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Intranasal mupirocin prophylaxis in elective surgery. A review of published studies
M Trautmann1, J Stecher, W Hemmer
1Institute of Hospital Hygiene, Klinikum Stuttgart, Germany. m.trautmann@katharinenhospital.de
Background:
Mupirocin is a natural antibiotic from Pseudomonas fluorescens which is available as a 2% ointment. The drug has been used mainly for topical treatment of the nasal vestibulum in patients carrying methicillin-resistant Staphylococcus aureus (MRSA). However, mupirocin is also active against methicillin-sensitive S. aureus. Nasal colonization with S. aureus has been identified as a significant risk factor for surgical site infection (SSI).
Methods:
Randomized trials and sequential cohort studies investigating mupirocin nasal treatment for prophylaxis of SSI in elective surgery in comparison with placebo or no treatment were found by Medline review and additional manual search. Evaluable studies were analyzed regarding the influence of mupirocin on the rate of all SSIs and, specifically, of SSIs due to S. aureus. The effect in cardiosurgical patients was analyzed in detail.
Results:
Four randomized and seven sequential open cohort studies were analyzed. Study design and mupirocin application schemes varied considerably. Three out of 5 studies carried out in cardiac surgery patients showed a significant reduction in sternotomy site infections. However, all three studies were open sequential cohort studies. By contrast, the only prospective, randomized, double-blind study in cardiosurgical patients showed no benefit of mupirocin. In other surgical disciplines, results were inconclusive or negative. Two studies specifically addressing the prevention of SSIs due to MRSA showed a significant effect of mupirocin on postsurgical infections due to this organism.
Conclusions:
Because of the heterogeneity of the studies and the variability of results, no recommendation can be given for the general use of mupirocin in elective surgical patients. Specifically, because of the negative result of a recently published high-quality study, no recommendation can be made for the use of mupirocin in cardiosurgical patients. By contrast, eradication of MRSA before surgery appears to lower SSI rates due to MRSA and is therefore recommended.
Insights
Mupirocin nasal ointment may not prevent surgical site infections (SSIs) in general elective surgery. However, eradicating methicillin-resistant Staphylococcus aureus (MRSA) before surgery is recommended to lower MRSA-related SSIs.
Area of Science:
- Infectious Diseases
- Surgical Prophylaxis
- Antibiotic Resistance
Background:
- Mupirocin, an antibiotic from Pseudomonas fluorescens, is used topically for nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA).
- Nasal colonization with Staphylococcus aureus (S. aureus) is a risk factor for surgical site infections (SSIs).
- Mupirocin is effective against both MRSA and methicillin-sensitive S. aureus.
Purpose of the Study:
- To evaluate the efficacy of mupirocin nasal treatment for SSI prophylaxis in elective surgery.
- To analyze the impact of mupirocin on SSIs caused by S. aureus, including MRSA.
- To specifically assess the effect in cardiosurgical patients.
Main Methods:
- A systematic review of randomized trials and sequential cohort studies comparing mupirocin nasal treatment with placebo or no treatment.
- Analysis focused on overall SSI rates and S. aureus-related SSI rates.
- Detailed examination of studies conducted in cardiosurgical patients.
Main Results:
- Heterogeneous study designs and application schemes were observed.
- Three of five cardiac surgery studies showed reduced sternotomy site infections, but these were open-label cohort studies.
- The sole prospective, randomized, double-blind study in cardiac surgery found no benefit.
- Studies in other surgical disciplines yielded inconclusive or negative results.
- Two studies demonstrated mupirocin's effectiveness in preventing MRSA-related SSIs.
Conclusions:
- Due to study heterogeneity and variable results, general recommendations for mupirocin in elective surgery are not supported.
- High-quality evidence does not support mupirocin use in cardiosurgical patients.
- Preoperative MRSA eradication is recommended to reduce MRSA-related SSIs.
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Possible causes of this condition include high blood pressure, trauma, low humidity, upper respiratory tract infections, allergies, foreign bodies, nasal inhalation of corticosteroids or illicit drugs, excessive use of decongestant nasal sprays, facial or nasal surgery, anatomic malformation, tumors, or systemic...