Skip to main content

Does the Nose Know? An Update on MRSA Decolonization Strategies

Current Infectious Disease Reports volume 15, pages 455–464 (2013)Cite this article

Abstract

Colonization with methicillin-resistant Staphylococcus aureus (MRSA) is an important step in the pathogenesis of active infection and is a key factor in the epidemiology of MRSA infection. Decolonization of patients found to have MRSA carriage may be of value in certain patient populations, especially those undergoing elective surgery. However, the most commonly used agent for decolonization, mupirocin, comes with a considerable risk of resistance if widely employed. Recent studies of other novel agents for decolonization show promise, but further research is necessary. This review focuses on the pathogenesis from MRSA colonization to infection, identifies the risk factors for colonization, and summarizes decolonization strategies, including novel approaches that may have a role in decreasing MRSA disease burden.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Hsueh PR, Chen ML, Sun CC, et al. Antimicrobial drug resistance in pathogens causing nosocomial infections at a university hospital in Taiwan, 1981–1999. Emerg Infect Dis. 2002;8(1):63–8.

    PubMed  Article  Google Scholar 

  2. Tiemersma EW, Bronzwaer SL, Lyytikainen O, et al. Methicillin-resistant Staphylococcus aureus in Europe, 1999–2002. Emerg Infect Dis. 2004;10(9):1627–34.

    PubMed  Article  Google Scholar 

  3. Wertheim HF, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005;5(12):751–62.

    PubMed  Article  Google Scholar 

  4. Williams RE. Healthy carriage of Staphylococcus aureus: its prevalence and importance. Bacteriol Rev. 1963;27:56–71.

    PubMed  CAS  Google Scholar 

  5. Schechter-Perkins EM, Mitchell PM, Murray KA, Rubin-Smith JE, Weir S, Gupta K. Prevalence and predictors of nasal and extranasal staphylococcal colonization in patients presenting to the emergency department. Ann Emerg Med. 2011;57(5):492–99.

    Google Scholar 

  6. Smith TC, Forshey BM, Hanson BM, Wardyn SE, Moritz ED. Molecular and epidemiologic predictors of Staphylococcus aureus colonization site in a population with limited nosocomial exposure. Am J Infect Control. 2012;40(10):992–96.

    Google Scholar 

  7. McKinnell JA, Huang SS, Eells SJ, Cui E, Miller LG. Quantifying the impact of extranasal testing of body sites for methicillin-resistant Staphylococcus aureus colonization at the time of hospital or intensive care unit admission. Infect Control Hosp Epidemiol. 2013;34(2):161–70.

    Google Scholar 

  8. Reagan DR, Doebbeling BN, Pfaller MA, et al. Elimination of coincident Staphylococcus aureus nasal and hand carriage with intranasal application of mupirocin calcium ointment. Ann Intern Med. 1991;114(2):101–6.

    PubMed  Article  CAS  Google Scholar 

  9. Parras F, Guerrero MC, Bouza E, et al. Comparative study of mupirocin and oral co-trimoxazole plus topical fusidic acid in eradication of nasal carriage of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 1995;39(1):175–9.

    PubMed  Article  CAS  Google Scholar 

  10. Armstrong-Esther CA. Carriage patterns of Staphylococcus aureus in a healthy non-hospital population of adults and children. Ann Hum Biol. 1976;3(3):221–7.

    PubMed  Article  CAS  Google Scholar 

  11. Noble WC, Williams RE, Jevons MP, Shooter RA. Some aspects of nasal carriage of staphylococci. J Clin Pathol. 1964;17:79–83.

    PubMed  Article  CAS  Google Scholar 

  12. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10(3):505–20.

    PubMed  CAS  Google Scholar 

  13. Wertheim HF, Vos MC, Ott A, et al. Risk and outcome of nosocomial Staphylococcus aureus bacteraemia in nasal carriers versus non-carriers. Lancet. 2004;364(9435):703–5.

