Anesth Analg 2003;97:222-225
© 2003 International Anesthesia Research Society
CRITICAL CARE AND TRAUMA
The Preventive Effects of Mupirocin Against Nasotracheal Intubation-Related Bacterial Carriage
Satoshi Takahashi*,
Kouichiro Minami
,
Midori Ogawa
,
Hiroshi Miyamoto,
Kunio Ikemura*,
Akio Shigematsu, and
Hatsumi Taniguchi
Department of *Oral and Maxillofacial Surgery,
Anesthesiology, and
Microbiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
Address correspondence and reprint requests to Kouichiro Minami, MD, PhD, Department of Anesthesiology, School of Medicine, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan. Address e-mail to kminami{at}med.uoeh-u.ac.jp
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Abstract
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Nasotracheal intubation is often required during dental and maxillofacial surgery. The complications of nasotracheal intubation are well documented, but there have been few systematic attempts to find methods for their prevention. We examined intubation-related carriage of bacteria, especially methicillin-resistant Staphylococcus aureus (MRSA), into the trachea and evaluated the effects of topical nasal treatment with mupirocin on intubation-related bacterial colonization. Of 38 patients without mupirocin treatment (nontreatment group), 27 (71.1%) showed general bacterial colonization in the nasal cavities before intubation. MRSA was isolated from 13.2% of the patients in this group. However, 10 of 22 patients (45%) treated with mupirocin (treatment group) showed colonization by general bacteria, and 2 (9%) were MRSA carriers before intubation. After nasal intubation, general bacteria and MRSA were isolated from the endotracheal tube tip in 66.2% and 16.7% of these patients in the nontreatment group, respectively. In contrast, general bacteria were isolated from the endotracheal tube tip in 19.2% of these patients after oral intubation, but no MRSA was detected. However, after nasal intubation, general bacteria were isolated from the endotracheal tube tip in 3 of the patients in the treatment group (23.1%), and no MRSA was detected, whereas no bacteria were isolated from oral intubation tubes. These results indicate that bacteria were carried into the trachea at a more frequent rate by nasal intubation as compared with oral intubation, and nasal treatment with mupirocin eliminated the nasal carriage of S. aureus. Topical nasal treatment with mupirocin before nasal intubation is thus suggested to be effective for preventing carriage of bacteria into the trachea.
IMPLICATIONS: We studied the carriage rate of bacteria into the trachea caused by nasal intubation. The bacterial carriage by nasal intubation was more frequent than that by oral intubation, and intranasal administration of mupirocin eliminated the carriage of S. aureus. These results indicate that topical nasal treatment with mupirocin is effective to prevent carriage of bacteria into the trachea.
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Introduction
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Nasal intubation is often required during dental and maxillofacial surgery, despite the well-documented complications associated with such procedures (1). Nasal sinusitis has been reported as a complication of prolonged nasotracheal intubation. Moreover, nasal septal and parapharyngeal abscesses have been reported after short-term nasotracheal intubation (2). Holzapfel et al. (3) reported that nosocomial pneumonia and septicemia were more frequent in patients with nasotracheal intubation than in those intubated orotracheally. However, there have been few studies to find methods for the prevention of such complications.
Methicillin-resistant Staphylococcus aureus (MRSA) is a nosocomial pathogen that has become a great concern in hospitals worldwide (4). Up to 40% of the normal population carry S. aureus in the anterior nares, and this carriage rate is often increased in hospitalized patients and their attendants. The increasing incidence of MRSA has been associated with hospital outbreaks leading to considerable morbidity and disruption of hospital services.
Mupirocin is a novel antibiotic that is completely unrelated in chemical structure and mode of action to any other clinically useful class of antibiotics. This drug has greatest antibacterial activity against aerobic Gram-positive cocci, i.e., S. aureus, S. epidermidis, Streptococcus pyogenes, and other ß-hemolytic streptococci. In an unblinded intervention trial with historical controls, perioperative nasal carriage of S. aureus was eliminated using nasal mupirocin ointment, and a significant reduction in surgical site infection was observed postintervention in patients treated with this antibiotic (5). Mupirocin has also been used in hemodialysis patients in an attempt to eradicate nasal carriage of S. aureus and to prevent infection caused by this microorganism (6). Mupirocin nasal ointment was effective in eradicating nasal carriage of S. aureus and in preventing S. aureus infections, including MRSA (7–9).
