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same level of evidence yet as mupirocin, but it's a much simpler regimen that's especially attractive to outpatient surgery centers. Keep in mind that all PI isn't created equal, how- ever. At least three companies market a PI product indicated for intranasal use. These intranasal ver- sions of PI contain chemicals that help it attach bet- ter to the nasal mucosa, which is where the mecha- nism of action is. There's a cost issue here, unfortu- nately: These specialized PI preparations are multi- ple times more expensive than generic over-the- counter PI swabs. However, one study shows that, in terms of eradication rates, the intranasal prepara- tions are better than the less expensive prepara- tions. If someone asks me, I tell them to stick with the intranasal PI preparation until someone proves over-the-counter versions are more effective. Sure, it's more expensive than generic PI, but it's not nearly as expensive as an SSI. • Alcohol-based antiseptic. At least one peer- reviewed study confirms that alcohol-based nasal decolonization swabs can be effective. The mitigat- ing issue with alcohol is that it has a very short duration of action. It must be applied multiple times a day, which leads to the compliance issues inher- ent to mupirocin. The key takeaway here is that alcohol treatments must be applied frequently to keep colony counts down. • Photodynamic therapy. This emerging regimen is fascinating. Most peer-reviewed studies involving this technology are coming from Canada, because the FDA hasn't approved it as a device in the U.S. Photodynamic therapy carries no compliance con- cerns; it's applied just before surgery. You place a material in the nose, generally a methylene blue kind of preparation. Then you deliver a certain wavelength of photodynamic therapy that combines with the methylene blue to eradicate bacteria very safely. Some peer-reviewed studies show it does reduce SSI risk. While we can't use this therapy in 3 8 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 2 0 the U.S. yet, it's worth keeping an eye on it. These four regimens are the most viable nasal decolonization methods that have been shown to be effective. But again, none of them has the same level of evidence or the same number of publications that mupirocin has. There's a fifth possibility — retapamulin, which is currently used for skin and soft tissue infections. It has lost favor, however, mostly due to bleeding and irritation associated with its intranasal use, and there's still very limited information about its use for nasal colonization. It really does seem to work, though, so I think it's still a potential option down the road. Evidence-gathering continues Nasal decolonization is just one part of a larger SSI prevention protocol. From those of us who are vet- erans in hospital infection prevention for years, heed this advice: If you want good results, perform evidence-based interventions consistently well. I was involved in a published study that looked at 20 hospitals that were performing total joints or open heart surgery. Our analysis showed that those facili- ties that complied fully with a robust, evidence- based SSI prevention protocol — screening, decolo- nization, administering the appropriate surgical antibiotics for prophylaxis — had lower infection rates than those that were partially compliant. It's about doing the small things consistently well. The SSI prevention chain is only as strong as its weakest link, and with nasal decolonization meth- ods still developing, it's important to strengthen that link in the chain as our knowledge of each agent and approach expands. I anticipate that the nasal decolonization picture will likely become clearer in the next couple of years. For now, the important thing is to fully understand how each agent works and follow their related evidence-based protocols to the letter. OSM Dr. Septimus (eseptimus@gmail.com) is an infectious disease specialist and a professor of internal medicine at Texas A&M College of Medicine in Houston. The nasal decolonization picture will likely become clearer in the next couple of years.