Why Nasal Decolonization is Needed for Infection Prevention in 2020

For Healthcare Professionals

March 11, 2020

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Ever since Ignaz Semmelweis’s discovery, in 1847, that handwashing with a chlorine solution significantly reduced maternal mortality, the medical profession has been making incremental strides in the theory of infection prevention1. In the 20th century, the focus was on pathogen vectors; sanitizing and sterilizing contaminated surfaces, blocking airborne transmission, and handwashing were instrumental in reducing the spread of infectious agents. However, hospital acquired infections (HAIs) continue to burden the healthcare industry and antimicrobial resistance is rendering some traditional infection prevention measures ineffective. 

The beginning of the 21st century is witnessing a paradigm-shift in infection prevention. Nasal decolonization is being effectively used to target pathogens at their source without increasing antimicrobial resistance through the use of antiseptics. Hospitals across the country have incorporated nasal decolonization into their infection prevention programs, with promising results. 

What is nasal decolonization?

The nasal vestibule (or anterior nares) host diverse microbiota, including potentially pathogenic bacteria2. Asymptomatic carriers may unwittingly contaminate nearly everything they come into contact with, putting hospitalized patients at risk for potentially life-threatening infections. Increased hand hygiene practices among hospital staff, patients, and visitors have helped to limit the spread of bacteria, but hand-to-nose contact and sneezing are still major drivers for the spread of infectious particles. 

Nasal decolonization refers to the intranasal application of a topical bactericidal agent. The antibiotic mupirocin was considered by many to be the “gold standard” nasal decolonizer; however,  concerns over antibiotic resistance and a growing need for more prudent antibiotic stewardship have led researchers to seek out non-antibiotic alternatives. Recently, alcohol-based nasal antiseptics  have been shown to significantly reduce the number of pathogenic bacteria that are harbored in the nasal vestibule without contributing to antibiotic resistance3

Nozin® Nasal Sanitizer® is a patented, highly effective alcohol-based nasal antiseptic and is the first that has been incorporated into hospital infection prevention programs across the United States.  Mounting evidence continues to prove that its use in hospital infection prevention programs is associated with significant reductions in both S. aureus and MRSA infections3,4. In addition, nasal decolonization is associated with increased patient satisfaction and cost savings. 

Which infections does nasal decolonization help to prevent?

Recently published data support the use of an alcohol-based nasal decolonization agent to help reduce the risk for infections caused by several types of bacteria. Although the majority of studies have focused on Gram-positive S. aureus, alcohols have known bactericidal activity against both Gram-positive and Gram-negative bacteria. Thus, alcohol-based nasal decolonization is expected to be similarly effective against both types of bacteria. 


Gram-positive bacteria like Staphylococcus and Streptococcus frequently colonize nasal vestibules and are major contributors to the spread of HAIs

Staphylococcus aureus

S. aureus, colloquially known as ‘staph,’ is a permanent, asymptomatic colonizer of the nasal vestibules in up to 30% of Americans, and most people are intermittent carriers of S. aureus5. In other words, up to 30% of people have persistent nasal colonies of S. aureus in their nose, but do not develop symptoms of infection. In healthy people, staph is relatively benign as long as it does not enter the bloodstream. However, bacteremia can quickly lead to life-threatening sepsis. 

Immunocompromised people, including High Risk patients (e.g., transplant, surgical, dialysis) are less tolerant of staph infections. In healthy people, staph outbreaks activate the innate and adaptive arms of the immune system, which limit the pathogenicity. A suppressed immune system is unable to control the infection, and S. aureus can quickly cause pneumonia or bacteremia5

Two subclasses of S. aureus warrant further consideration:

  • Methicillin-resistant S. aureus (MRSA):

MRSA is infamous as one of the first “superbugs,” and MRSA infections are associated with increased morbidity and mortality compared to S. aureus. An estimated 2% of the American population are asymptomatic carriers, and over 4% of healthcare workers carry MRSA6,7.

  • Methicillin-susceptible S. aureus (MSSA):

MSSA-related infections have become more common in hospitals than MRSA in recent years, but they have a reduced mortality rate8. MSSA can cause skin and soft tissue infections, bacteremia, and pneumonia among others. 

Streptococcus pneumoniae

Streptococcus pneumoniae is a common type of Gram-positive bacteria that colonizes the nasal vestibule; nearly 10% of adults are carriers and, by some estimates, up to 65% of children are asymptomatic carriers of S. pneumoniae9. Pneumonia, sepsis, and meningitis are associated with S. pneumoniae infections. 


