What are the treatment options for persistent Methicillin-resistant Staphylococcus aureus (MRSA) colonization in the groin area?

From the Guidelines

For persistent MRSA colonization in the groin, I recommend a comprehensive decolonization protocol including daily chlorhexidine body washes (4% solution) for 5-7 days, application of mupirocin 2% ointment to the groin area twice daily for 5-7 days, and oral antibiotics such as doxycycline 100mg twice daily or trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily for 7-10 days in cases of recurrent infections. The guidelines from the Infectious Diseases Society of America, as outlined in the study 1, suggest that decolonization strategies may be considered in selected cases, such as recurrent skin and soft tissue infections (SSTIs) despite optimizing wound care and hygiene measures. Key points to consider in the treatment of persistent MRSA colonization in the groin include:

• The use of nasal decolonization with mupirocin twice daily for 5-10 days, as recommended in the study 1
• The application of topical body decolonization regimens with a skin antiseptic solution, such as chlorhexidine, for 5-14 days or dilute bleach baths, as suggested in the study 1
• The importance of maintaining good personal hygiene, including regular bathing and cleaning of hands with soap and water or an alcohol-based hand gel, as emphasized in the study 1
• The need to avoid reusing or sharing personal items that have contacted infected skin, as recommended in the study 1
• The potential use of oral antibiotics, such as doxycycline or TMP-SMX, in cases of recurrent infections, as suggested in the study 1
• The importance of screening and treating family members who may be colonized with MRSA to prevent recolonization, as recommended in the study 1
• The need for regular follow-up cultures to confirm successful decolonization or indicate the need for additional treatment cycles, as suggested in the example answer. It is essential to note that the treatment of persistent MRSA colonization in the groin should be individualized based on the patient's clinical response and should take into account the potential risks and benefits of different treatment strategies, as outlined in the studies 1, 1, and 1. Additionally, the use of rifampin as a single agent or as adjunctive therapy for the treatment of SSTI is not recommended, as stated in the study 1. The choice of antibiotic therapy should be guided by the results of culture and susceptibility testing, as recommended in the study 1. In summary, a comprehensive decolonization protocol that includes topical antiseptics, targeted antibiotics, and environmental decontamination, along with good personal hygiene and screening of family members, is essential for the effective treatment of persistent MRSA colonization in the groin.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION A small amount of mupirocin ointment should be applied to the affected area three times daily. The answer to persistent MRSA colonisation in the groin is not directly addressed in the provided drug label.

• Mupirocin ointment is applied to the affected area three times daily.
• The label does not specifically mention groin or persistent MRSA colonisation. 2

From the Research

Treatment of Persistent MRSA Colonization in the Groin

• The treatment of persistent MRSA colonization in the groin can be challenging, but several studies have shown that decolonization regimens can be effective 3, 4, 5, 6, 7.
• A study published in 2008 found that a standardized decolonization regimen consisting of mupirocin nasal ointment, chlorhexidine mouth rinse, and full-body wash with chlorhexidine soap for 5 days was highly effective in decolonizing MRSA carriers, with a success rate of 87% 3.
• Another study published in 2007 found that treatment with topical mupirocin, chlorhexidine gluconate washes, oral rifampin, and doxycycline for 7 days was safe and effective in eradicating MRSA colonization in hospitalized patients for at least 3 months 4.
• A more recent study published in 2023 found that a repeated post-discharge decolonization regimen for MRSA carriers reduced MRSA colonization overall and at multiple body sites, including the axilla/groin 5.
• A narrative review published in 2025 summarized the evidence on strategies for the elimination of MRSA colonization in community-onset MRSA carriers and found that topical therapy is proven to be effective in nasal-only carriage and in temporary load reduction, while addition of orally administered antibiotics likely increases success rates compared with topical therapy alone 6.
• A randomized controlled trial published in 2021 compared initial MRSA clearance and subsequent MRSA recolonization rates over a 12-month period after standard decolonization or systemic decolonization and found that initial MRSA clearance was more readily achieved with systemic decolonization than with standard decolonization 7.

Factors Influencing Decolonization Treatment Failure

• Several factors can influence decolonization treatment failure, including the presence of mupirocin-resistant isolates at baseline 4.
• The decision to pursue community-onset MRSA eradication treatment in the individual patient should be based on the combination of the treatment objective and the likelihood of successful decolonization, which is influenced by both individual risk factors for treatment failure and the risk of recolonization 6.

Decolonization Regimens

• Several decolonization regimens have been studied, including topical chlorhexidine gluconate, intranasal mupirocin, oral rifampin, and doxycycline 4, 7.
• The use of a combination of topical therapy with rifampin and another antimicrobial agent is supported by the majority of evidence 6.
• Decolonization treatment with probiotics is a promising novel non-antibiotic strategy 6.