    PubMed  Article  Google Scholar 

  14. Davis KA, Stewart JJ, Crouch HK, Florez CE, Hospenthal DR. Methicillin-resistant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effect on subsequent MRSA infection. Clin Infect Dis. 2004;39(6):776–82.

    PubMed  Article  Google Scholar 

  15. von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344(1):11–6.

    Article  Google Scholar 

  16. Williams RE, Jevons MP, Shooter RA, et al. Nasal staphylococci and sepsis in hospital patients. Br Med J. 1959;2(5153):658–62.

    PubMed  Article  CAS  Google Scholar 

  17. Huang SS, Platt R. Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis. 2003;36(3):281–5.

    PubMed  Article  Google Scholar 

  18. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380–90.

    PubMed  Article  CAS  Google Scholar 

  19. Stevens AM, Hennessy T, Baggett HC, Bruden D, Parks D, Klejka J. Methicillin-resistant Staphylococcus aureus carriage and risk factors for skin infections, Southwestern Alaska, USA. Emerg Infect Dis. 2010;16(5):797–803.

    Google Scholar 

  20. Robicsek A, Suseno M, Beaumont JL, Thomson Jr RB, Peterson LR. Prediction of methicillin-resistant Staphylococcus aureus involvement in disease sites by concomitant nasal sampling. J Clin Microbiol. 2008;46(2):588–92.

    PubMed  Article  Google Scholar 

  21. Safdar N, Bradley EA. The risk of infection after nasal colonization with Staphylococcus aureus. Am J Med. 2008;121(4):310–5.

    PubMed  Article  Google Scholar 

  22. Harbarth S, Liassine N, Dharan S, Herrault P, Auckenthaler R, Pittet D. Risk factors for persistent carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2000;31(6):1380–5.

    PubMed  Article  CAS  Google Scholar 

  23. Forster AJ, Oake N, Roth V, et al. Patient-level factors associated with methicillin-resistant Staphylococcus aureus carriage at hospital admission: a systematic review. Am J Infect Control. 2013;41(3):214–20.

    Google Scholar 

  24. Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299(10):1149–57.

    PubMed  Article  CAS  Google Scholar 

  25. van Rijen MM, Bonten M, Wenzel RP, Kluytmans JA. Intranasal mupirocin for reduction of Staphylococcus aureus infections in surgical patients with nasal carriage: a systematic review. J Antimicrob Chemother. 2008;61(2):254–61.

    PubMed  Article  Google Scholar 

  26. Garcia AM, Villa MV, Escudero ME, et al. Use of nasal mupirocin for Staphylococcus aureus: effect on nasal carriers and nosocomial infections. Biomedica. 2003;23(2):173–9.

    PubMed  Google Scholar 

  27. Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, et al. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35(4):353–8.

    PubMed  Article  CAS  Google Scholar 

  28. Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006;64(2):162–8.

    PubMed  Article  CAS  Google Scholar 

  29. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med. 2002;346(24):1871–7.

    PubMed  Article  CAS  Google Scholar 

  30. Muder RR, Boldin M, Brennen C, et al. A controlled trial of rifampicin, minocycline, and rifampicin plus minocycline for eradication of methicillin-resistant Staphylococcus aureus in long-term care patients. J Antimicrob Chemother. 1994;34(1):189–90.

    PubMed  Article  CAS  Google Scholar 

  31. Mulhausen PL, Harrell LJ, Weinberger M, Kochersberger GG, Feussner JR. Contrasting methicillin-resistant Staphylococcus aureus colonization in Veterans Affairs and community nursing homes. Am J Med. 1996;100(1):24–31.

    PubMed  Article  CAS  Google Scholar 

  32. Niclaes L, Buntinx F, Banuro F, Lesaffre E, Heyrman J. Consequences of MRSA carriage in nursing home residents. Epidemiol Infect. 1999;122(2):235–9.

    PubMed  Article  CAS  Google Scholar 

  33. Mody L, Kauffman CA, McNeil SA, Galecki AT, Bradley SF. Mupirocin-based decolonization of Staphylococcus aureus carriers in residents of 2 long-term care facilities: a randomized, double-blind, placebo-controlled trial. Clin Infect Dis. 2003;37(11):1467–74.

