Industry Roundtable: Nasal Decolonization

ICT: What is the primary science driving the efficacy of your nasal decolonization product?

Antibiotic-resistant infections are a global issue. A recent study in Health Affairs showed that antibiotic resistance adds nearly $1400 to the bill for treating bacterial infection and cost the nation more than $2 billion annually.1 One example is Staphylococcus aureus, a gram positive bacteria part of the normal flora of the body that is frequently found in the nose, respiratory tract and on the skin. Approximately 30 percent of the population is colonized with Staph aureus and the average per-patient cost for an SSI caused by resistant strains of S. aureus can be as high as $60,000.2 Medline has created a bundled approach called Ready.Set.Care. that uses effective, easy-to-use and non-resistant antiseptics to decolonize bacteria and help healthcare providers feel confident when reassuring their patients how it will reduce the risk of HAI. The Medline Nasal Antiseptic swabs have several driving factors that help give physicians reassurance and confidence in an effective alternative to the antibiotic mupirocin. The swabs are pre-saturated, ready-to-use swabs that are used in patient nostrils prior to surgery as part of a bundled intervention for patient decolonization to help reduce the risk of post-operative surgical site infections (SSIs). When used as part of preoperative or inpatient protocol, the swabs are proven to be a safe and effective alternative to antibiotics for nasal decolonization, which can help enable antibiotic stewardship plans, as there is no clinical evidence of bacteria developing resistance to povidone-iodine antiseptics. Additionally, they have a 99.99 percent efficacy against S. aureus after 12 hours; 99.4 percent efficacy after one hour. The swabs require only one application by a healthcare professional, not the patient, resulting in higher compliance.
References:
1. Thorpe KE, et al. Antibiotic-Resistant Infection Treatment Costs Have Doubled Since 2002, Now Exceeding $2 Billion Annually. Health Affairs. Vol. 37,4.
2. Anderson DJ, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. 2009 Dec 15; 4(12).
-- Rosie D. Lyles, clinical affairs director, Medline

Nozin® Nasal Sanitizer® antiseptic utilizes a patented alcohol-based formula to accomplish decolonization of nasal pathogens including methicillin-resistant and methicillin-susceptible Staphylococcus aureus (MRSA and MSSA). Alcohol has been topically used to safely and quickly kill a broad spectrum of pathogens for decades including use with hand sanitizers. The patented formula in Nozin® Nasal Sanitizer® provides up to 12 hours of decolonization persistence and includes moisturizing emollients resulting in a pleasant application. Because it is alcohol based, the Nozin® product acts quickly and does not promote antibiotic resistance. In vitro tests show Nozin® works as effectively as ethyl alcohol by itself. A hospital clinical study demonstrated a 99 percent knockdown of nasal Staph. aureus when the Nozin product was used by colonized nurses active in a hospital environment.1 This nasal antiseptic can be applied quickly and easily and has been used safely by thousands for nasal decolonization.
Reference:
1. Steed LL, Costello J, Lohia S, Jones T, Spannhake EW, Nguyen S. Reduction of nasal Staphylococcus aureus carriage in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antiseptic. Am J Infect Control. 2014 Aug;42(8):841-6.
-- Ernst Wm. Spannhake, PhD, chief science officer, Global Life Technologies Corp./Nozin

