Decolonisation treatment for MRSA

Introduction

• Decolonisation is the process of eradicating or reducing asymptomatic carriage of MRSA.
• 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 the infection has cleared.
• When an individual has MRSA, contamination of their environment and clothing can occur due to the shedding of skin scales and touching surfaces with contaminated skin or hands.

Indications

The decision to recommend decolonisation should follow an assessment of the individual (and their close contacts) that includes their willingness and capability to comply with the regimen.

Decolonisation is generally recommended when individuals or their household contacts:

• have recurrent MRSA or staphylococcal-like infections
• are at increased risk of infection due to other existing medical conditions
• are healthcare workers or carers
  or
• when there are ongoing MRSA infections occurring in a well-defined, closely-associated cohort, for example a dormitory, day-care centre or sports club.

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.

Decolonisation is not always successful on the first attempt, and may need to be repeated.

Decolonisation treatment regimen

Body wash

Daily for 5 days. Use triclosan 1per cent (500ml) or chlorhexidine gluconate 4 per cent (500ml). Both products are available over-the-counter at pharmacies. The estimated cost to the patient $16-$24. Chlorhexidine gluconate is contraindicated in people with a perforated eardrum.

Nasal ointment

Twice daily for 5 days – use mupirocin 2 per cent (3g bactroban tube). A prescription is required and the estimated cost of private prescriptions is up to $26. This item is on the Pharmaceutical Benefit Scheme (PBS) for Aboriginal or Torres Strait Islander person only, for the purpose of treatment of nasal colonisation with S.aureus.

Dentures

Patients with dentures should soak them overnight in a denture cleaning product, for example Steradent or Polident.

Patients with known throat carriage

Gargle twice daily with a 0.2 per cent chlorhexidine-based mouthwash for example, Savacol or Rivacol, which are available over-the-counter at pharmacies.

Post-decolonisation screening for clearance

• Post-decolonisation screening to determine clearance is not routinely recommended. However, it can be conducted when the outcome of screening is considered useful for the management of  the 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
  • decolonisation and clearance is requested by the Department of Health.
• 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, at week 1 and week 12 post-decolonisation.

Factors contributing to decolonisation failure

• Decolonisation is less likely to be successful if the individual has throat carriage, chronic or open wounds or permanent indwelling devices in situ.
• There is the potential for failure and/or re-colonisation if there is non-compliance with the requirements for personal hygiene and environmental cleanliness.
• 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 skin treatments may exacerbate their condition.
• Any underlying exfoliative skin condition should be treated first, in consultation with a dermatologist.

Important information

• 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 diseases physician or clinical microbiologist.
• Mupirocin resistance has been associated with widespread, prolonged use and its use should initially be limited to 2 consecutive decolonisation treatments.
• 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) should not be commenced in the community unless specifically recommended by an infectious diseases physician or clinical microbiologist.

Decolonisation treatment for MRSA - fact sheet for healthcare provider (PDF 137 KB) 

Decolonisation treatment for MRSA - fact sheet for consumer (PDF 1.2MB)