Decolonization Management for Recurrent MRSA Infections
For patients with recurrent MRSA skin and soft tissue infections, decolonization should only be attempted after optimizing wound care and hygiene measures have failed, using a combination of intranasal mupirocin twice daily for 5-10 days plus topical antiseptic body decolonization with chlorhexidine for 5-14 days or dilute bleach baths. 1
When to Consider Decolonization
Decolonization is not a first-line intervention and should only be considered in specific circumstances: 1
- After failure of hygiene measures: When a patient develops recurrent SSTI despite optimizing wound care and personal hygiene 1
- Ongoing household transmission: When transmission continues among household members or close contacts despite hygiene interventions 1
Important caveat: The evidence supporting decolonization efficacy for recurrent community-acquired MRSA infections is limited, with no published data conclusively demonstrating prevention of recurrent MRSA SSTI 1
Stepwise Approach to Management
Step 1: Optimize Hygiene Measures First (Before Decolonization)
These foundational interventions must be implemented and optimized before considering decolonization: 1
Wound management:
- Keep all draining wounds covered with clean, dry bandages 1
- Maintain hand hygiene with soap and water or alcohol-based gel, especially after touching infected skin 1
- Avoid sharing personal items (razors, linens, towels) that contact infected skin 1
Environmental hygiene:
- Focus cleaning on high-touch surfaces (counters, doorknobs, bathtubs, toilet seats) that contact bare skin 1
- Use commercially available cleaners according to label instructions 1
For lower extremity infections specifically:
- Examine interdigital toe spaces carefully and treat any fissuring, scaling, or maceration, as this may reduce recurrence 1
Step 2: Decolonization Regimens (If Step 1 Fails)
Recommended decolonization protocols (choose one): 1
Option A - Nasal decolonization alone:
- Intranasal mupirocin 2% ointment twice daily for 5-10 days 1
Option B - Combined nasal and body decolonization (preferred):
- Intranasal mupirocin 2% ointment twice daily for 5-10 days PLUS
- Chlorhexidine body wash daily for 5-14 days 1
- OR dilute bleach baths: 1 teaspoon per gallon of water (or ¼ cup per ¼ tub/13 gallons), 15 minutes twice weekly for up to 3 months 1
Critical point: Decolonization strategies must be offered in conjunction with ongoing reinforcement of hygiene measures, not as a replacement 1
Step 3: Household Contact Management
When household transmission is suspected: 1
- Evaluate all contacts for evidence of S. aureus infection 1
- Symptomatic contacts: Evaluate and treat active infection first; consider decolonization after treating active infection 1
- Asymptomatic household contacts: Nasal and topical body decolonization may be considered 1
- Apply personal and environmental hygiene measures to all household members 1
Recent evidence suggests that household-wide decolonization may be more effective than treating the index patient alone, though compliance is critical 2
Role of Cultures
Screening cultures are NOT routinely recommended in most situations: 1
- Before decolonization: Do not obtain screening cultures if at least one prior infection was documented as MRSA 1
- After decolonization: Surveillance cultures following decolonization are not routinely recommended in the absence of active infection 1
- Exception: Clinical monitoring for signs of active infection is preferred over surveillance cultures 3
Important Caveats and Pitfalls
Mupirocin Resistance Concerns
Emerging resistance is a significant concern: Recent data shows mupirocin resistance rates of 22.5% among MRSA strains in some settings, making it a suboptimal strategy in high-resistance areas 4. The Infectious Diseases Society of America guidelines acknowledge that widespread mupirocin use correlates with resistance development 5.
Consider alternative agents (such as intranasal povidone-iodine) in patients at high risk for infection when local mupirocin resistance rates are elevated 4
Limited Evidence Base
The evidence supporting decolonization for recurrent community-acquired MRSA is weak: 1
- Most studies showing benefit were conducted in healthcare settings or with MSSA, not community-acquired MRSA 1
- One randomized trial in military personnel found that nasal mupirocin did NOT reduce subsequent skin infections despite MRSA nasal carriage 1
- The optimal regimen, frequency, and duration remain unclear 1
Success Rates and Risk Factors for Failure
Decolonization success rates are modest (approximately 65% in some studies), with spontaneous clearance occurring in 22% without intervention 6. Risk factors for decolonization failure include: 6
- Respiratory tract colonization (9-fold increased odds of failure) 6
- Certain MRSA spa-types 6
- Poor compliance with the decolonization protocol 2, 7
Most recurrences occur within 270 days after decolonization, suggesting a reasonable follow-up period of approximately 1 year 6
When Decolonization May Not Work
Do not expect decolonization to be effective if: 1
- Local factors are present (foreign material, hidradenitis suppurativa, pilonidal cyst) - these require surgical management 1
- Neutrophil dysfunction exists (consider immunologic evaluation in children with recurrent abscesses from early childhood) 1
- Compliance with the protocol is poor 2, 7
Adjunctive Antibiotic Therapy
For recurrent abscesses specifically: After obtaining cultures, treat with a 5-10 day course of an antibiotic active against the pathogen 1. However, the benefits of adjunctive antimicrobial therapy in preventing recurrences remain unknown 1.
Oral antibiotics for decolonization should only be considered in conjunction with topical agents and when all other decolonization attempts and environmental controls have been exhausted 5