    PubMed  Article  Google Scholar 

  34. Kluytmans JA, Manders MJ, van Bommel E, Verbrugh H. Elimination of nasal carriage of Staphylococcus aureus in hemodialysis patients. Infect Control Hosp Epidemiol. 1996;17(12):793–7.

    PubMed  Article  CAS  Google Scholar 

  35. Peacock SJ, Mandal S, Bowler IC. Preventing Staphylococcus aureus infection in the renal unit. QJM. 2002;95(6):405–10.

    PubMed  Article  CAS  Google Scholar 

  36. Sandri AM, Dalarosa MG, Ruschel de Alcantara L, da Silva Elias L, Zavascki AP. Reduction in incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection in an intensive care unit: role of treatment with mupirocin ointment and chlorhexidine baths for nasal carriers of MRSA. Infect Control Hosp Epidemiol. 2006;27(2):185–7.

    PubMed  Article  Google Scholar 

  37. • Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255–65. This study found that in ICUs, universal decolonization with nasal mupirocin and daily chlorhexidine bathing was more effective than targeted decolonization or screening and isolation in reducing rates of bloodstream infection.

  38. Ammerlaan HS, Kluytmans JA, Berkhout H, et al. Eradication of carriage with methicillin-resistant Staphylococcus aureus: effectiveness of a national guideline. J Antimicrob Chemother. 2011;66(10):2409–17.

    PubMed  Article  CAS  Google Scholar 

  39. Ward A, Campoli-Richards DM. Mupirocin. A review of its antibacterial activity, pharmacokinetic properties and therapeutic use. Drugs. 1986;32(5):425–44.

    PubMed  Article  CAS  Google Scholar 

  40. Patel JB, Gorwitz RJ, Jernigan JA. Mupirocin resistance. Clin Infect Dis. 2009;49(6):935–41.

    PubMed  Article  CAS  Google Scholar 

  41. Eltringham I. Mupirocin resistance and methicillin-resistant Staphylococcus aureus (MRSA). J Hosp Infect. 1997;35(1):1–8.

    PubMed  CAS  Google Scholar 

  42. Hodgson JE, Curnock SP, Dyke KG, Morris R, Sylvester DR, Gross MS. Molecular characterization of the gene encoding high-level mupirocin resistance in Staphylococcus aureus J2870. Antimicrob Agents Chemother. 1994;38(5):1205–8.

    PubMed  Article  CAS  Google Scholar 

  43. Udo EE, Jacob LE, Mathew B. Genetic analysis of methicillin-resistant Staphylococcus aureus expressing high- and low-level mupirocin resistance. J Med Microbiol. 2001;50(10):909–15.

    PubMed  CAS  Google Scholar 

  44. Harbarth S, Dharan S, Liassine N, Herrault P, Auckenthaler R, Pittet D. Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 1999;43(6):1412–6.

    PubMed  CAS  Google Scholar 

  45. Simor AE, Phillips E, McGeer A, et al. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44(2):178–85.

    PubMed  Article  CAS  Google Scholar 

  46. Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. 2009;48(7):922–30.

    PubMed  Article  CAS  Google Scholar 

  47. Dryden MS, Dailly S, Crouch M. A randomized, controlled trial of tea tree topical preparations versus a standard topical regimen for the clearance of MRSA colonization. J Hosp Infect. 2004;56(4):283–6.

    PubMed  Article  CAS  Google Scholar 

  48. Ellis MW, Griffith ME, Dooley DP, et al. Targeted intranasal mupirocin to prevent colonization and infection by community-associated methicillin-resistant Staphylococcus aureus strains in soldiers: a cluster randomized controlled trial. Antimicrob Agents Chemother. 2007;51(10):3591–8.

    PubMed  Article  CAS  Google Scholar 

  49. Caffrey AR, Quilliam BJ, LaPlante KL. Risk factors associated with mupirocin resistance in meticillin-resistant Staphylococcus aureus. J Hosp Infect. 2010;76(3):206–10.

