Alcohol-Based Antiseptics Show Promise for Nasal Decolonization and SSI Prevention

Karen Hoffmann, MS, RN, CIC, FSHEA, FAPIC

(Image credit: KH)

Nasal decolonization of Staphylococcus aureus is an effective strategy to reduce surgical site infections (SSI). Recent guidelines expanded the use of alcohol-based antiseptics (ABAs) beyond high-risk populations.

A recent meta-analysis of 7 studies evaluating ABA efficacy in SSI prevention found significant reductions in infection rates compared to no intervention (OR = 3.178, P < .001), mupirocin (OR = 4.110, P < .01), and iodophor (OR = 3.043, P < .01). The study analyzed 16,212 patients, demonstrating ABA's effectiveness in surgical settings. These findings support ABAs as a viable alternative for nasal decolonization to enhance infection prevention strategies.

The lead author, Karen Hoffmann, MS, RN, CIC, FSHEA, FAPIC, a previous winner of Infection Control Today Educator of the Year^TM of the study named “The efficacy of an alcohol-based nasal antiseptic versus mupirocin or iodophor for preventing surgical site infections: A meta-analysis,” interviewed with Infection Control Today^® (ICT^®).

ICT: What was the primary motivation or research question that led you to conduct this study, and why do you believe it is important?

Karen Hoffmann, MS, RN, CIC, FSHEA, FSPIC: Surgical site infections (SSI) continue to be the most common preventable complication after surgery despite progress resulting from the implementation of surgical site bundles. SSIs are also the leading cause of readmissions to the hospital following surgery, and approximately 3% of patients who contract an SSI will die as a consequence. Nasal decolonization has been recognized for decades as an effective strategy to prevent SSIs by reducing the number of bacteria in the nose before surgery. The nasal vestibule is a primary reservoir for pathogens that can spread to cause healthcare-associated infections.

However, current SHEA and CDC guidelines recommend using nasal decolonization only for high-risk surgical patients (eg, orthopedic and cardiothoracic) and the ICU. Expanding nasal decolonization programs has been hindered by concerns about compliance and antibiotic resistance with mupirocin and, more recently, by concerns about cost and patient satisfaction with povidone-iodine. Alcohol-based antiseptics avoid the resistance problems of mupirocin and appear to largely resolve the cost and patient and staff satisfaction problems of povidone-iodine. We selected the alcohol-based antiseptic (ABA) nasal decolonization product with the most published outcomes data.

ICT: Can you briefly explain the methodology you used in the study and why you chose this approach?

KH: Currently, there has not been a large multicenter or randomized controlled study using alcohol-based nasal antiseptic on SSI outcomes. However, there are multiple single-site hospital before-after cohort reports of SSI outcomes using the alcohol-based nasal antiseptic, which spurred my interest in using a meta-analysis to examine its effectiveness. A meta-analysis is a quantitative, formal, epidemiological study design used to systematically assess the results of previous research to derive conclusions about that body of research. Meta-analysis provides a more precise estimate of the effect size and increases the generalizability of the results of individual studies. I have some experience with meta-analyses, and I understood that combining small studies into one larger study would be more accurate and more likely to show a statistically significant effect. Many researchers have tried to evaluate nasal decolonization products based on their ability to reduce nasal carriage. This is notoriously difficult because of the topography of the nares and the dynamic nature of the environment. We chose to measure outcomes, which is a better measure of performance and much easier to measure accurately.

ICT: What were the key findings of your study, and how do they contribute to the existing body of knowledge in your field?

KH: The resulting analysis demonstrated a statistically significant improvement in infection reduction compared to either mupirocin or povidone-iodine. For many years, mupirocin was the only available decolonization agent, which limited the use of nasal decolonization due to antibiotic resistance concerns. In the last decade, nasal antiseptics have become available that eliminate resistance concerns and offer immediate action, a broad-spectrum effect, and better compliance. This flexibility has led to expanding nasal decolonization to and including all surgical and inpatient programs.

ICT: What are your findings' potential implications or applications, and what future research directions do you suggest based on your study?

KH: Doubts about the effectiveness of an ABA hindered adoption. Our analysis helps to dispel these concerns. Studies of SSI reduction suggest that decolonizing all surgical patients makes sense for several reasons, including the fact that compliance with antibiotics is poor and pre-surgical screening is ineffective and expensive. ABAs appear to address these problems, allowing for the economical decolonization of all surgical patients. Further, studies have, for some time now, shown that decolonizing entire cohorts, and even all hospital in-patients, is superior to targeting for reducing HAIs generally. The adoption of nasal decolonization for these applications has been slowed by the lack of a suitable product for use. This study suggests that the ABA may also offer a solution to these applications.

ICT: Do you have anything else you’d like to add?

KH: I believe nasal decolonization should be available to all surgical and in-hospital patients. Outcomes data and clinical practice are moving in that direction. I hope this analysis encourages other researchers to look at the effectiveness of decolonizing all patients. What’s next for me is looking at other HAI outcomes (eg, bloodstream, pneumonia, and urinary tract) using an alcohol-based nasal antiseptic. I am working on a new meta-analysis of bloodstream infection outcomes using an alcohol-based nasal antiseptic. As more hospitals publish results from these other HAI sites, additional meta-analyses will be allowed to continue to expand the science. While large multicenter studies are great, they take enormous resources and time and often do not reflect the true impact in actual practice. I believe universal nasal decolonization will become the standard of care, and this study makes some small contribution toward that end.