized:

• Continue mupirocin and chlorhexidine as above 6
• Add chlorhexidine mouth rinse for oropharyngeal colonization 6
• For intestinal colonization: oral vancomycin 6
• For urinary tract colonization: trimethoprim-sulfamethoxazole 2, 6
• For vaginal colonization: povidone-iodine or chlorhexidine ovula 6
• Consider adding oral rifampin plus doxycycline for 7 days for persistent colonization at multiple sites 8

This enhanced regimen achieved 87% decolonization success in hospitalized patients with multi-site colonization. 6

Essential Hygiene Measures (Must Accompany Decolonization)

Decolonization without hygiene reinforcement has limited durability. 1 Implement concurrently:

• Cover all draining wounds with clean, dry bandages 1
• Avoid sharing personal items (razors, towels, linens) that contact skin 1
• Clean high-touch surfaces (doorknobs, counters, bathtubs, toilet seats) with standard household cleaners 1
• Frequent handwashing with soap and water or alcohol-based sanitizer 4

Household Contact Management

When household transmission is documented:

• Evaluate all symptomatic contacts for active infection and treat appropriately first 1, 3
• Consider simultaneous decolonization of asymptomatic household contacts only when ongoing transmission persists despite hygiene measures 1, 3, 4
• Treating both patient and contacts together reduces recurrence rates compared to treating the patient alone 3

Role of Cultures

• Do not obtain screening cultures before decolonization if at least one prior infection was documented as MRSA 1
• Do not perform surveillance cultures after decolonization in the absence of active infection 1, 3
• Cultures are only indicated if new symptoms of infection develop 1

Critical Pitfalls to Avoid

• Mupirocin resistance: Baseline mupirocin resistance increases treatment failure risk 9-fold 8. Avoid prolonged or indiscriminate use, as resistance develops with increased utilization 7
• Recolonization is common: 40-60% of patients recolonize within 3 months after therapy 3. This is expected and does not require repeat treatment unless recurrent infections develop 4
• Limited infection prevention data: While decolonization reduces colonization burden, evidence that it prevents subsequent infections in community settings is limited 9. One study showed mupirocin delayed time to infection but did not reduce overall infection risk 9
• Do not use hexachlorophane in children under 2 months due to neurological toxicity risk 3, 4
• Avoid treating simple nasal trauma or minor wounds without infection signs, as this promotes resistance without benefit 3

Special Populations

• Immunocompromised patients or those with prosthetic joints may warrant more aggressive, prolonged protocols 2
• Pre-surgical patients should complete decolonization 1-2 weeks before elective procedures 2
• Pediatric dosing: Same mupirocin regimen applies; chlorhexidine body washes are safe in children over 2 months 4