In this study, we investigated whether mupirocin nasal ointment can prevent the complications associated with nasotracheal intubation. For this purpose, we examined intubation-related carriage of bacteria into the trachea by nasal intubation and evaluated the effects of topical nasal treatment with mupirocin.
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Methods
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This study protocol was performed with permission from our university ethics committee. Adult patients presenting for dental or maxillofacial surgery, ASA physical status I or II, were enrolled in the present study. Written informed consent was obtained from all patients. Patients were randomly assigned to receive either mupirocin calcium ointment or a placebo ointment that was identical in appearance. Each patient could be enrolled in the study only once. Patients who had airway difficulties, nasal sinusitis, or known hypersensitivity to mupirocin were excluded.
Cotton swabs were used by the same anesthesiologist to apply 2% mupirocin calcium ointment or placebo to the interior of each anterior naris 10 h before anesthesia. General anesthesia was induced with propofol at a dose of 2–2.5 mg/kg IV after preoxygenation. Laryngoscopy and intubation were facilitated with vecuronium at a dose of 1.0 mg/kg IV. Endotracheal tubes with a low-pressure cuff (SheridanTM; Kendall Healthcare Products Co, Inc, Mansfield, MA) were used in this study. The patients were intubated orally with tubes 7.0 and 7.5 mm in inner diameter or nasally with tubes 6.0 and 6.5 mm in inner diameter. Nasal bacteria were obtained from the interior of each anterior naris of all patients by using cotton swabs. Intubations were performed by the same anesthesia resident with an autoclaved curved laryngoscope under supervision by an instructor. A lubricant containing 10% lidocaine was applied to the endotracheal tubes to facilitate intubation. The resident was blinded to group assignment. Patients in whom more than two attempts at passage of the endotracheal tube were required were eliminated from the study. After insertion of the tube into the nasal cavity, bacteria attached to the endotracheal tube tip were sampled through the oral cavity using cotton swabs. In the patients who were intubated orally, just after insertion of the tube, bacteria attached to the endotracheal tube tip above the root of tongue were sampled through the oral cavity using cotton swabs. The cuff was inflated just to the point of obtaining a seal in the presence of positive airway pressure.
The bacteria obtained with cotton swabs were suspended in 1 mL of phosphate buffered saline by vortexing for 20 s. Aliquots of 0.1 mL of these suspensions were inoculated onto nutrient agar plates (Nissui Pharmaceutical Co, Ltd, Tokyo, Japan). After one day of incubation at 37°C, the number of colony forming units was counted as the general bacterial number. The general bacteria were replicated onto both yolk salt agar (Nissui Pharmaceutical) and MRSA screening agar (Nippon Becton Dickinson Co, Ltd, Tokyo, Japan); the latter contained 6 µg of oxacillin and 4% NaCl. These plates were incubated overnight at 37°C, and methicillin-resistant lipase-producing colonies were identified as MRSA. The presence of MRSA was confirmed by Gram staining, an agglutination test for protein A and clumping factor (Staphylo LA; Denka Seiken, Tokyo, Japan), and amplification of mecA genes by polymerase chain reaction (10).
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Results
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The study population consisted of 60 patients; 35 underwent oral intubation, whereas the remaining 25 underwent nasal intubation. Thirteen patients in the nasal intubation group and nine patients in the oral intubation group were treated with mupirocin (Table 1).
Of 38 patients who did not receive mupirocin treatment (nontreatment group), 27 (71.1%) showed general bacterial colonization in the nasal cavities before intubation, and MRSA was isolated from 5 (13.2%) of the patients in this group. However, of 22 patients treated with mupirocin (treatment group), 10 (45%) showed colonization by general bacteria, and 2 (9%) were MRSA carriers before intubation (Table 2).