    Google Scholar 

  50. McConeghy KW, Mikolich DJ, LaPlante KL. Agents for the decolonization of methicillin-resistant Staphylococcus aureus. Pharmacotherapy. 2009;29(3):263–80.

    PubMed  Article  CAS  Google Scholar 

  51. O’Grady S, Hirji Z, Pejcic-Karapetrovic B, et al. A double-blind, randomized, controlled trial of topical polysporin triple compound versus topical mupirocin for the eradication of colonization with methicillin-resistant Staphylococcus aureus in a complex continuing care population. Can J Infect Dis Med Microbiol. 2009;20(3):e49–55.

    PubMed  Google Scholar 

  52. Pastagia M, Euler C, Chahales P, Fuentes-Duculan J, Krueger JG, Fischetti VA. A novel chimeric lysin shows superiority to mupirocin for skin decolonization of methicillin-resistant and -sensitive Staphylococcus aureus strains. Antimicrob Agents Chemother. 2011;55(2):738–44.

    Google Scholar 

  53. Blackwood B, Thompson G, McMullan R, et al. Tea tree oil (5%) body wash versus standard care (Johnson’s Baby Softwash) to prevent colonization with methicillin-resistant Staphylococcus aureus in critically ill adults: a randomized controlled trial. J Antimicrob Chemother. 2013.

  54. Rittenhouse S, Biswas S, Broskey J, et al. Selection of retapamulin, a novel pleuromutilin for topical use. Antimicrob Agents Chemother. 2006;50(11):3882–5.

    PubMed  Article  CAS  Google Scholar 

  55. Candel FJ, Morales G, Picazo JJ. In vitro activity of retapamulin against linezolid and methicillin-resistant Staphylococcus aureus isolates. Rev Esp Quimioter. 2011;24(3):127–30.

    Google Scholar 

  56. Naderer OJ, Anderson M, Roberts K, et al. Nasal Decolonization of Persistent Staphylococcus aureus Carriers with Twice Daily Retapamulin Treatment for 3 or 5 Days. Presentation Number L-1492. 48th ICAAC/46th IDSA Annual Meeting, Washington, DC, October 25–28, 2008.

  57. Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167(19):2073–9.

    PubMed  Article  Google Scholar 

  58. Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533–42.

    Google Scholar 

  59. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338(8763):339–43.

    PubMed  Article  CAS  Google Scholar 

  60. • Milstone AM, Elward A, Song X, et al. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet. 2013;381(9872):1099–1106. This study found that critically ill children receiving daily chlorhexidine bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine and the treatment was well tolerated.

  61. Heggers JP, Sazy JA, Stenberg BD, et al. Bactericidal and wound-healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil. 1991;12(5):420–4.

    PubMed  Article  CAS  Google Scholar 

  62. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18–55.

    Google Scholar 

  63. Fisher RG, Chain RL, Hair PS, Cunnion KM. Hypochlorite killing of community-associated methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2008;27(10):934–5.

    PubMed  Article  Google Scholar 

  64. Fritz SA, Camins BC, Eisenstein KA, et al. Effectiveness of measures to eradicate Staphylococcus aureus carriage in patients with community-associated skin and soft-tissue infections: a randomized trial. Infect Control Hosp Epidemiol. 2011;32(9):872–80.

    Google Scholar 

  65. Chang SC, Hsieh SM, Chen ML, Sheng WH, Chen YC. Oral fusidic acid fails to eradicate methicillin-resistant Staphylococcus aureus colonization and results in emergence of fusidic acid-resistant strains. Diagn Microbiol Infect Dis. 2000;36(2):131–6.

    PubMed  Article  CAS  Google Scholar 

  66. Peterson LR, Quick JN, Jensen B, et al. Emergence of ciprofloxacin resistance in nosocomial methicillin-resistant Staphylococcus aureus isolates. Resistance during ciprofloxacin plus rifampin therapy for methicillin-resistant S aureus colonization. Arch Intern Med. 1990;150(10):2151–5.

