Adding Nasal Decolonization to Infection Prevention Bundles

May 30, 2017

Infection Prevention Bundles with Nasal Decolonization

A bundle approach has been used to support prevention of many types of healthcare associated infections including CLABSI, CAUTI, VAP, and SSI.  Over the past few years, nasal decolonization has been added as a bundle element with increasing frequency, to reduce the risk of all of these types of infections.  With the advent of nasal antiseptics, nasal decolonization has never been cheaper and easier. And even more important, antiseptics do not contribute to emerging antibiotic resistance. Prudent use of antiseptics in place of antibiotics where efficacy is equal is becoming an important component of any comprehensive antibiotic stewardship program.

History of Bundles

In 2001, the Institute for Healthcare Improvement (IHI) developed the “bundle” concept as part of an IHI and Voluntary Hospital Association (VHA) joint project focused on Intensive Care Units (ICU).  This project involved 13 hospitals and focused on improving patient care in ICUs. The goal was to increase reliability of care processes to improve outcomes.  Focus areas were those with potential for great harm and high cost due to negative outcomes such as infection and where the evidence base for prevention was strong.

Care of patients on ventilators and those who had central lines became a strong focus. It was discovered during this process that by using a “bundle” — a small set of evidence-based interventions for a defined patient population and care setting — the improvements in patient outcomes exceeded expectations of both teams and faculty.

Thus began an innovative approach to improving care: the use of bundles. Read more here:

Important IP bundles

Clinical evidence supports adding nasal decolonization to infection prevention bundles for:

Replacing MRSA Contact Precautions
High Risk Patients

Surgical Site Infection (SSI) Prevention
A Baylor medical center study was recently published on their SSI reduction results after adding nasal decolonization with an alcohol based nasal antiseptic (Nozin® Nasal Sanitizer®) to their existing SSI prevention bundle.  Nasal decolonization was performed on patients pre-op and post-op. Medical staff were also encouraged to use the nasal antiseptic to help protect against possible transmission to patients. The Baylor study reported an
81% decrease in surgical site infections from 1.76 to 0.33 per 100 surgeries during the 15-month trial.(1)  Read about it here:

Device Associated Infection Prevention Including CRBSI, CAUTI, VAP in the ICU
Patients in intensive care units (ICU) typically have one or more indwelling devices including central venous catheters, ventilators, indwelling urinary catheters.  These devices serve as a direct conduit to organ spaces through which bacteria can migrate from the environment and result in infection.  One reservoir for contamination of the patient environment is the patient’s own nose.  Consequently nasal decolonization has been reported to be successful in reducing the rate of device associated infections, typically paired with skin decolonization with chlorhexidine.  Septimus in 2016, reported a decrease in CLABSI of 23.5% over six month after implementation of nasal and skin decolonization(1).  Although this study was performed using mupirocin for nasal decolonization, use of nasal antiseptics for ICU patients are being used to support antibiotic stewardship programs, as well as due to mupirocin resistance, treatment failure and cost.

MRSA and Other Staph aureus Infection Prevention
Contact precautions for patients colonized with MRSA is being reconsidered in an increasing number of facilities as unnecessary when a bundle including nasal and skin decolonization is performed.  Nina Deatherage at Marshal Medical Center, an acute care facility with 113 beds, reported that effective elimination of CP in MRSA non-infected patients while maintaining low infection rates and improving staff and patient satisfaction was achieved with nasal and skin decolonization. A significant reduction in CP-related PPE costs also resulted. Marshall used the Nozin® Nasal Sanitizer® alcohol based nasal antiseptic. (2)

A more recent study in March of 2017 reports that Of 320 HCWs, 96 (30%) were found to be nasal carriers of S. aureus, 20 of whom (6.3%) carried methicillin-resistant S. aureus (MRSA). All sensitive S. aureus (MSSA) was resistant to mupirocin. The purpose of the study was to highlight the relevance of nasal carriage of MRSA and MSSA in health care personnel and the risk of transmission to patients, and to recommend HCW screening decolonization strategies (3).

High Risk Patient Infections
Patients with co-morbidities and/or immunosuppression including burn patients, oncology patients, transplant patients and those on peritoneal dialysis or hemodialysis are at exceptionally high risk of serious morbidity or mortality in the event of a healthcare associated infection.  Visitors, healthcare workers and patients themselves can contaminate the patient environment, resulting in potential infection. Infections in these high risk groups are associated with significant morbidity, patient and family suffering and costs. Studies of nasal and skin decolonization of burn patients conclude that decolonization can reduce infection risk(4).  Studies of nasal and skin decolonization in dialysis patients concludes the same, though repeated treatment is required (5).  

The nasal vestibule can be a reservoir for pathogens in the healthcare environment. Evidence increasingly supports adding a nasal antiseptic to infection prevention bundles designed to improve care and reduce hospital acquired infections.  The availability of a well tolerated, alcohol based nasal antiseptic that conforms with antibiotic stewardship should further encourage this practice.
  1. Mullen A, et al. Perioperative participation of orthopedic patients and surgical staff. AJIC, 2017, Vol 45, Issue 5, 554 - 6. (Link)
  2. Septimus E et al. “Closing the Translation Gap: Toolkit-based Implementation of Universal Decolonization in Adult Intensive Care Units Reduces Central Line-associated Bloodstream Infections in 95 Community Hospitals”. Clin Infect Dis 2016 Jul 15;63(2):172-7.
  3. Deatherage N. “Impact of reduced isolation and contact precaution procedures on infection rates and facility costs at a nonprofit acute care hospital”. American Journal of Infection Control 2016 44:6 (S101-S102).  
  4. Boncompain CA1Suárez CA2Morbidoni HR3. Staphylococcus aureus nasal carriage in health care workers: First report from a major public hospital in Argentina. Rev Argent Microbiol. 2017 Mar 24. pii: S0325-7541(17)30010-X.
  5. Gray D1Foster K2Cruz A1Kane G1Toomey M1Bay C3Kardos P2Ostovar GA4.  Universal decolonization with hypochlorous solution in a burn intensive care unit in a tertiary care community hospital.  Am J Infect Control. 2016 Apr 11. pii: S0196-6553(16)00159-0.
  6. Karanika S1Zervou FN1Zacharioudakis IM1Paudel S1Mylonakis E2.  Risk factors for methicillin-resistant Staphylococcus aureus colonization in dialysis patients: a meta-analysis.  J Hosp Infect. 2015 Nov; 91(3):257-63.

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