The majority of research into the effectiveness of alcohol-based nasal decolonization as a way to help reduce the risk for infection has been done using Gram-positive S. aureus, but recent studies have demonstrated that Gram-negative bacteria are also susceptible to decolonization4. These findings are especially important in light of the increasing numbers of multi-drug resistant Gram-negative bacteria. 

Escherichia coli

E. coli is an example of a common Gram-negative bacteria that can be found in the nasal vestibule. Some strains of E. coli are rapidly developing multi-drug resistance, underscoring the need for new approaches to preventing outbreaks10. Alcohol has bactericidal activity against E. coli without contributing to antimicrobial resistance. 


Fungi, including yeast, have recently become increasingly common causes of infections in hospitalized patients. Candida is a type of yeast that causes several types of infections in people, and it colonizes the nasal vestibules. Alcohol-based sanitizers are effective at killing Candida without increasing antimicrobial resistance11

Candida auris

C. auris is a new strain of Candida, having first been identified in 2009. The first case of C. auris infection in the US was diagnosed in 2016, and since then 16 states have confirmed C. auris infections in hospitals12. The emergence and rapid spread of C. auris led the CDC to classify it as an emerging pathogen, and early reports suggest it has a mortality rate of 30-60%13. Alarmingly, hospital-acquired C. auris infections are often resistant to the three main classes of antifungal medications, underscoring the need for new methods to prevent contamination and infection14. Preliminary studies on nasal decolonization of C. auris are very promising15, and Nozin® Nasal Sanitizer® antiseptic has been shown to reduce C. auris colonies by over 99.9% in in vitro studies. 


Why nasal decolonization should be part of your infection prevention protocol

In 2013, the CDC published an enhanced protocol for infection control in ICUs based on the results of their REDUCE MRSA (Randomized Evaluation of Decolonization vs. Universal Clearance to Eliminate Methicillin Resistant Staphylococcus aureus) Trial16. The goal of the trial was to evaluate whether universal decolonization (providing decolonization treatment to every ICU patient upon admission) was more effective at preventing the spread of MRSA than standard screen-and-treat protocols. The results support the use of a universal decolonization strategy over a more targeted approach for ICU patients. These findings have since been repeated and expanded on, with one recent computational simulation study finding that universal ICU decolonization of all ICU beds in Orange County, CA translated to a 3.2% reduction in countywide MRSA prevalence17.

There are a number of reasons why all hospitals should incorporate universal alcohol-based nasal decolonization into their infection prevention programs:

  • A growing body of literature supports the effectiveness of nasal decolonization to help reduce the risk of spreading infection. Recent studies have shown that implementation of universal alcohol-based nasal decolonization programs for patients can reduce S. aureus surgical site infections by up to 98% and MRSA bacteremia by as much as 96%4,18.
  • All healthcare facilities have an important role to play in antimicrobial stewardship. The rise of multi-drug resistant bacteria poses a very serious risk to patients; alcohol-based nasal antiseptic effectively reduces the prevalence of many types of bacteria without increasing risk for antimicrobial-resistance10.
  • Universal nasal decolonization among patients reduces the need for contact precautions, which has been shown to increase patient satisfaction and reduce hospital expenditures5,19.
  • Evidence shows that incorporating universal decolonization is more effective than standard screening protocols and targeted decolonization at preventing the spread of MRSA. “Colonization pressure” (the fraction of MRSA carriers in a facility) is an important driver of MRSA transmission; implementing universal decolonization significantly reduces colonization pressure20.
  • The Society for Healthcare Epidemiology of America (SHEA), the Health Research and Educational Trust (HRET), and the Centers for Disease Control and Prevention (CDC) all include nasal decolonization as a component of infection prevention protocols10,21,22


Nasal colonization by pathogenic bacteria poses a substantial risk to both hospitals and the broader community. While conventional infection prevention protocols have significantly reduced the frequency of hospital-acquired infections (HAIs), they are still a frustratingly common challenge for hospitals. 

Well designed infection prevention programs that include nasal decolonization, specifically with Nozin® Nasal Sanitizer® antiseptic, can be an effective way to significantly reduce the spread of bacteria and fungi while simultaneously increasing patient satisfaction and reducing the financial burden of HAIs. The results include healthier patients and staff members who have a positive impact on the health of the broader community. 



