title: Decolonization in Prevention of Health Care-Associated Infections.
abstract: Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.
authors.affiliation: Hospital Corporation of America, Nashville, Tennessee, USA Texas A&M Health Science Center, College of Medicine, Houston, Texas, USA Edward.septimus@hcahealthcare.com.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Septimus
authors.affiliation: University of Iowa Carver College of Medicine, Iowa City, Iowa, USA Iowa City VA Health Care System, Iowa City, Iowa, USA University of Iowa College of Public Health, Iowa City, Iowa, USA.
authors.forename: Marin L
authors.initials: ML
authors.lastname: Schweizer
mesh_terms: D000287:Administration, Topical; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000494:pharmacology; D001419:Bacteria / Q000187:drug effects*; D003428:Cross Infection / Q000382:microbiology / Q000517:prevention & control*; D024881:Drug Resistance, Bacterial / Q000187:drug effects; D005658:Fungi / Q000187:drug effects*; D041981:Gastrointestinal Tract / Q000187:drug effects / Q000382:microbiology; D006801:Humans; D009666:Nose / Q000187:drug effects / Q000382:microbiology; D012867:Skin / Q000187:drug effects / Q000382:microbiology
chemical_list: D000900:Anti-Bacterial Agents
references.citation: Infect Control Hosp Epidemiol. 2005 Dec;26(12):916-22
references.pmid: 16417031
references.citation: J Antimicrob Chemother. 2002 Dec;50(6):857-64
references.pmid: 12461004
references.citation: J Hosp Infect. 2000 Oct;46(2):147-52
references.pmid: 11049709
references.citation: BMJ. 2014;348:g2197
references.pmid: 24687313
references.citation: Arch Intern Med. 2006 Feb 13;166(3):306-12
references.pmid: 16476870
references.citation: Infect Control Hosp Epidemiol. 2015 Sep;36(9):1095-7
references.pmid: 26074153
references.citation: Infect Control Hosp Epidemiol. 2013 Aug;34(8):818-24
references.pmid: 23838222
references.citation: Am J Manag Care. 2010 Jul;16(7):e163-73
references.pmid: 20645662
references.citation: Crit Care Med. 2007 Feb;35(2):595-602
references.pmid: 17205028
references.citation: Pharmacotherapy. 2015 Mar;35(3):328-36
references.pmid: 25809180
references.citation: Clin Infect Dis. 2008 Jan 15;46(2):274-81
references.pmid: 18171263
references.citation: Infect Control Hosp Epidemiol. 2015 Oct;36(10):1155-62
references.pmid: 26072936
references.citation: JAMA. 2006 Nov 22;296(20):2460-6
references.pmid: 17119142
references.citation: Int J Infect Dis. 2010 Oct;14 Suppl 4:S3-5
references.pmid: 20851010
references.citation: Photomed Laser Surg. 2006 Dec;24(6):680-3
references.pmid: 17199465
references.citation: Can J Infect Dis Med Microbiol. 2009 Fall;20(3):e49-55
references.pmid: 20808456
references.citation: JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46
references.pmid: 23999949
references.citation: Infect Control Hosp Epidemiol. 2009 Dec;30(12):1158-65
references.pmid: 19852665
references.citation: Ann Thorac Surg. 2001 May;71(5):1572-8; discussion 1578-9
references.pmid: 11383802
references.citation: Clin Infect Dis. 2008 Mar 1;46(5):752-60
references.pmid: 18220477
references.citation: Clin Infect Dis. 2009 Jul 1;49(1):118-21
references.pmid: 19480576
references.citation: Nat Rev Immunol. 2013 Nov;13(11):790-801
references.pmid: 24096337
references.citation: Infect Control Hosp Epidemiol. 2012 Jan;33(1):14-9
references.pmid: 22173517
references.citation: J Hosp Infect. 2012 May;81(1):20-4
references.pmid: 22463978
references.citation: Expert Rev Anti Infect Ther. 2014 Jan;12(1):75-89
references.pmid: 24308709
references.citation: N Engl J Med. 2014 Mar 27;370(13):1198-208
references.pmid: 24670166
references.citation: Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14
references.pmid: 21460463
references.citation: Emerg Infect Dis. 2013 Apr;19(4):623-9
references.pmid: 23631854
references.citation: J Infect Dis. 2009 Jun 15;199(12):1820-6
references.pmid: 19419332
references.citation: Infect Control Hosp Epidemiol. 2000 Jul;21(7):459-64
references.pmid: 10926396
references.citation: JAMA. 2014 Oct 8;312(14):1429-37
references.pmid: 25271544
