Infections in Hospitals Are Rising—The Nose Is a Primary Source 


Rates of health care-associated infections rose during the COVID-19 pandemic. Investigators have found that often the infections came from the patients themselves. But how?

Nose germs  (Adobe Stock, unknown)

Nose germs

(Adobe Stock, unknown)

New data from The Leapfrog Group, a watchdog organization focused on health care safety, found that several health care-associated infections (HAIs) dramatically increased during the pandemic, providing the most up-to-date assessment of patient safety during COVID-19. The specific HAIs, including methicillin-resistant Staphylococcus aureus (MRSA), catheter-associated urinary tract infections (CAUTI), and central line-associated blood infections (CLABSI) remain at a 5-year high as the public health emergency ends.

Karen Hoffmann, MS, BSN, RN, CIC, FAPIC, FSHEA

Karen Hoffmann, MS, BSN, RN, CIC, FAPIC, FSHEA

(Picture courtesy of the author)

It may seem counterintuitive at first—that infections within hospital walls continued to rise while health systems were increasing personal protective equipment (PPE) and implementing new COVID-19 prevention measures. An article in Infection Control & Hospital Epidemiology sheds light on this paradox. Investigators found that preexisting strategies for preventing HAIs were compromised. The authors reported reduced time devoted to infection prevention process adherence monitoring, such as CLABSI insertion and maintenance bundles. Also, hospital rounding with health care workers' coaching was impacted, potentially increasing the risk of HAIs.

HAIs can mean life or death for some patients, significantly costing the health care system. CLABSIs, which increased by 60% during the pandemic, are associated with 28,000 deaths yearly and cost over $2 billion. CAUTI increased by 19% and is associated with approximately 13,000 yearly deaths. MRSA increased by 15% during COVID-19 and was associated with an estimated 20,000 deaths in 2017.

As hospitals regain their strength post-pandemic, it’s time to recommit to “the basics” regarding infection prevention strategies—evidence-based practices that reduce risk—and consider new ways to reduce infections, especially implementing practices that will help withstand future emergencies.

Strategies such as hand hygiene, environmental cleaning and disinfection, and transmission-based precautions are fundamental practices, surgical site infection (SSI), ventilator-associated pneumonia (VAP), and CLABSI bundles that require renewed attention and monitoring to improve adherence. Innovative solutions like virtual reality education can improve frontline staff engagement and encourage behavior change.

Connie Steed, MSN, RN, CIC, FAPIC

Connie Steed, MSN, RN, CIC, FAPIC

(Photo courtesy of the author)

Another important strategy adopted at hundreds of hospitals across the US is nasal decolonization with an alcohol-based nasal antiseptic—basically like hand sanitizer but specially formulated for the nose. This simple strategy is effective because it attacks germs that can potentially cause infections at its source. The nose is a critical reservoir for many pathogens. For example, most surgical site infections (SSI) and bloodstream infections (BSI) have been traced back to bacteria in the patient’s nose.


Right now, we’re seeing a paradigm shift related to nasal decolonization. In the 1980s, an antibiotic ointment called Mupirocin was implemented for MRSA decolonization in the nose. However, it is effective only for Staphylococcus aureus and only after 5 days of treatment, lacks patient acceptance resulting in adherence issues, and has an ongoing risk of antibiotic resistance. In the past 10 years, we started seeing the introduction of alcohol-based nasal antiseptics into the marketplace as an alternative. Many studies have shown a significant decrease in infections when a nasal antiseptic was added to existing prevention protocols.

Now, universal nasal decolonization protocols are becoming more prevalent. Hospitals are taking nasal antiseptics from a targeted, individual-level approach and applying them to all patients in a facility. If 30% of the population carries S aureus in their nose, why not eliminate it at the source before there’s a chance for it to spread?

Clinical data show that the universal application of alcohol-based nasal antiseptics can lead to significant infection reduction, resulting in major costs avoided for hospitals. In fact, one acute-care hospital that replaced nasal screening with daily universal nasal decolonization with an alcohol-based antiseptic in combination with daily bathing calculated nearly $1.4 million in cost savings. Other settings, like intensive care units, see up to a 100% reduction in dangerous MRSA bacteremia after implementing a similar protocol.

As hospitals reevaluate their strategies to reduce HAIs and recommit to “the basics,” they should take the opportunity to assess emergent, evidence-based practices proven to reduce the risk of infections. Specifically, hospitals should promote the daily use of alcohol-based nasal antiseptics for all patients to reduce pathogen transmission and help return to the decline in HAIs we saw before the pandemic.

To protect any patient, we should protect all patients.

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