Preoperative Treatment for MRSA Carriers
MRSA-positive carriers scheduled for surgery should receive a combined intervention consisting of 5-day nasal mupirocin 2% twice daily PLUS chlorhexidine gluconate 4% body wash daily for decolonization, along with targeted antibiotic prophylaxis using vancomycin (15 mg/kg) added to standard cefazolin on the day of surgery. 1
Decolonization Protocol
The decolonization regimen must be completed 1-2 weeks before the scheduled surgery date:
- Intranasal mupirocin 2% ointment: Apply twice daily to both nostrils for 5 consecutive days 1, 2, 3
- Chlorhexidine gluconate 4% body wash: Daily full-body wash for 5 consecutive days 1, 2, 3
- This combination is significantly more effective than mupirocin alone, with studies demonstrating MRSA eradication rates approaching 100% and MSSA reduction from 22% to 2.8% (p<0.001) 4
Evidence supporting this approach is particularly strong for cardiac and orthopedic surgery, where combined interventions reduced MRSA surgical site infections by 93% (RR 0.069,95% CI: 0.02-0.29, p<0.001) in cardiothoracic surgery 1 and decreased overall SSIs from 1.11% to 0.34% (p<0.05) in orthopedic procedures 1.
Modified Surgical Antibiotic Prophylaxis
On the day of surgery, MRSA carriers require dual antibiotic prophylaxis:
- Vancomycin 15 mg/kg IV: Infuse over 1-2 hours, starting 1-2 hours before surgical incision 1, 2, 3
- PLUS standard cefazolin (or cefuroxime): Do not replace the beta-lactam with vancomycin; both agents must be given 1
This dual approach is critical because vancomycin alone increases the risk of postoperative MSSA infections 1. The European Society of Clinical Microbiology and Infectious Diseases explicitly recommends glycopeptides be administered with a beta-lactam to prevent this complication 1.
Surgery-Specific Considerations
The strength of evidence varies by surgical type:
- Cardiac and orthopedic surgery: Conditional recommendation with very low certainty of evidence, but consistent benefit across multiple studies 1
- Highest impact demonstrated in cardiothoracic surgery: MRSA-SSI reduction of 93%, with overall SSI rates decreasing from 2.1% to 0.8% (p<0.001) 1
- Orthopedic surgery with hardware implantation: SSI reduction from 3.8% to 1.1% (p=0.02) with decolonization protocols 5
Critical Implementation Details
Timing is essential for protocol success:
- Complete the 5-day decolonization course as close to surgery as possible, ideally finishing 1-2 weeks preoperatively 3
- Vancomycin infusion must begin early enough to achieve adequate tissue levels before incision (1-2 hours pre-incision) 2, 3
- For urgent procedures where 5-day decolonization is not feasible, targeted prophylaxis with vancomycin plus cefazolin should still be administered 1
Common Pitfalls to Avoid
Do not implement universal decolonization without screening, as this promotes mupirocin resistance without targeting those at highest risk 2. The European guidelines specifically recommend screening-based targeted decolonization rather than universal protocols 1.
Do not use vancomycin monotherapy for surgical prophylaxis in MRSA carriers, as this increases MSSA infection risk 1. Always combine with a beta-lactam agent.
Adverse effects are minimal: Only mild skin irritation from chlorhexidine bathing was reported in large studies (4 cases among 38,049 patients), with no significant emergence of vancomycin-resistant enterococci 1.
Verification of Decolonization Success
While not universally required, repeat nasal screening on the day of surgery can verify decolonization success, with studies showing reduction in MRSA colonization from 4.6% to 0.35% (p=0.0073) after the 5-day protocol 6. However, even if repeat screening shows persistent colonization, proceed with the modified antibiotic prophylaxis as planned 1.