Becker's Clinical Quality & Infection Control

21 Executive Briefing Sponsored by: N asal carriage of Staphylococcus aureus has been reported in 30 percent of the population, and methicillin-resistant Staphylococcus aureus in 3 percent to 5 percent of the population. These are major risk factors for infection in community and healthcare environments. It is also now well understood that the nose, as a primary reservoir for such pathogens, can be a prolific source of contamination. Clinical evidence reveals that nasal decolonization can significantly reduce the risk of transmission. However, the traditional use of the topical antibiotic mupirocin for nasal decolonization is not supportive of antibiotic stewardship guidelines. New infection prevention programs using alcohol- based Nozin® Nasal Sanitizer® antiseptic allow for wider application of nasal decolonization than previously available with subsequent lowering of pathogenic burden. The benefits to the healthcare community can be profound with significant reduction of infection risks, improvements in patient care as well as substantial cost savings in the intensive care unit, operating room and other high-risk areas. Evidence demonstrating that S. aureus nasal colonization was an infection risk led to efforts to identify effective antibiotics to control that risk. By the early 1980s, it became clear that S. aureus was capable of developing resistance to many antibiotics, including methicillin. Both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) are the cause of many infections. The antibiotic mupirocin became recognized as an effective S. aureus topical nasal decolonizing agent to reduce infection risk from both MRSA and MSSA in surgical and medical patients. A distinct disadvantage of mupirocin is its contribution to bacterial antibiotic resistance and the potential for transference of resistance to other bacteria. The pre-operative MRSA/MSSA decolonization procedure with mupirocin typically involves a five-day, twice-daily topical application to the vestibule. However, poor patient compliance with self-administration of the multiple applications is an issue. Furthermore, an increasing body of research indicates that the consistency of successful decolonization with mupirocin may be less than previously thought, even when applied by trained staff. The necessary multiday process also restricts its usefulness for patients requiring immediate surgery. The emergence of nasal antiseptics as a new approach to decolonization In response to these concerns, alternatives to antibiotic use for nasal bacterial decolonization were developed. Primary among these are nasal antiseptics which conform with antibiotic stewardship guidelines. Unlike mupirocin, which kills the cells slowly by interfering with cellular functions, antiseptics kill on contact. In the case of the Nozin® Nasal Sanitizer® antiseptic, the alcohol immediately dissolves the bacterial cell membrane and coagulates its proteins. The carriage of MRSA, MSSA and other potentially infectious pathogens can be reduced upon application of the antiseptic with simple reapplications to maintain decolonization. The magnitude and time course of the alcohol-based bactericidal activity is substantial, achieving multiple log reductions in overall bacterial levels within seconds, with persistence extending for 12 hours, requiring only twice-daily applications to maintain patient safety. Bacteria are not known to develop resistance to alcohol's effects. Programs using Nozin® Nasal Sanitizer® antiseptic Perioperative strategies The perioperative use of the Nozin® antiseptic adopted by many hospitals addresses the belief that not all surgical site infections are initiated intra-operatively and that infection risk extends to the post-operative period. To maintain decolonization post-surgery, the patient enters a twice-daily regimen of Nozin® applications that extends until discharge. Because of the cross-inoculation that has been demonstrated between nasal and body skin colonization, a bundle of nasal decolonization and daily skin decolonization with baths or wipes is recommended. To minimize contamination of at-risk surgical wounds through the common pathway of nose-to- hand transmission following early (1 to 3 day) discharge, some facilities send the Nozin® product home for continued use by both patient and home caregiver. In one study published in the American Journal of Infection Control in 2017, perioperative use of the alcohol nasal antiseptic in spine patients was added to existing infection control protocols that included CHG bathing. The addition of nasal decolonization resulted in an 81 percent decrease in S. aureus SSIs, compared to the nine-month baseline period, which was maintained during the 15-month study period. Protection was extended to those with patient contact; pre- operative staff and surgical team members also voluntarily adopted daily self-use of the Nozin® antiseptic. In a study presented at the 2018 American Academy of Orthopedic Surgeons conference, the addition of perioperative alcohol-based nasal decolonization to existing CHG bathing in hip and knee patients was assessed. All-cause SSI rates decreased 78.5 percent to 0.34 percent in treated patients during the prospective seven-month study period compared to 1.5 percent in matched control patients in the preceding 12 months. More information is available at Nozin.com. The importance of advances in nasal decolonization for current and future infection prevention

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