Decolonization is an evidence-based practice to reduce the incidence of healthcare-associated infections. Nasal decolonization, with or without chlorhexidine gluconate bathing, has become an important strategy for reducing surgical site infections (SSIs) due to S. aureus – the primary pathogen responsible for these infections -- and for the control of methicillin-resistant Staphylococcus aureus (MRSA) transmission in healthcare settings with endemic prevalence. The gold standard for nasal decolonization has been mupirocin; however, as seen with widespread use of other antibiotics, selective pressure has led to mupirocin-resistant strains of S. aureus and treatment failures. As part of an overall approach to antibiotic stewardship, investigators have looked to antiseptics as alternatives for nasal decolonization. Povidone-iodine (PVP-I) has more rapid bactericidal activity against S. aureus compared with that of mupirocin and has activity against emerging mupirocin-resistant MRSA strains. The use of PVP-I for nasal decolonization in combination with chlorhexidine bathing has revealed statistically significant reductions in SSIs among patients undergoing orthopedic and spinal surgeries and a 40 percent reduction in MRSA nasal carriage and a 60 percent reduction in any MRSA carriage among nursing home residents. Greater patient satisfaction with PVP-I vs. mupirocin has been reported. 3.4 percent of patients receiving PVP-I reported an unpleasant or very unpleasant experience compared with 38.8 percent of those using mupirocin (P<.0001). There have been no reports of bacterial resistance or increased tolerance associated with PVP-I.
-- Joan Hebden MS, RN, CIC, FAPIC, president, IPC Consulting Group, LLC, for PDI

ICT: How do clinicians determine if a nasal decolonization product is right for their hospital and what kind of business case can be made for the introduction of this product in their institution?

Due to the increasing demands for antimicrobial stewardship and the need to prevent further spread of resistance across the globe, there is renewed interest in evaluating newer effective agents and alternative methods for intranasal decolonization. For the business case, healthcare professionals are looking for an effective topical antiseptic to prevent against multidrug resistance organisms (MDROs). Povidone-iodine (PI) is an excellent alternative for intranasal decolonization because it has a broad activity against gram-positive and gram-negative bacteria. Hill et al. evaluated the in vitro activity of 5 percent povidone-iodine as a possible alternative to mupirocin for the elimination of nasal carriage of S. aureus.1 The results suggested povidone iodine may have a role in the prevention of colonization and infection due to MRSA, including mupirocin-resistant strains.
Reference:
1. Hill R, et al. The in-vitro activity of povidone-iodine cream against Staphylococcus aureus and its bioavailability in nasal secretions. J Hosp Infect 2000;45: 198-205.
-- Rosie D. Lyles, clinical affairs director, Medline

Most hospitals can benefit from a well-designed nasal decolonization program. If you screen and isolate or screen and treat for MRSA colonization, you can safely reduce such programs with a universal patient decolonization protocol. Re-ducing contact isolation precautions can improve care, lower costs as well as increase patient and staff satisfaction. Surgical site infections (SSIs) and bacteremias can result from bacterial contamination of the surgical wound or other portals and can originate during surgery or the post-operative recovery period prior to wound healing.1 Studies have shown that >80 percent of SSIs and bacteremias were caused by the bacteria in the patient’s own nose.2-3 A portion of the other 20 percent likely comes from caregivers. If your program does not include protecting patients post-operatively and does not decolonize caregivers in contact with patients, you may benefit from a Nozin® 360™ pro-gram. Added to existing bundles, the program has been shown to reduce Staph aureus SSIs by 81 percent and all-cause SSIs by 79 percent in two independent studies4-5 The Nozin IP program assessment tools can help present the business case on the impact of a Nozin implementation. These proprietary analytical tools are available to help evalu-ate your existing programs and review new Nozin IP program benefit assessments. Substantial savings can accrue from reduced screening and reduced use of personal protection equipment. Other benefits can include less staff isolation fatigue and improved patient care with fewer isolation days.References:

