Management of MRSA Colonization in Tracheostomy
MRSA colonization in a tracheostomy does not require routine decolonization treatment, but standard infection prevention precautions with appropriate PPE during tracheostomy care are essential to prevent transmission. 1
Key Management Principles
Standard Infection Control (Not Decolonization)
MRSA colonization in the respiratory tract, including tracheostomy sites, should be managed with standard infection prevention precautions rather than active decolonization protocols. 1
The evidence for decolonization protocols applies primarily to nasal MRSA colonization before surgical procedures, not to established respiratory tract colonization in patients with tracheostomies. 1
Routine decolonization of multidrug-resistant Gram-negative bacteria carriers is not recommended, and similar principles apply to MRSA colonization in non-surgical contexts. 1
Personal Protective Equipment Requirements
All healthcare workers performing tracheostomy care on MRSA-colonized patients must use:
- Gloves and aprons for all direct contact with the tracheostomy 1
- Eye protection for all tracheostomy care procedures 1
- Fluid-repellent surgical face mask for routine care 1
- Enhanced PPE (FFP3/N95 respirator or PAPR plus long-sleeved fluid-repellent gown) for aerosol-generating procedures including suctioning 1
Tracheostomy-Specific Precautions
Use closed inline suction systems to minimize aerosolization, particularly for ventilated patients 1
For non-ventilated patients with deflated cuffs, consider having them wear a fluid-resistant surgical mask to reduce dispersal of respiratory secretions 1
Maintain cuff inflation when possible for patients on positive-pressure ventilation to minimize aerosolization 1
Review the requirement for oxygen, humidification, and frequency of inner tube care daily 1
When Decolonization May Be Considered
Decolonization protocols are only appropriate in specific pre-operative contexts, not for established tracheostomy colonization:
If a patient with a tracheostomy requires elective cardiac or orthopedic surgery, pre-operative decolonization with mupirocin 2% nasal ointment twice daily for 5 days plus chlorhexidine gluconate body washes may be considered 1, 2
The decolonization should be completed 1-2 weeks before the planned surgical procedure 1, 3
This approach targets nasal colonization and is distinct from managing established respiratory tract colonization 1
Important Caveats
Colonization versus infection distinction is critical:
MRSA colonization in a tracheostomy without signs of active infection (fever, purulent secretions, elevated white blood cell count, clinical deterioration) does not warrant antibiotic treatment 4
Surveillance cultures demonstrating MRSA presence do not indicate need for treatment in the absence of clinical infection 5
The presence of MRSA in respiratory secretions increases infection risk but does not mandate decolonization attempts outside of pre-operative protocols 4
Decolonization limitations in respiratory colonization:
Mupirocin-based decolonization protocols have limited effectiveness for patients colonized at multiple body sites beyond the nares 4
Respiratory tract colonization is particularly difficult to eradicate compared to nasal colonization alone 4
Inappropriate use of decolonization protocols may lead to mupirocin resistance 1
Discharge and Long-Term Management
Patients discharged to community settings with tracheostomies should have clear care plans communicated to receiving facilities regarding PPE requirements and infection prevention precautions 1
Community locations must be equipped to deliver safe care following standard infection prevention principles 1
Continue standard precautions based on ongoing risk assessment rather than attempting eradication of colonization 1