    PubMed  Article  CAS  Google Scholar 

  67. Walsh TJ, Standiford HC, Reboli AC, et al. Randomized double-blinded trial of rifampin with either novobiocin or trimethoprim-sulfamethoxazole against methicillin-resistant Staphylococcus aureus colonization: prevention of antimicrobial resistance and effect of host factors on outcome. Antimicrob Agents Chemother. 1993;37(6):1334–42.

    PubMed  Article  CAS  Google Scholar 

  68. Rouse MS, Rotger M, Piper KE, et al. In vitro and in vivo evaluations of the activities of lauric acid monoester formulations against Staphylococcus aureus. Antimicrob Agents Chemother. 2005;49(8):3187–91.

    PubMed  Article  CAS  Google Scholar 

  69. Kokai-Kun JF, Walsh SM, Chanturiya T, Mond JJ. Lysostaphin cream eradicates Staphylococcus aureus nasal colonization in a cotton rat model. Antimicrob Agents Chemother. 2003;47(5):1589–97.

    PubMed  Article  CAS  Google Scholar 

  70. LaPlante KL. In vitro activity of lysostaphin, mupirocin, and tea tree oil against clinical methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis. 2007;57(4):413–8.

    PubMed  Article  CAS  Google Scholar 

  71. Fritsche TR, Rhomberg PR, Sader HS, Jones RN. In vitro activity of omiganan pentahydrochloride tested against vancomycin-tolerant, -intermediate, and -resistant Staphylococcus aureus. Diagn Microbiol Infect Dis. 2008;60(4):399–403.

    PubMed  Article  CAS  Google Scholar 

  72. Embleton ML, Nair SP, Cookson BD, Wilson M. Selective lethal photosensitization of methicillin-resistant Staphylococcus aureus using an IgG-tin (IV) chlorin e6 conjugate. J Antimicrob Chemother. 2002;50(6):857–64.

    PubMed  Article  CAS  Google Scholar 

  73. Embleton ML, Nair SP, Cookson BD, Wilson M. Antibody-directed photodynamic therapy of methicillin resistant Staphylococcus aureus. Microb Drug Resist. 2004;10(2):92–7.

    PubMed  Article  CAS  Google Scholar 

  74. Roos K, Simark-Mattsson C, Grahn Hakansson E, Larsson L, Sandberg T, Ahren C. Can probiotic lactobacilli eradicate persistent carriage of meticillin-resistant Staphylococcus aureus? J Hosp Infect. 2011;78(1):77–78.

    Google Scholar 

  75. Vipra AA, Desai SN, Roy P, et al. Antistaphylococcal activity of bacteriophage derived chimeric protein P128. BMC Microbiol. 2012;12:41.

    Google Scholar 

Download references

Funding

Nasia Safdar received a MERIT grant from the Department of Veterans Affairs.

Compliance with Ethics Guidelines

ᅟ

Conflict of Interest

C.L. Abad M. S. Pulia and N. Safdar declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Affiliations

  1. Section of Infectious Diseases, Department of Medicine, The Medical City, Pasig City, Philippines

    C. L. Abad

  2. Section of Emergency Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    M. S. Pulia

  3. William S. Middleton Memorial Veterans Affairs Medical Center, Madison, WI, USA

    N. Safdar

  4. Section of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, MFCB 5221, 1685 Highland Ave, Madison, WI, 53705, USA

    N. Safdar

Authors
  1. C. L. Abad
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. S. Pulia
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. N. Safdar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to N. Safdar.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Abad, C.L., Pulia, M.S. & Safdar, N. Does the Nose Know? An Update on MRSA Decolonization Strategies. Curr Infect Dis Rep 15, 455–464 (2013). https://doi.org/10.1007/s11908-013-0364-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11908-013-0364-y

Keywords

  • MRSA
  • Decolonization
  • Mupirocin
  • Infection control