1. Cassir N, De La Rosa S, Melot A, et al. Risk factors for surgical site infections after neurosurgery: A focus on the postoperative period. Am J Infect Control 2015;43:1288-1291.
2. Coates T, Bax R, Coates A. Nasal decolonization of Staphylococcus aureus with mupirocin: strengths, weaknesses and future prospects. J Antimicrobe Chemother. 2009;64:9-15.
3. 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.
4. Mullen A, Wieland HJ, Wieser ES, Spannhake EW, Marinos RS. Perioperative participation of orthopedic patients and surgical staff in a nasal decolonization intervention to reduce Staphylococcus spp surgical site infections. Am J Infect Control. 2017;45(5):554-556.
5. Bostian P, Murphy TR, Klein AE, Frye BM, Dietz MJ. Lindsey BA. A Novel Protocol for Nasal Decolonization Using Prolonged Application of an Alcohol Based Nasal Antiseptic Reduces Surgical Site Infections. West Virginia School of Medicine, Dept of Orthopedics. Poster presented at AAOS 2018.
-- Ernst Wm. Spannhake, PhD, chief science officer, Global Life Technologies Corp./Nozin

The anterior nares is the primary reservoir for S. aureus carriage and approximately 20 percent to 30 percent of healthy individuals are persistently colonized. Since the 1950s, it has been recognized that endogenous strains of S. aureus are associated with the pathogenesis of serious staphylococcal infection. Multiple studies have demonstrated that eradication of S. aureus nasal colonization results in decreased infections, specifically for those patients undergoing surgery or receiving care in an intensive care unit (ICU). The estimated excess length of hospital stay (LOS) for SSIs is 11 days with a cost of $20,785; if MRSA is the causative pathogen, the LOS and cost increases to 23 days and $42,300, respectively. The healthcare epidemiology team can provide the necessary data regarding the contribution of S. aureus to the facility’s infection rates and a cost-benefit analysis can be performed.
-- Joan Hebden MS, RN, CIC, FAPIC, president, IPC Consulting Group, LLC, for PDI

ICT: What's the best way to educate around and implement a nasal decolonization product in the acute-care setting?

Within a hospital, a collaborative team across several departments implements evidence-based protocols, provides ongoing education to staff and patients, and maintains compliance of infection control strategies to reduce the risk of a broad range of infections. Antibiotic-resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacteriaceae (CRE) and multi-drug resistant Acinetobacter, are increasing in prevalence worldwide, resulting in infections that are difficult and expensive to treat. Understanding why there’s a rise of MDROs is essential for awareness, educating and implementing a nasal decolonization product in any healthcare facility. For many years, if you knew the bug, you knew the drug to treat an infection. When educating and implementing a nasal decolonization product, the antiseptic product should be a part of the horizontal approaches to reduce risk of a broad range of infections and not pathogens specific:
• Proper hand hygiene
• Universal use of gloves or gloves and gowns
• Universal decolonization (daily optimal bathing with chlorhexidine gluconate (CHG), povidone-iodine, mupirocin)
• Antimicrobial stewardship program
• Evidence-based environmental cleaning and disinfection products
Decolonization methods are essential to the horizontal approaches. The main challenge for facilities is educating their staff on how to implement better protocols to achieve compliance. Even the best prevention protocols can’t stop the spread of infection if they are not followed or implemented correctly. To maintain compliance; awareness, educating, training, monitoring and real-time feedback are critical in an acute care setting.
-- Rosie D. Lyles, clinical affairs director, Medline

To ensure the best chance of successful education regarding any new infection prevention product or practice it is critical to identify an executive champion who can help integrate efficacious interventions into the practice of providers and other healthcare workers. This will set the stage for successful educational programs provided collaboratively with the local IP department, local clinical managers, and the clinical experts at Nozin. Programs that replace MRSA screen and isolate, like a universal ICU patient decolonization, require some planning before an implementation is scheduled. Surgery implementations replacing mupirocin require pre-op staff to include nasal decolonization in their prep regimens. Nozin programs that can include patient post-op decolonization require some staff and patient training. It is important to have a clear, documented plan outlining steps, timeframes, training aids, assistance, on-site training and implementation support before “going live." An experienced Nozin advisor can help guide you to a successful plan.
-- Ernst Wm. Spannhake, PhD, chief science officer, Global Life Technologies Corp./Nozin

