What should be done for a patient with nasal colonization undergoing hip replacement surgery?

Pre-Operative Decolonization for Hip Replacement Surgery with Positive Nasal Colonization

Administer intranasal mupirocin 2% twice daily for 5 days combined with daily chlorhexidine gluconate body wash, completing the regimen 1-2 weeks before surgery, and add vancomycin to standard cephalosporin prophylaxis on the day of surgery. 1, 2

Decolonization Protocol

The strongest evidence supports a dual-agent decolonization approach for orthopedic surgery patients:

• Apply mupirocin 2% ointment into each nostril twice daily for 5 consecutive days 1, 3
• Combine with chlorhexidine gluconate 4% body wash daily during the same 5-day period 1, 2
• Complete this regimen 1-2 weeks before the scheduled hip replacement surgery 1, 2

The European Society of Clinical Microbiology and Infectious Diseases provides a strong recommendation with moderate certainty of evidence specifically for orthopedic surgery, making this one of the most robust guideline recommendations available. 1 The landmark Bode et al. study demonstrated that this combination reduced deep surgical site infections by 79% (RR 0.21; 95% CI: 0.07-0.62) in orthopedic and cardiac surgery patients. 1

Critical timing consideration: If the 5-day decolonization course cannot be completed preoperatively, complete it post-surgery rather than omitting it entirely. 1 For elective procedures, consider postponing surgery to allow completion of decolonization if this poses no additional risk to the patient. 1

Modified Surgical Prophylaxis

On the day of surgery, modify the antibiotic prophylaxis regimen:

• Add vancomycin 15 mg/kg to the standard cephalosporin prophylaxis (do not replace the cephalosporin) 2
• Administer vancomycin as an infusion starting 1-2 hours before incision to ensure adequate tissue levels 2
• Continue standard weight-based cephalosporin administration less than 60 minutes before skin incision 1

This dual-prophylaxis approach is specifically recommended for MRSA-colonized patients undergoing orthopedic surgery with prosthetic material implantation. 2 The rationale is that hip replacement involves prosthetic material, which creates a particularly high-risk scenario for Staphylococcus aureus surgical site infections. 1

Evidence Supporting This Approach

The combination strategy is superior to single-agent approaches:

• Mupirocin alone reduces MSSA surgical site infections by 50% (RR 0.50,95% CI: 0.37-0.69) and MRSA infections by 70% (RR 0.30,95% CI: 0.15-0.62) 1
• The mupirocin plus chlorhexidine combination provides even greater protection, with one study showing only 1.3% infection rate in decolonized carriers versus 1.7% in non-decolonized controls 4
• Meta-analysis demonstrates that decolonization reduces overall Staphylococcus aureus infectious complications by 45% (RR 0.55,95% CI: 0.34-0.89) 1, 3

Important caveat: Research shows that even after decolonization, previously colonized patients remain at higher risk than never-colonized patients. 5 One study found that colonized patients who underwent decolonization still had 4.35% infection rates compared to 2.39% in non-colonized patients, suggesting decolonization is protective but not completely normalizing risk. 5

Post-Operative Management

Implement enhanced surveillance protocols:

• Monitor the surgical site closely starting 48 hours postoperatively 2
• Maintain a low threshold for obtaining wound cultures if any signs of infection develop 2
• Treat any suspected infection empirically with MRSA-active antibiotics given the documented colonization history 2

Additional Bundle Components

Integrate these evidence-based interventions to maximize infection prevention:

• Ensure appropriate glycemic control perioperatively 1
• Use electric clippers (not razors) for hair removal close to surgery time 1
• Apply sterile dressing and change within 48 hours postoperatively 1
• Consider daily incision washing with chlorhexidine after dressing removal 1

The cardiac surgery guidelines emphasize that these interventions work best as a bundle, with care bundles of 3-5 evidence-based interventions demonstrating significant surgical site infection reduction. 1

Resistance Monitoring Considerations

Local antimicrobial stewardship is essential:

• Implementation should follow assessment of local Staphylococcus aureus prevalence and infection patterns 1
• Monitor for mupirocin resistance in colonizing isolates, though no emergence of multidrug-resistant bacteria has been observed due to decolonization selection pressure 1, 3
• Routine decolonization without prior screening is more cost-effective than selective treatment based on screening results 3