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Table 2. The Effects of Mupirocin Treatment on the Culture of Bacteria from the Extremity of the Intubation Tube were Obtained by Cotton Swabs in the Patients After Oral Intubation or Nasal Intubation
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Bacteria were isolated from the endotracheal tube tip after oral intubation in 5 patients (19.2%) in the nontreatment group (Table 2), and MRSA was not detected in these patients. However, after nasal intubation, bacteria were detected on the endotracheal tube tip in 8 patients (66.2%) in the nontreatment group, and MRSA was detected in 2 of these patients (Table 2). No bacteria were detected on the endotracheal tube tip after oral intubation in the mupirocin-treated group (Table 2). Mupirocin treatment reduced the number of bacteria in the nasal intubation tube tip. After nasal intubation, general bacteria were isolated from the endotracheal tube tip in 3 of the patients in the treatment group (23.1%), and no MRSA was detected (Table 2).
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Discussion
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The results of the present study indicate that bacteria are carried into the trachea by nasal intubation at a much more frequent rate than they are by oral intubation. This is the first report of the carriage of bacteria from the nasal cavity into the trachea because of nasal intubation, although several investigators have reported that nasal cannulation for endotracheal and gastric intubation is a major risk factor for nosocomial infection (3,11,12). Our results are consistent with these previous reports, and the carriage of bacteria from the nasal cavity to the trachea may be one of the causes of nosocomial pneumonia after nasotracheal intubation.
In the present study, the nasal carriage rate of MRSA was 13.2% (5 of 38 patients). Dupeyron et al. (13) reported nasal carriage rates of 18.8% for methicillin-sensitive S. aureus and 16.3% for MRSA in 551 cirrhotic patients with a total of 589 consecutive hospital stays. Corbella et al. (14) performed a prospective study of S. aureus colonization and infection in 752 consecutive patients admitted to intensive care units. Of 752 patients studied, 166 (22.1%) were nasal S. aureus carriers at admission to the intensive care unit. Of these 166 nasal carriers, 163 harbored methicillin-sensitive S. aureus, whereas the remaining 3 harbored MRSA. The carriage rates reported here are similar to these previous results. Mupirocin treatment eliminated the nasal carriage of S. aureus, which was consistent with previous reports (7–9,15). These results indicate that mupirocin treatment before anesthesia would be effective for preventing the carriage of MRSA into the operating room.
In a few previous studies, disinfection of the nasal cavity was performed before nasal intubation, usually using vasoconstrictors and local anesthetics. Dinner et al. (16) reported that the risk of bacteremia is not prevented by use of topically applied vasoconstrictors. Although Schmidt and Rosenkranz (17) reported that lidocaine has antimicrobial activity, pretreatment of the nasal cavity with lidocaine did not show any antimicrobial effect. In the present study, mupirocin reduced the numbers of bacteria isolated from the nasal cavity and the endotracheal tube tip after nasal intubation, consistent with the results of previous reports (7–9,15). These results suggested that pretreatment with mupirocin would be useful for prevention of the carriage of bacteria into the trachea by nasal intubation. However, it should be pointed out that MRSA has been isolated from patients undergoing prolonged skin treatment with mupirocin (18). Casewell and Hill (19) reported that administration of mupirocin yielded negative cultures in all of 22 patients within 24 hours. Therefore, we applied mupirocin topically before intubation. Moreover, there has been no evidence for the emergence of mupirocin resistance as a mechanism of relapse of nasal carriage (5,18); however, care should be taken to avoid repeat treatment with mupirocin to prevent the development of mupirocin-resistant MRSA.
In conclusion, we demonstrated that bacteria were carried into the trachea at a more frequent rate by nasal intubation as compared with oral intubation and that nasal treatment with mupirocin eliminated the nasal carriage of S. aureus. In the present study, no nosocomial pneumonia was observed after nasotracheal intubation. Further studies are required to clarify the preventive effects of mupirocin against nosocomial pneumonia. However, topical nasal treatment with mupirocin before nasal intubation is suggested to be effective for preventing the carriage of bacteria into the trachea.
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References
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Accepted for publication February 25, 2003.
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Abstract
Introduction
