Decolonisation treatment for MRSA – information for healthcare providers

• The purpose of this fact sheet is to guide healthcare providers in the management of Methicillin resistant Staphylococcus aureus (MRSA) decolonisation in patients and healthcare workers.
• Decolonisation is the process of eradicating or reducing asymptomatic carriage of MRSA by using a topical body wash and an antibiotic nasal ointment for 5 days. The nares are the primary site of colonisation. Other sites of colonisation include the nasopharynx, skin (especially skin folds), perineum, axillae and the gastrointestinal tract.
• Decolonisation should only commence once any active infection has cleared.

Indications

The decision to recommend decolonisation should follow an assessment of the individual and their household contacts, that includes considering their willingness and capability to comply with the regimen. Decolonisation should be considered when individuals or their household contacts:

• have recurrent MRSA or staphylococcal-like infections
• are at increased risk for acquiring staphylococcal infection, such as those with chronic skin disorders, diabetes, peripheral vascular disease or immunosuppression
• are planning on having major surgery
• when there are ongoing MRSA infections occurring in a well-defined, closely-associated cohort or group, for example a dormitory, day care centre or sports club.
• are healthcare workers or carers
• if there are ongoing infections in a household despite treatment, decolonisation of all household members should be considered, even if some members do not have an active infection. All household members should commence decolonisation on the same day.

Personal hygiene and household cleaning

When an individual has MRSA, contamination of their environment and clothing can occur due to the shedding of skin cells and touching surfaces with contaminated skin or hands. Personal hygiene and household cleaning is important to maintain during decolonisation. It is important you provide the person who is undergoing decolonisation with the MRSA decolonisation treatment fact sheet that explains these requirements and the procedure to be undertaken.

Decolonisation treatment

The following are the essential requirements for decolonisation:

• Body wash: daily for 5 days. Use triclosan 1% (500ml) or chlorhexidine gluconate 2-4% CHG (500ml). Octenisan body wash may be recommended when triclosan or chlorhexidine cannot be used due to allergy. All products are available over-the-counter from pharmacies. Chlorhexidine gluconate is contraindicated in people with a perforated eardrum as it is ototoxic and has been documented to cause middle and inner ear damage, including deafness¹.
• Nasal ointment: twice daily for 5 days. Use mupirocin 2% (3g Bactroban tube). A prescription is required. This item is on the Pharmaceutical Benefit Scheme (PBS) for Aboriginal or Torres Strait Islander people only, for the purpose of treatment of nasal colonisation with S. aureus.
• Dentures: clean and soak dentures overnight in a denture cleaning product for example Steradent or Polident.
• If there is known throat carriage: gargle twice daily with a 0.2% chlorhexidine-based mouthwash, for example, Savacol or Rivacol, which are available over-the-counter at a pharmacy.
• In the rare event a bleach bath may be required as part of the decolonisation treatment, please seek advice from an Infectious Diseases Physician and the Therapeutic Guidelines.

Decolonisation should not be commenced on people with scabies or active exfoliative skin conditions, such as eczema or psoriasis, as it is likely to fail, and the decolonisation skin treatment may exacerbate their condition. Any underlying exfoliative skin condition should be treated first, in consultation with a dermatologist.

Decolonisation treatment is unlikely to result in clearance of MRSA and removal of a micro-alert status if a patient has an indwelling medical device such as a percutaneous enterostomy tube, intravascular device and tracheostomy. However, these people are likely to benefit through reduced device associated infections from topical MRSA suppression treatment.

Skin care

The skin is an important barrier against infection, and it is essential to prevent dryness or skin tears by following these recommendations:

• gently pat dry your skin with a towel, avoiding rubbing
• use a non-perfumed sorbolene-based cream regularly for any itchy or dry areas.
• if skin irritation or redness occurs, stop using the treatment and discuss with your doctor/staff health department immediately.

Post-decolonisation screening for clearance

Post-decolonisation screening to determine if clearance has been achieved is not routinely recommended. However, it can be conducted when the outcome of screening is considered useful for the management of MRSA, for example, when:

• individuals are at increased risk for infection due to other existing medical conditions
• there are ongoing infections occurring in households or a well-defined, closely-associated cohort, such as a dormitory, sports club or day-care centre
• individuals request to know their outcome
• healthcare workers are requested to provide evidence of successful decolonisation.

If clearance screening is indicated, obtain swabs (pre-moisten dry sites with sterile water or saline) from nostrils, throat and any wounds or skin lesions. Two sets of swabs are to be taken at least three months from the last known positive result, and at least one week from the last use of topical antiseptics. The patient must not be on antibiotics at the time the clearance swabs are taken.

Factors contributing to decolonisation failure

Decolonisation is less likely to be successful in the following situations:

• The individual has throat carriage, chronic wounds or permanent indwelling devices in-situ
• If there is non-compliance with the requirements for personal hygiene and household cleaning.

Additional important information

• Mupirocin resistance has been associated with widespread, prolonged use and its use should initially be limited to 2 consecutive decolonisation treatments.
• Specific antibiotics may need to be prescribed as part of the decolonisation regimen for people who have recurrent infections following two consecutive decolonisation treatments. This should be in consultation with an infectious disease’s physician or clinical microbiologist.
• If rifampicin is used, it will always be recommended in combination with other antibiotics (never as a single agent). Rifampicin is an authority-required antimicrobial and MRSA treatment is not one of the indications for its use in the PBS.
• Decolonisation treatment of neonates (< 2 months of age) should not be commenced in the community unless specifically recommended by an infectious disease’s physician or clinical microbiologist.

Reference 1: Lai, P., Coulson, C., Pothier, D., Rutka, J. (2011) Chlorhexidine ototoxicity in ear surgery, part 1: review of the literature. Journal of Otolaryngology Head and Neck Surgery 40 (6), pages 437-440. Available from: https://pubmed.ncbi.nlm.nih.gov/22420428/

Decolonisation instructions

For information on decolonisation for children, please visit PCH Staphylococcus aureus decolonisation

For more information on MRSA visit Healthy WA