What is the recommended treatment for a patient with Methicillin-resistant Staphylococcus aureus (MRSA) colonization, specifically using Bactroban (mupirocin)?

Bactroban (Mupirocin) for MRSA Colonization

Direct Recommendation

For MRSA colonization, use mupirocin 2% ointment applied to both anterior nares twice daily for 5-10 days, combined with chlorhexidine gluconate body washes, but only pursue decolonization in specific clinical scenarios—not for simple asymptomatic colonization. 1

When to Decolonize (Critical Decision Points)

Decolonization is not routinely recommended for asymptomatic MRSA carriers. 1 Pursue decolonization only in these specific situations:

• Recurrent MRSA skin and soft tissue infections despite optimized wound care and hygiene measures 1
• Ongoing household transmission among close contacts despite hygiene interventions 1, 2
• Pre-operative decolonization before high-risk surgeries (cardiac, orthopedic, or other procedures with prosthetic implants), which has the strongest evidence for reducing surgical site infections 3, 1

Standard Decolonization Protocol

Nasal Decolonization

• Mupirocin 2% ointment applied to both anterior nares twice daily for 5-10 days 1, 2
• The nasal cavity serves as the primary MRSA reservoir, making this the cornerstone of therapy 2

Body Decolonization (Essential Adjunct)

Choose one of the following:

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

Pre-operative Protocol Specifics

For surgical patients, the cardiac surgery guidelines recommend:

• Start at least 48 hours before surgery 3
• Continue for a total duration of 5-7 days 3
• Combine with twice-daily chlorhexidine mouthwash for oropharyngeal decontamination 3
• This protocol reduces postoperative SA infections (RR 0.55) without requiring pre-screening 3

Essential Concurrent Hygiene Measures

All MRSA carriers require these interventions regardless of decolonization:

• Keep draining wounds covered with clean, dry bandages 1
• Frequent handwashing with soap and water or alcohol-based sanitizer 1
• Avoid sharing personal items that contact skin (towels, razors, clothing) 1
• Clean high-touch household surfaces regularly 1
• Wash towels, sheets, and clothing in hot water 1

Household Contact Management

Treating both the patient and household contacts together results in significantly fewer recurrences than treating the patient alone. 1

• Evaluate and treat symptomatic contacts for active MRSA infection first 2
• Consider decolonization of asymptomatic household contacts only when ongoing transmission is documented despite hygiene measures 1, 2

Critical Pitfalls and Emerging Resistance Concerns

Mupirocin Resistance

A major concern is emerging mupirocin resistance, with recent data showing 22.5% of MRSA strains resistant to mupirocin. 5 This makes the traditional decolonization strategy increasingly problematic:

• High-level mupirocin resistance has been documented and is increasing 5
• Prolonged or indiscriminate use accelerates resistance development 2
• For high-risk surgical patients in settings with high mupirocin resistance, consider intranasal povidone-iodine as an alternative 5

Temporary Effect

• Decolonization provides only temporary clearance in most cases 1
• Recolonization occurs in 40-60% of patients within 3 months after stopping therapy 1, 2
• One study showed mupirocin temporarily reduced colonization but did not decrease subsequent infection risk over long-term follow-up 6

Contraindications and Safety

• Never use hexachlorophane in children under 2 months due to neurological complications 1, 2
• Avoid tetracyclines in children under 8 years 1
• Do not use mupirocin for simple nasal trauma without signs of infection—this promotes resistance without benefit 2

Monitoring and Follow-up

• Routine surveillance cultures after decolonization are not recommended in the absence of active infection 1, 2
• Screening cultures prior to decolonization are unnecessary if at least one prior MRSA infection was documented 1
• For patients with recurrent infections despite decolonization, address underlying factors: foreign material, hidradenitis suppurativa, pilonidal cysts, or neutrophil dysfunction 1

Evidence Quality Considerations

The strongest evidence supports pre-operative decolonization, where a meta-analysis of four randomized trials demonstrated a 45% reduction in postoperative SA infections (RR 0.55). 3 However, a large 2019 randomized controlled trial showed that post-discharge decolonization reduced MRSA infections by 30% (hazard ratio 0.70), with even greater benefit (44% reduction) in fully adherent patients. 7 The effectiveness was particularly notable given that 84.8% of MRSA infections led to hospitalization. 7