Reduction Of Conjunctival Bacterial Flora With The Use Of Mupirocin Nasal Ointment Terry J. Alexandrou, MD Ophthalmology Resident The University of Chicago School of Medicine Department of Ophthalmology and Visual Science

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

Seenu Hariprasad

William F. Mieler

Joseph Benevento

Anthony Mazzulla

Michael Saidel

Susan Ksiazek

Kenneth Thompson

Sue Boonlayangoor

Grant Support:

Research to Prevent Blindness Foundation

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-positive coagulase-negative organisms ( Staphylococcus epidermidis) Gram-negative organisms Other Gram-positive organisms

94.2% of isolates gram-positives

(70% S. epidermidis )

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

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

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 (C 26 H 43 O9) 2 Ca●2H20

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.

Reduction of Surgical Site Infections Effectiveness 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

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

Reduction of Surgical Site Infections Effectiveness of using Mupirocin Can use of Mupirocin ointment to eliminate nasal bacterial carriage prior to intraocular surgery be effective in reducing conjunctival bacterial flora?

Can use of Mupirocin ointment to eliminate nasal bacterial carriage prior to intraocular surgery be effective in reducing conjunctival bacterial flora?

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)

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

Methods Cultures & 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% CO 2 Daily examination of plates until final report issued by blinded microbiologist

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% CO 2

Daily examination of plates until final report issued by blinded microbiologist

Results Nasal Cultures 100% Positive 9% S. Aureus (3 MRSA / 3 MSSA) 16% S. viridans 22% Corynebacterium 8% Others 45% Coag. Neg. Staph

Results Conjunctival Cultures

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.

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.

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.

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

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

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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