references.citation: Lancet Infect Dis. 2005 Dec;5(12):751-62
references.pmid: 16310147
references.citation: J Hosp Infect. 2008 Sep;70(1):27-34
references.pmid: 18632184
references.citation: J Hosp Infect. 1997 Jan;35(1):1-8
references.pmid: 9032630
references.citation: Am J Respir Crit Care Med. 2010 Mar 1;181(5):452-7
references.pmid: 19965807
references.citation: Antimicrob Agents Chemother. 2002 Feb;46(2):438-42
references.pmid: 11796355
references.citation: Clin Infect Dis. 2009 Sep 15;49(6):935-41
references.pmid: 19673644
references.citation: Infect Control Hosp Epidemiol. 2007 Oct;28(10):1155-61
references.pmid: 17828692
references.citation: Infect Control Hosp Epidemiol. 2010 Jun;31(6):592-7
references.pmid: 20402589
references.citation: Am J Infect Control. 2013 Dec;41(12):1167-72
references.pmid: 24274912
references.citation: Clin Infect Dis. 2011 Feb 1;52(3):285-92
references.pmid: 21217178
references.citation: Photochem Photobiol. 2010 May-Jun;86(3):617-27
references.pmid: 20408973
references.citation: J Am Coll Surg. 2008 Aug;207(2):233-9
references.pmid: 18656052
references.citation: Br Med J. 1973 Dec 8;4(5892):586-9
references.pmid: 4586059
references.citation: J Antimicrob Chemother. 2003 Mar;51(3):613-7
references.pmid: 12615862
references.citation: Lancet Infect Dis. 2013 May;13(5):409-15
references.pmid: 23473661
references.citation: Am J Otolaryngol. 2012 Sep-Oct;33(5):572-5
references.pmid: 22503099
references.citation: Drugs. 1986 Nov;32(5):425-44
references.pmid: 3098541
references.citation: Am J Kidney Dis. 2002 Feb;39(2):337-41
references.pmid: 11840374
references.citation: Antimicrob Agents Chemother. 1974 Dec;6(6):712-21
references.pmid: 4217582
references.citation: Am J Transplant. 2008 Aug;8(8):1737-43
references.pmid: 18557723
references.citation: Antimicrob Agents Chemother. 2007 Oct;51(10):3591-8
references.pmid: 17682105
references.citation: Am J Infect Control. 2002 Dec;30(8):S1-46
references.pmid: 12461507
references.citation: Clin Infect Dis. 2007 Jan 15;44(2):178-85
references.pmid: 17173213
references.citation: Am J Kidney Dis. 1996 May;27(5):687-94
references.pmid: 8629629
references.citation: J Hosp Infect. 2010 Nov;76(3):206-10
references.pmid: 20846747
references.citation: Antimicrob Agents Chemother. 2003 Nov;47(11):3613-5
references.pmid: 14576128
references.citation: Infect Control Hosp Epidemiol. 2010 Nov;31(11):1130-8
references.pmid: 20923285
references.citation: J Hosp Infect. 2013 May;84(1):5-12
references.pmid: 23414705
references.citation: Clin Infect Dis. 2015 May 15;60(10):1489-96
references.pmid: 25648237
references.citation: Curr Infect Dis Rep. 2013 Dec;15(6):455-64
references.pmid: 24150839
references.citation: Microb Drug Resist. 2004 Summer;10(2):92-7
references.pmid: 15256023
references.citation: Clin Infect Dis. 1997 Oct;25(4):929-30
references.pmid: 9356817
references.citation: Infect Control Hosp Epidemiol. 2012 Feb;33(2):152-9
references.pmid: 22227984
references.citation: N Engl J Med. 2009 Jan 1;360(1):20-31
references.pmid: 19118302
references.citation: J Hosp Infect. 2000 Nov;46(3):236-7
references.pmid: 11073734
references.citation: Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S10-4
references.pmid: 25376064
references.citation: JAMA. 2015 Jan 27;313(4):369-78
references.pmid: 25602496
references.citation: Chest. 1996 Jun;109(6):1556-61
references.pmid: 8769511
references.citation: Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S89-107
references.pmid: 25376071
references.citation: J Hosp Infect. 2012 May;81(1):15-9
references.pmid: 22463977
references.citation: BMJ. 1998 Apr 25;316(7140):1275-85
references.pmid: 9554897
references.citation: Clin Microbiol Infect. 2015 Jun;21(6):553-9
references.pmid: 25677630
references.citation: Am J Crit Care. 2009 Sep;18(5):428-37; quiz 438
references.pmid: 19723863
references.citation: ASAIO J. 1995 Jan-Mar;41(1):127-31
references.pmid: 7727815
references.citation: Crit Care. 2006 Feb;10(1):R35
references.pmid: 16507165
references.citation: Crit Care Med. 2015 Feb;43(2):382-93
references.pmid: 25377019
