Decolonisation for recurrent staphylococcal skin infections

Decolonisation is used for some patients with recurrent staphylococcal skin infections but should not be used until acute lesions have healed. Decolonisation aims to eradicate staphylococcal carriage but is only successful in around half of patients treated.

Before decolonisation, collect nasal and/or perineal swabs to confirm S. aureus colonisation. Extended susceptibility testing is not required for the initial decolonisation attempt.

Decolonising all household contacts, or household contacts with a history of staphylococcal skin infection in the last 12 months, is more effective in preventing recurrent infections than decolonising the index case aloneHogan, 2021.

For decolonisation, useFritz, 2011:

mupirocin 2% nasal ointment inside each nostril, 12-hourly for 5 days mupirocin mupirocin mupirocin

PLUS EITHER

for use in baths – use 60 mL (approximately 1/4 [one-quarter] cup) of 4.2% bleach for a standard average-sized bath (80 litres); wash once daily for 5 days. For printable instructions, see Patient information: Instructions on how to use bleach baths for reducing recurrent skin infections

OR

for use in showers – an antiseptic wash or soap containing chlorhexidine 2%; wash once daily for at least 5 days, paying particular attention to areas of hairy skin.

Figure 1. Patient information: Instructions on how to use bleach baths for reducing recurrent skin infections. Printable figure

Ayre, 2023Fritz, 2011Zheng, 2015The Royal Children's Hospital Dermatology department (RCH), 2020

Prepare the bleach bath

Household bleach brands vary in strength; check the label to confirm the strength. Standard household bleach in Australia has a sodium hypochlorite strength of 4.2% (42 g/L).

Use bleach without added fragrance because allergies can occur to fragrances.

For an average-sized bath (80 litres), use 60 mL (about 1/4 [one-quarter] cup) of bleach.

For smaller baths, measure the size of the bath using a bucket (an average-sized bucket is usually 10 litres). Add 10 mL of bleach for each 10 litres of water.

If there is a bleach smell, the bleach bath may be too strong.

After preparing the bleach bath
  • Soak in the bath for 10 minutes.
  • Wash head and face with the water, but do not place head under water.
  • Do not rinse the skin after soaking.
  • Dry the skin with a towel (use old or white towels to avoid bleaching coloured towels).
  • Apply a moisturiser because bleach baths can worsen dry skin.

If infection recurs in the index case, consider decolonisation of household contacts if it was not performed initially.

If infection recurs despite decolonisation of both the index case and household contacts, treat with an oral rifampicin-based regimen, together with the decolonisation regimen above. The oral regimen should be based on the susceptibility of the isolate – seek expert advice. Although this approach can reduce colonisation, data demonstrating a reduced risk of infection recurrence are lacking. An alternative approach is 12 months of mupirocin nasal ointment (see regimen above) used for the first 5 days of every monthRaz, 1996.