1. Kadar, N., Romero, R., Papp, Z. (2018). Ignaz Semmelweis: the “Savior of Mothers”. American Journal of Obstetrics and Gynecology. doi:10.1016/j.ajog.2018.10.036

2. Kumpitsch, C., et al. (2019) The microbiome of the upper respiratory tract in health and disease. BMC Biology 17, 87. https://doi.org/10.1186/s12915-019-0703-z 

3. Steed, L. L., et al. (2014). Reduction of nasal Staphylococcus aureus carriage in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antiseptic. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2014.04.008

4. Arden, S. (2019). 567-Does Universal Nasal Decolonization with an Alcohol-Based Nasal Antiseptic Reduce Infection Risk and Cost? Poster presented at: IDWeek; 2019 October 2-6; Washington D.C.

5. Sakr, A., et al. (2018). Staphylococcus aureus Nasal Colonization: An Update on Mechanisms, Epidemiology, Risk Factors, and Subsequent Infections. Frontiers in Microbiology. doi:10.3389/fmicb.2018.02419

6. Kavanagh, K. T. (2019). Control of MSSA and MRSA in the United States: protocols, policies, risk adjustment and excuses. Antimicrobial Resistance & Infection Control 8(103). https://doi.org/10.1186/s13756-019-0550-2

7. Dulon, M., Peters, C., Schablon, A., & Nienhaus, A. (2014). MRSA carriage among healthcare workers in non-outbreak settings in Europe and the United States: a systematic review. BMC Infectious Diseases, 14, 363. doi:10.1186/1471-2334-14-363

8. David, M. Z., Boyle-Vavra, S., Zychowski, D. L., & Daum, R. S. (2011). Methicillin-susceptible Staphylococcus aureus as a predominantly healthcare-associated pathogen: a possible reversal of roles?. PloS One, 6(4), e18217. doi:10.1371/journal.pone.0018217

9. Weiser, J. N., Ferreira, D. M., & Paton, J. C. (2018). Streptococcus pneumoniae: transmission, colonization and invasion. Nature Reviews. Microbiology, 16(6), 355–367. doi:10.1038/s41579-018-0001-8

10. Septimus, E. J., & Schweizer, M. L. (2016). Decolonization in Prevention of Health Care-Associated Infections. Clinical Microbiology Reviews, 29(2), 201–222. doi:10.1128/CMR.00049-15

11. Peters, B. M., et al. (2013). Efficacy of ethanol against Candida albicans and Staphylococcus aureus polymicrobial biofilms. Antimicrobial Agents and Chemotherapy, 57(1), 74–82. https://doi.org/10.1128/AAC.01599-12 

12. Centers for Disease Control and Prevention. (2020). Tracking Candida auris. Accessed February 17, 2020. 

13. Tsay, S., et al. (2018). Approach to the Investigation and Management of Patients With Candida auris, an Emerging Multidrug-Resistant Yeast. Clinical Infectious Diseases 66(2), 306–311. 

14. Forsberg, K., et al. (2019). Candida auris: The recent emergence of a multidrug-resistant fungal pathogen. Medical Mycology 57(1):1-12. 

15. Schelenz, S., et al. (2016). First hospital outbreak of the globally emerging Candida auris in a European hospital. Antimicrobial Resistance and Infection Control, 5, 35. https://doi.org/10.1186/s13756-016-0132-5

16. REDUCE MRSA Trial Working Group (under contract HHSA290201000008i). (2013). Universal ICU Decolonization: An Enhanced Protocol. AHRQ Publication No. 13-0052-EF. Rockville, MD: Agency for Healthcare Research and Quality.

17. Lee, B. Y., et al. (2016). Beyond the Intensive Care Unit (ICU): Countywide Impact of Universal ICU Staphylococcus aureus Decolonization. American Journal of Epidemiology, 183(5), 480–489. https://doi.org/10.1093/aje/kww008

18. Stegmeier, H. (2019). 1238 - Alcohol-based Nasal Antiseptic as Part of a Bundle to Reduce the Incidence of Contact Precautions and Surgical Site Infections. Poster presented at: IDWeek; 2019 October 2-6; Washington D.C.

19. Mehrotra, P., et al. (2013). Effects of contact precautions on patient perception of care and satisfaction: a prospective cohort study. Infection Control and Hospital Epidemiology, 34(10), 1087–1093. doi:10.1086/673143

20. Septimus, E., et al. (2016). 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. Clinical Infectious Diseases. 2016 Jul 15; 63(2):172-7.  

21. Health Research & Educational Trust (2018). Surgical Site Infections Change Package: 2018 Update. Chicago, IL: Health Research & Educational Trust. Accessed February 6, 2020. 

22. Centers for Disease Control and Prevention. (2019). Strategies to Prevent Hospital-onset Staphylococcus aureus Bloodstream Infections in Acute Care Facilities. Accessed February 6, 2020.

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