references.citation: Clin Infect Dis. 2003 Dec 15;37(12):1629-38
references.pmid: 14689344
references.citation: Antimicrob Agents Chemother. 2003 May;47(5):1589-97
references.pmid: 12709327
references.citation: Infect Control Hosp Epidemiol. 1999 May;20(5):351-3
references.pmid: 10349956
references.citation: N Engl J Med. 2010 Jan 7;362(1):9-17
references.pmid: 20054045
references.citation: J Arthroplasty. 2012 Jun;27(6):870-6
references.pmid: 22397861
references.citation: Diagn Microbiol Infect Dis. 2007 Apr;57(4):413-8
references.pmid: 17141452
references.citation: J Hosp Infect. 2007 Oct;67(2):149-55
references.pmid: 17900759
references.citation: Clin Infect Dis. 2004 Sep 15;39(6):806-11
references.pmid: 15472812
references.citation: Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S17-22
references.pmid: 25222893
references.citation: Clin Microbiol Rev. 1997 Jul;10(3):505-20
references.pmid: 9227864
references.citation: Eur J Cardiothorac Surg. 2011 Jan;39(1):68-74
references.pmid: 20663681
references.citation: Perit Dial Int. 2001 Nov-Dec;21(6):554-9
references.pmid: 11783763
references.citation: Clin Infect Dis. 2009 Apr 1;48(7):922-30
references.pmid: 19231978
references.citation: Infect Control Hosp Epidemiol. 2014 Jul;35(7):826-32
references.pmid: 24915210
references.citation: Arch Intern Med. 1996 Jul 8;156(13):1458-62
references.pmid: 8678715
references.citation: Clin Infect Dis. 2016 Mar 1;62(5):618-30
references.pmid: 26503378
references.citation: Infect Control Hosp Epidemiol. 2003 May;24(5):342-6
references.pmid: 12785407
references.citation: Ann Intern Med. 2006 Mar 7;144(5):318-25
references.pmid: 16520472
references.citation: BMJ. 2007 Apr 28;334(7599):889
references.pmid: 17387118
references.citation: Lancet Infect Dis. 2011 May;11(5):372-80
references.pmid: 21420908
references.citation: J Antimicrob Chemother. 2013 Oct;68(10):2375-82
references.pmid: 23719234
references.citation: Infect Control Hosp Epidemiol. 2014 Sep;35(9):1192-4
references.pmid: 25111931
references.citation: J Antimicrob Chemother. 1994 Jul;34(1):189-90
references.pmid: 7961212
references.citation: Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S23-31
references.pmid: 25222894
references.citation: Clin Infect Dis. 2015 Apr 15;60(8):1153-61
references.pmid: 25537877
references.citation: Cochrane Database Syst Rev. 2009;(4):CD000022
references.pmid: 19821262
references.citation: Clin Microbiol Infect. 2010 Dec;16(12):1747-53
references.pmid: 20331684
references.citation: Clin Infect Dis. 2010 Jan 15;50(2):210-7
references.pmid: 20001537
references.citation: Infect Control Hosp Epidemiol. 2015 Jan;36(1):17-27
references.pmid: 25627757
references.citation: BMJ. 2008 Apr 26;336(7650):927-30
references.pmid: 18417521
references.citation: Clin Infect Dis. 2002 Feb 15;34(4):425-33
references.pmid: 11797167
references.citation: Eur J Clin Microbiol Infect Dis. 2014 Jun;33(6):1053-61
references.pmid: 24500598
references.citation: Am J Infect Control. 2015 Jun;43(6):640-3
references.pmid: 25798778
references.citation: J Hosp Infect. 1991 Feb;17(2):133-7
references.pmid: 1674259
references.citation: Antimicrob Agents Chemother. 2004 Aug;48(8):3112-8
references.pmid: 15273128
references.citation: J Antimicrob Chemother. 2008 Feb;61(2):254-61
references.pmid: 18174201
references.citation: J Hosp Infect. 2004 Apr;56(4):283-6
references.pmid: 15066738
references.citation: Antimicrob Agents Chemother. 2006 Jul;50(7):2583-6
references.pmid: 16801451
references.citation: Clin Infect Dis. 2011 Jun 15;52(12):1422-30
references.pmid: 21628482
references.citation: Kidney Int. 2005 Mar;67(3):1084-92
references.pmid: 15698449
references.citation: Infect Control Hosp Epidemiol. 2000 May;21(5):319-23
references.pmid: 10823564
references.citation: Am J Manag Care. 2011 Oct;17(10):693-700
references.pmid: 22106462
references.citation: Infect Control Hosp Epidemiol. 2014 Apr;35(4):440-2
references.pmid: 24602954
references.citation: Clin Microbiol Infect. 2010 Dec;16(12):1740-6
references.pmid: 20673265
references.citation: J Hosp Infect. 2006 Mar;62(3):327-32
