Recommendation ID

Is the use of chlorhexidine body wash associated with increased antimicrobial resistance?

Any explanatory notes
(if applicable)

Why the committee made the recommendations

Evidence was identified on the use of mupirocin alone and mupirocin in combination with a chlorhexidine body wash. Mupirocin alone was effective in reducing Staphylococcus aureus infections caught in hospital in people who were identified as carriers of S. aureus. However, mupirocin alone did not reduce surgical site infections across all people undergoing surgery.

The evidence also showed that people identified as carriers of S. aureus who used nasal mupirocin in combination with a chlorhexidine body wash before surgery had fewer surgical site infections caused by S. aureus (including deep infections, methicillin-sensitive infections and infections caught in hospital) than those who did not have the intervention. However, the evidence was very limited and only covered S. aureus carriers.

Economic studies favoured the use of mupirocin alone. However, the studies were not UK-based and could not be applied to NHS practice (for example, because of the high cost of treating surgical site infections in US studies). An economic model based on UK data demonstrated that, compared with no treatment, using mupirocin with a chlorhexidine body wash before all operations was an efficient use of resources in most specialist surgeries. However, there was less certainty of cost effectiveness for surgery with a low risk of surgical site infections caused by S. aureus.

Because of the limited evidence, the committee were unable to make strong recommendations on nasal decolonisation before surgery and agreed that it should not be offered to all people having surgery. The committee applied their clinical understanding and experience of current best practice, and recommended that nasal mupirocin with chlorhexidine body wash should be considered before procedures that have an increased risk of surgical site infection caused by S. aureus, for which there would be the most benefit.

The recommendation does not define the surgical procedures in which S. aureus is a likely cause of a surgical site infection. The committee agreed that although cardiac and orthopaedic surgery can be considered high risk, decisions should be made locally through discussions between surgical and infection control teams, and should also take into account patient risk factors, such as whether the person is an S. aureus carrier and the potential impact of infection on the person, including the cost of managing the infection. The recommendation does not give an optimal timing for nasal decolonisation because of a lack of evidence. But the committee were aware that mupirocin with chlorhexidine can be given from 2 days before surgery to 3 days after surgery.

The committee also took into consideration the potential side effects of mupirocin (such as a burning sensation and local reactions) and the cautions identified for the use of chlorhexidine solution in people with existing skin conditions and in preterm newborn babies. The committee noted that the Medicines and Healthcare products Regulatory Agency (MHRA) has published advice on the use of chlorhexidine for skin disinfection in premature babies.

There was also a lack of evidence on antimicrobial resistance associated with the use of mupirocin and chlorhexidine body wash. The committee agreed that it would be helpful to encourage service providers to maintain surveillance on antimicrobial resistance associated with the use of mupirocin. This would allow any increase in resistance to be captured.

The committee developed a research recommendation on the effectiveness of nasal mupirocin with chlorhexidine body wash across all surgical procedures to help determine whether this should be extended to all people having surgery. Antimicrobial resistance associated with the use of chlorhexidine body wash was also identified by the committee as an important area for a research recommendation.

How the recommendations might affect practice

There is considerable variability in practice. In some services decolonisation is always offered before certain types of surgery, for example, before orthopaedic surgery. In other services decolonisation is offered only to people who are identified as methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA) carriers.

The new recommendation reflects best practice and allows services the flexibility to consider decolonisation for people who are likely to benefit the most. The recommendation may reduce surgical site infections in people undergoing surgical procedures for which the consequences of an infection are severe, such as cardiac surgery. The evidence suggests that any additional costs incurred in providing decontamination are likely to be more than recouped by savings associated with a lower incidence of surgical site infections. However, the committee acknowledged that there may be training implications for those implementing the recommendation.

Maintenance of surveillance systems assessing antimicrobial resistance associated with the use of mupirocin will reinforce good practice.

Full details of the evidence and the committee's discussion are in evidence review A: nasal decontamination in the prevention of surgical site infection.

Source guidance details

Comes from guidance
Surgical site infections: prevention and treatment
Date issued
April 2019

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 11/04/2019