replacement surgery.
You can screen patients for S. aureus weeks before their procedures
and treat carriers with mupirocin nasal ointment twice a day for 5 days
before surgery and vancomycin plus cefazolin for pre-op antibiotic pro-
phylaxis, says Antonia Chen, MD, MBA, director of research and arthro-
plasty services at Brigham and Women's Hospital in Boston, Mass.
That's a viable option, but outpatient facilities are moving away from
screening and instead treating patients for S. aureus, says Dr. Sporer.
"Patients who undergo joint replacements in the same-day setting
tend to be younger, and it's challenging to schedule them for the
screening and the follow-up appointments needed to prescribe the
nasal antibiotic therapy," he says. "For logistical reasons, it makes
more sense to assume everyone is a carrier when they arrive on the
day of surgery, and implement nasal decolonization."
Joanne Epstein, BSN, RN, CNOR, surgical services educator at Saint
Francis Hospital in Wilmington, Del., says a lack of compliance with
pre-procedure antibiotic regimens is another reason to treat every
patient as a carrier of S. aureus. "Our orthopedic surgeons prescribe
intranasal mupirocin to total joint patients," says Ms. Epstein. "And
what we have discovered when questioning patients in pre-op is that
very few of them use the mupirocin as prescribed."
Nasal decolonization, therefore, "is a good option for outpatient sur-
gery, where you may not get to test everyone and you may not be able
to administer pre-operative antibiotics as needed," adds Dr. Chen.
There are 2 ways to achieve nasal decolonization:
• Intranasal povidone-iodine. Nurses at Rush Medical Center treat
the nares of patients who present for joint replacement surgery with a
povidone-iodine nasal solution. The nurses use a total of 4 swabs, 2
per nostril, to swab surfaces inside the nose for alternating 15-second
intervals. The povidone-iodine sticks to the nares and keeps the nose
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