Can Nasal Bactroban Before Surgery Prevent MRSA?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections have been catastrophic for patients—they result in longer hospital stays and poorer outcomes. More than 80% of the time, infections result because of Staph aureus that we are carrying, in our nose or on our skin.

For those of us who may be carriers of Staph aureus (it lives in our nose)—does attempting to decolonize our nose with Bactroban (mupirocin) antibiotic ointment help prevent these infections after surgery? Let’s find out.

First, know that in most studies about 10 – 18% of us will have a positive nasal swab for Staph aureus, meaning we are a carrier of that bacteria in our noses.

The medical community has spent the last few years trying to answer whether Bactroban 2% ointment used twice a day for 5 days in your nostrils prior to surgery prevents surgical site infections. How this works: during your pre-operative visit a nasal screening swab is done and if you are positive for S. aureus you are treated with 5 nights of ointment in your nose before your surgery. So should we do it before all surgeries?

Hip and knee replacement surgeries:

Here, the data is the most convincing. For reducing infections after hip and knee replacement, the answer appears to be yes. If your nasal swab is positive for S. aureus, treatment with Bactroban for 5 days before surgery has been shown to decrease surgical site infections by 69%.

Which other surgical patients get the most benefit from pre-screening and treatment?

Cardiovascular or vascular procedures with implantation of prosthetic grafts and orthopedic joint procedures. The benefit of Bactroban in other device-related surgical procedures like hernia mesh is unknown and currently not supported by the medical/surgical literature.

Does it lower risk of death along with lower surgical site infection risk?

In a large study using Bactroban ointment and chlorhexidine wipes, the authors found that treatment prior to surgery (in those whose nasal swabs were positive) reduced infections by 60%. The bonus here was that longer-term follow up also noted decreased mortality in those screened and treated. Detection and decolonization of Staph aureus not only prevents surgical-site infections but also reduces 1-year mortality in some surgical patients (Bode, NEJM Jan 2010).

What do I use?

The best regimen to decolonize your nose and skin of Staph aureus isn’t clear. The current recommendation is nasal Bactroban twice a day for 5 days. To decolonize the skin, some also recommend using 2% or 4% chlorhexidine gluconate (also known as Hibiclens) body cleansing once a day for 2 – 3 days prior to surgical admission.

How do I use it?

Bactroban (mupirocin), one gram in each nostril, twice a day for 5 days. It’s a prescription that comes in prepacked tubes (a pack of 10, each with 1 gram). You should know though, it’s much cheaper to get a tube (22 grams) of Bactroban ointment and estimate a gram in each nostril. One gram is two finger tip units, so squeeze along your fingertip to estimate.

Take home message:

While there is some debate, hospital-acquired infections with S. aureus in surgical patients can be prevented by screening to see if you are a carrier—and treating with Bactroban nasal ointment if S. aureus is found.

Dr O.

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