references.pmid: 16377029
references.citation: Am J Crit Care. 2002 Nov;11(6):567-70
references.pmid: 12425407
references.citation: Ann Intern Med. 2002 Jun 4;136(11):792-801
references.pmid: 12044127
references.citation: MBio. 2013;4(4). pii: e00534-13. doi: 10.1128/mBio.00534-13
references.pmid: 23963180
references.citation: Lancet. 1991 Aug 10;338(8763):339-43
references.pmid: 1677698
references.citation: J Am Acad Dermatol. 2008 Jan;58(1):1-21
references.pmid: 18158924
references.citation: Am J Infect Control. 2014 Aug;42(8):841-6
references.pmid: 24881497
references.citation: Clin Infect Dis. 2012 Mar;54(6):743-51
references.pmid: 22198793
references.citation: Clin Infect Dis. 2003 Dec 1;37(11):1467-74
references.pmid: 14614669
references.citation: Arch Intern Med. 2007 Oct 22;167(19):2073-9
references.pmid: 17954801
references.citation: JAMA Surg. 2015 May;150(5):390-5
references.pmid: 25738898
references.citation: Infect Control Hosp Epidemiol. 2000 Oct;21(10):653-5
references.pmid: 11083183
references.citation: J Hosp Infect. 1998 May;39(1):19-26
references.pmid: 9617681
references.citation: J Hosp Infect. 2014 Oct;88(2):89-95
references.pmid: 25171975
references.citation: Expert Rev Pharmacoecon Outcomes Res. 2009 Oct;9(5):417-22
references.pmid: 19817525
references.citation: JAMA Intern Med. 2014 May;174(5):751-61
references.pmid: 24663255
references.citation: Infect Control Hosp Epidemiol. 2011 Sep;32(9):872-80
references.pmid: 21828967
references.citation: JAMA. 2015 Jun 2;313(21):2162-71
references.pmid: 26034956
references.citation: Cochrane Database Syst Rev. 2003;(4):CD003340
references.pmid: 14583969
references.citation: Antimicrob Agents Chemother. 2006 Nov;50(11):3882-5
references.pmid: 17065625
references.citation: Antimicrob Agents Chemother. 1993 Jun;37(6):1334-42
references.pmid: 8328783
references.citation: J Clin Microbiol. 1999 Oct;37(10):3133-40
references.pmid: 10488166
references.citation: Clin Microbiol Infect. 2011 Nov;17(11):1717-26
references.pmid: 21595796
references.citation: N Engl J Med. 2013 Feb 7;368(6):533-42
references.pmid: 23388005
references.citation: Lancet Infect Dis. 2013 Apr;13(4):328-41
references.pmid: 23352693
references.citation: J Hosp Infect. 2000 Jul;45(3):198-205
references.pmid: 10896798
references.citation: Infect Control Hosp Epidemiol. 2012 Nov;33(11):1094-100
references.pmid: 23041806
references.citation: Infect Control Hosp Epidemiol. 2004 Feb;25(2):105-8
references.pmid: 14994933
references.citation: J Clin Microbiol. 2011 Mar;49(3):1119-21
references.pmid: 21209169
references.citation: J Med Microbiol. 2001 Oct;50(10):909-15
references.pmid: 11599741
references.citation: Diagn Microbiol Infect Dis. 2008 Apr;60(4):399-403
references.pmid: 18178361
references.citation: Lancet. 2013 Mar 30;381(9872):1099-106
references.pmid: 23363666
references.citation: BMJ. 2013;346:f2743
references.pmid: 23766464
references.citation: Lancet Infect Dis. 2014 Jan;14(1):31-9
references.pmid: 24161233
references.citation: Cochrane Database Syst Rev. 2008;(4):CD006216
references.pmid: 18843708
references.citation: Emerg Infect Dis. 2005 Oct;11(10):1539-44
references.pmid: 16318693
references.citation: Antimicrob Agents Chemother. 2014 Aug;58(8):4404-10
references.pmid: 24841265
references.citation: Infect Control Hosp Epidemiol. 2006 Dec;27(12):1304-12
references.pmid: 17152027
references.citation: J Antimicrob Chemother. 2003 Jan;51(1):185-6
references.pmid: 12493811
references.citation: Diagn Microbiol Infect Dis. 2014 Sep;80(1):32-4
references.pmid: 24952987
references.citation: Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27
references.pmid: 24799638
references.citation: N Engl J Med. 2013 Jun 13;368(24):2255-65
references.pmid: 23718152
references.citation: J Antimicrob Chemother. 2015 Oct;70(10):2681-92
references.pmid: 26142407
references.citation: Lancet Infect Dis. 2011 Nov;11(11):845-54
references.pmid: 21798809
references.citation: N Engl J Med. 2002 Jun 13;346(24):1871-7
references.pmid: 12063371
references.citation: J Hosp Infect. 2014 Aug;87(4):194-202
references.pmid: 24996517