Management of MRSA-Positive Nasal Swab Before Surgery
Implement a 5-day decolonization protocol with intranasal mupirocin 2% twice daily combined with daily chlorhexidine gluconate 4% body wash, completed 1-2 weeks before surgery, and add vancomycin to standard surgical prophylaxis on the day of surgery. 1, 2, 3
Preoperative Decolonization Protocol
Timing and Agents
- Complete the decolonization regimen 1-2 weeks before the scheduled surgery date to maximize effectiveness 3, 4
- Apply mupirocin 2% ointment into each nostril twice daily for 5 consecutive days 1, 3, 4
- Combine with chlorhexidine gluconate 4% body wash daily during the same 5-day period 1, 3, 4
- The combination approach is superior to mupirocin alone, with studies demonstrating 69% reduction in surgical site infections when both agents are used together 5
Evidence Supporting Decolonization
- Mupirocin-based decolonization reduces MRSA surgical site infections by 70% (RR 0.30,95% CI: 0.15-0.62) 4
- The decolonization protocol successfully eliminates MRSA colonization in 96-100% of patients when compliance is adequate 6, 7
- Nasal MRSA colonization increases the odds of MRSA surgical site infection 14-fold (OR 14.23, p=0.02), making decolonization critical 8
Application Instructions
- For chlorhexidine body wash: apply liberally to skin and wash gently for at least 2 minutes, then rinse thoroughly 9
- Use with care in premature infants or infants under 2 months of age due to risk of irritation or chemical burns 9
- Pay particular attention to nails, cuticles, and interdigital spaces during washing 9
Intraoperative Antibiotic Prophylaxis Modification
Dual Prophylaxis Approach
- Add vancomycin 15 mg/kg to the standard cephalosporin prophylaxis—do not replace the standard agent 2, 3, 4
- Administer vancomycin as an infusion starting 1-2 hours before incision to ensure adequate tissue levels 2, 3, 4
- Continue standard weight-based cephalosporin administration less than 60 minutes before skin incision 4
Surgery-Specific Recommendations
- This dual prophylaxis approach is specifically recommended for cardiothoracic surgery, orthopedic surgery, and neurosurgery in MRSA carriers 1, 2
- The addition of vancomycin to standard prophylaxis provides protective effect against MRSA surgical site infections (RR 0.40,95% CI 0.20-0.80) 1
Postoperative Surveillance
Monitoring Strategy
- Begin careful inspection of the surgical site starting 48 hours postoperatively, as surgical site infections rarely occur in the first 48 hours 2, 3
- Maintain a low threshold for obtaining wound cultures if any signs of infection develop 2, 3, 4
- In the presence of surgical site infection, nasal MRSA colonization is associated with MRSA-positive wound cultures in 66.67% of cases 8
Treatment Approach if Infection Develops
- Empiric antibiotic therapy for suspected surgical site infection must cover MRSA given the documented colonization history 2, 3, 4
- Obtain wound cultures to guide definitive therapy 2
Additional Perioperative Measures
Complementary Interventions
- Use chlorhexidine gluconate antiseptic cloths the evening prior and the day of surgery 5
- Ensure appropriate glycemic control perioperatively 4
- Use electric clippers (not razors) for hair removal close to surgery time 4
- Apply sterile dressing and change within 48 hours postoperatively 4
- Consider daily incision washing with chlorhexidine after dressing removal 4
Common Pitfalls to Avoid
- Do not skip the chlorhexidine body wash component—mupirocin alone is less effective than the combination approach 7, 5
- Do not replace standard prophylaxis with vancomycin alone—both agents are needed for optimal coverage 3, 4
- If the 5-day decolonization course cannot be completed preoperatively, complete it post-surgery rather than omitting it entirely, as this approach has shown 79% reduction in deep surgical site infections (RR 0.21; 95% CI: 0.07-0.62) 4
- Recognize that approximately 3-4% of patients may remain colonized despite treatment, requiring vigilant postoperative monitoring 6, 10