Title : Breaking the mupirocin paradox: Light activated nasal decolonization achieves 66% SSI reduction and sustained cost savings without resistance signals in spine surgery over 8 years
Abstract:
Background: Nasal decolonization is central to SSI prevention, with mupirocin long regarded as the topical “gold standard” for eliminating Staphylococcus aureus carriage. However, real world implementation exposes a Mupirocin Paradox: programmes that successfully reduce SSIs also accelerate mupirocin resistant strains, require complex screening and adherence workflows, and risk eroding future prevention efficacy. Emerging evidence from the Carriage Study 2025 further suggests that repeated intranasal antibiotics targeting Gram positive organisms may disrupt the commensal nasal microbiome, potentially impairing host defence and fostering ecological conditions favourable to resistant or opportunistic pathogens. As AMR pressure intensifies, guidelines increasingly highlight the need for non antibiotic, resistance proof decolonization technologies that preserve both microbiome integrity and antimicrobial utility.
Aim: To contrast the Mupirocin Paradox and its microbiome implications with long term clinical and economic outcomes from a universal, non antibiotic nasal photodisinfection protocol in spine surgery, highlighting its potential as a durable, resistance proof alternative for SSI prevention and health system sustainability.
Methods: A large tertiary centre implemented a universal pre surgical decolonization bundle combining intranasal photodisinfection and chlorhexidine gluconate (CHG) body wipes for major spine procedures. Over an 8–14 year period, more than 13,000 spine surgery patients were followed under routine clinical conditions and infection prevention surveillance. We examined changes in SSI rates, estimated cost impact per surgical patient, and evaluated any emergence of resistance related performance loss or safety concerns. Findings were contextualized against the known constraints, microbiome disruption risk, and resistance liabilities of mupirocin based decolonization described in contemporary literature, including the Carriage Study (2025).
Results: Introduction of the universal nasal photodisinfection plus CHG protocol was associated with a 66–67% relative reduction in spine SSI rates (from 7.98% to 2.67%, p<0.001). Hospital economic analysis estimated net institutional savings of approximately $19.9 million over 8 years, corresponding to about $2.49–$2.58 million per year, or roughly $2,458–$2,578 saved per surgical patient. Across the entire study period, there were no reported protocol related serious adverse events and no evidence of diminished efficacy suggesting emergence of photodisinfection resistance. In contrast to mupirocin based programmes, this universal, procedure embedded approach eliminated the need for pre operative screening logistics and multi day home regimens, avoided selective pressure focused on Gram positive flora, and did not add to the antibiotic resistance reservoir.
Conclusion: The experience with universal nasal photodisinfection demonstrates that a non antibiotic decolonization bundle can deliver large, durable SSI reductions and substantial per patient cost savings without detectable resistance signals or antibiotic driven microbiome damage. This directly addresses the Mupirocin Paradox by decoupling SSI prevention from selective antibiotic pressure, microbiome disruption, and long term resistance risk. For health systems facing AMR, surgical backlogs, and budget constraints, resistance proof, microbiome sparing decolonization strategies offer a compelling path to protect patients, preserve antibiotic utility, and unlock recurring capacity and financial gains.