Introduction of a new product or technology designed to reduce healthcare-associated infections (HAI) should start with an examination of the science supporting the intervention. This analysis is best conducted by the healthcare epidemiology and antimicrobial stewardship teams. Involving key stakeholders, such as senior leadership who are focused on the potential economic and reputational risks associated with high HAI rates, clinicians who want to enhance patient safety and contribute to antimicrobial stewardship efforts, and microbiology leadership who monitor bacterial resistance patterns, is crucial.
-- Joan Hebden MS, RN, CIC, FAPIC, president, IPC Consulting Group, LLC, for PDI

ICT: How should clinicians monitor the impact of a nasal decolonization product and protocol on infection rates?

Active surveillance testing (AST) is conducted for the purpose of identifying patients with MRSA, typically by collecting a swab from the anterior nares. The rationale for conducting AST is to identify colonized patients so that additional precautions can be applied (e.g. Contact Precautions). In 2007, Illinois became the first state in the United States to mandate active surveillance of MRSA. The law applies to intensive care unit (ICU) patients; contact precautions are required for patients found to be MRSA colonized. However, the effectiveness of a legislated “search and isolate” approach to reduce MRSA burden among critically ill patients was uncertain. Myself and other colleagues from the Centers for Diseases Control and Prevention Chicago Prevention and Intervention Epicenter (C-PIE) for Prevention evaluated whether the prevalence of MRSA colonization declined in the five years after the start of mandatory active surveillance across several patient populations. In the adult population study that looked at 25 eligible hospitals (51 ICUs), MRSA colonization prevalence among critically ill adult patients did not decline during the time period following legislatively mandated MRSA active surveillance.1 In the neonates ICUs (NICUs) and pediatrics ICUs (PICUs), we found ongoing unchanged rates of MRSA colonization and acquisition among NICU and PICU patients with mandated active MRSA surveillance.2 However, a cluster-randomized trial showed in routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen.3
References:
1. Lin, MY et al. Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Adult Intensive Care Unit Patients Following State-Mandated Active Surveillance. Clinical Infectious Diseases, cix1056, https://doi.org/10.1093/cid/cix1056. Published: 07 December 2017
2. Lyles, RD et al. Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Critically Ill Children in a State With Mandated Active Surveillance. Journal of the Pediatric Infectious Diseases Society, Vol. 5, No. 4, pp. 409–16, 2016. DOI:10.1093/jpids/piv050.
3. Huang, SS et al. Targeted versus Universal Decolonization to Prevent ICU Infection. N Engl J Med 2013; 368:2255-2265.
-- Rosie D. Lyles, clinical affairs director, Medline

Reducing infections rates are an important part of the nasal decolonization program, but not the only measure of success. Programs to replace screen and isolate protocols are designed to deliver better patient care, better patient satisfaction, reduce “isolation fatigue” among staff, and lower isolation costs. Your materials management person can see savings by tracking personal protective equipment and MRSA screening costs. You can watch for reduction in isolated patients, conduct surveys of staff to identify their satisfaction levels and monitor HCAHPS scores to track patient satisfaction. Tracking infections from a baseline prior to the introduction of the nasal decolonization agent is a critical component of measuring results. Education reinforcement and adherence to protocols must be emphasized. Virtually any reductions in infections could pay for the program. Also, improvements in patient satisfaction can be monitored with surveys.
-- Ernst Wm. Spannhake, PhD, chief science officer, Global Life Technologies Corp./Nozin

Infection preventionists (IPs) have responsibility for the collection, analysis and reporting of HAI data. This data includes federal and state mandated SSI reporting as well as multidrug-resistant bacteria (MDRO), which includes MRSA. Analyzing HAI and MDRO data trends after the initiation of nasal decolonization along with monitoring protocol compliance will provide clinicians and administrators with the impact of the intervention.
-- Joan Hebden MS, RN, CIC, FAPIC, president, IPC Consulting Group, LLC, for PDI