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Reduction Of Conjunctival BacterialFlora With The Use Of
Mupirocin Nasal Ointment
Terry J. Alexandrou, MDOphthalmology Resident
The University of Chicago School of Medicine
Department of Ophthalmology and Visual Science
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Acknowledgements
• Seenu Hariprasad
• William F. Mieler
• Joseph Benevento
• Anthony Mazzulla
• Michael Saidel
• Susan Ksiazek
• Kenneth Thompson
• Sue Boonlayangoor
• Grant Support:
— Research to Prevent Blindness Foundation
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Post-Cataract Surgery Endophthalmitis
• 94.2% of isolates gram-positives
(70% S. epidermidis)
Han DP, et al. Am J Ophthalmol. 1996;122(1):1-17.
Endophthalmitis Vitrectomy Study
24%70%
6%
Gram-positivecoagulase-negative
organisms (Staphylococcusepidermidis)
Gram-negativeorganisms
OtherGram-positive
organisms
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Sources of Bacterial Contamination
• Gram-positive organisms are part of human normal flora
— Eyelids
— Eyelashes
— Conjunctiva
— Nasal Secretions
• Speaker and colleagues found that organisms isolated from the vitreous were genetically indistinguishable from those recovered from the eyelids, conjunctiva, or nose in 14 of 17 cases of endophthalmitis
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Mupirocin(Bactroban®, Glaxo-Smith Kline)
• Antibacterial agent produced by fermentation using the organism Pseudomonas fluorescens. Acts by interfering with the action of isoleucyl-transfer RNA synthetase
• Mupirocin is active against gram positive organisms, including Staphylococcus and Streptococcus spp.
• Available as a nasal ointment, and is used for the eradication of methicillin-resistant S. aureus.
• Nasal carriage of S. aureus was eliminated in 91% of colonized healthcare workers 2 to 4 days following treatment with mupirocin ointment.
Mupirocin (Bactroban®) Ointment (C26H43O9)2Ca●2H20
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Reduction of Surgical Site InfectionsEffectiveness of using Mupirocin: Non-Ophthalmic Literature
• Nasal carriage of gram positive organisms is a well established risk factor for surgical site infections (SSI).
— In a large multicenter study of S. aureus bacteremia, greater than 80% of the blood isolates were identical to those from the anterior nares.
• Kluytmans and collegues demonstrated that perioperative elimination of nasal carriage using mupirocin reduced SSI rate in cardiothoracic surgery patients
• The “Mupirocin Study Group” demonstrated that using mupirocin nasal ointment effectively reduced the incidence of S. aureus infections in hemodialysis and peritoneal dialysis patients
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Reduction of Surgical Site InfectionsEffectiveness of using Mupirocin
•Can use of Mupirocin ointment to eliminate nasal bacterial carriage prior to intraocular surgery be effective in reducing conjunctival bacterial flora?
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Methods
• Prospective, blinded, randomized clinical trial
• 42 patients undergoing elective Phaco/IOL or PPV
— 22 patients were enrolled in the control group and received no nasal medication
— 20 patients were enrolled in the treatment group and were asked to self-administer mupirocin ointment to each nostril twice daily for 5 days prior to surgery
A) B) C)
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MethodsCultures & Microbiology
• Nasal
— Obtained in all patients
— In treatment group, nasal cultures obtained prior to mupirocin administration.
• Conjunctival
— First before application of 5% povidone-iodine scrub
— Second immediately before surgery
— Care was taken to avoid touching the eyelid margin or lashes and patients did not received topical antibiotics prior to culture
• Microbiology
— Immediate innoculation on Columbia Agar with 5% Sheep Blood and Chocolate II Agar plates
— Plates were incubated overnight in 5-10% CO2
— Daily examination of plates until final report issued by blinded microbiologist
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Results Nasal Cultures 100% Positive
9% S. Aureus (3 MRSA / 3 MSSA)
16% S. viridans
22% Corynebacterium 8% Others
45% Coag. Neg. Staph
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Results Conjunctival Cultures
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Before Povodine-Iodine Prep After Povodine-Iodine Prep
Control
Mupirocin
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Discussion
• A significant reduction in conjunctival bacterial flora can be achieved with preoperative nasal application of mupirocin ointment
— Although the use of povidone-iodine is the “gold standard” for ocular surface sterilization, this reduction was observed with or without the use of povidone-iodine.
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Discussion
• It has been proposed that nasal secretions may breach the sterile drape and contaminate the operative field*
• Kuhn and associates describe 2 cases of clear mucous nasal secretions reaccumulating on the conjunctiva during vitrectomy
• Studies underway to investigate this further
* Nagle F, Cooper RL. Nasal secretions in ocular surgery under general and local anesthesia. Ophthalmic Surg 1993;24:13-15.
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Conclusions
• The goal of pre-operative prophylaxis of any type is to decrease the incidence of post-operative endophthalmitis
— Lower conjunctival contamination rates should theoretically reduce the incidence of postoperative endophthalmitis
• The use of mupirocin nasal ointment prior to intraocular surgery or intravitreal injections is a novel method for reducing conjunctival contamination rates
• Future studies will be needed to precisely define the role of mupirocin nasal ointment for the prophylaxis against intraocular infections
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Thank you for your attention