By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
Dr. Deresinski reports no financial relationships relevant to this field of study.
SYNOPSIS: In the context of other horizontally implemented, effective infection prevention measures, the use of contact precautions for most patients colonized or infected with MRSA or VRE fails to provide benefit.
SOURCE: Bearman G, Abbas S, Masroor N, et al. Impact of discontinuing contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: An interrupted time series analysis. Infect Control Hosp Epidemiol 2018;39:676-682.
Bearman and colleagues at the Virginia Commonwealth University evaluated the impact of seven individual horizontal infection prevention interventions implemented at various times at their 865-bed academic medical center. These were, in sequence:
- January 2011: Urinary catheter bundle implementation;
- June 2011: Chlorhexidine perineal care outside ICUs;
- March 2012: Hospital-wide chlorhexidine bathing outside ICUs (implemented in ICUs in 2007);
- April 2013: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization or infection (absent draining wounds not contained with a bandage);
- August 2014: Monitoring of compliance with contact precautions (still existing for other pathogens) and with “bare below elbows” (initiated in 2009);
- March 2015: Use of ultraviolet-C disinfection robot;
- March 2016: Automatic urinary catheter discontinuation at 72 hours.
Changes in infection rates in association with the interventions were assessed by segmented regression modeling. Hospital-acquired infection (HAI) rates decreased throughout the period analyzed. Following the discontinuation of contact precautions for VRE and MRSA, the rate of HAI due to MRSA decreased by 1.31 per 100,000 patients, while VRE HAI decreased by 6.25 per 100,000 patients; neither change was statistically significant. The rate of both combined fell by 7.56 per 100,000 patients (P = 0.21), while the rate of device-associated infections decreased by 2.44 per 100,000 patients (P = 0.23).
Based largely on observational studies involving outbreaks in which contact precautions were generally a part of a multifaceted bundle of interventions, since 2007 the CDC has recommended the use of personal protective equipment (PPE) during contact with patients either infected or colonized with multidrug-resistant organisms, including both VRE and MRSA. The recommended PPE includes gloves and isolation gowns. However, recent studies have strongly suggested that this admonition is, at best, ineffective, and, at worst, harmful.
Bearman and colleagues provided further evidence that it may be time to end the practice of contact precautions for all patients infected or colonized with VRE or MRSA. This is not a new concept and, in fact, has been addressed previously in Infectious Disease Alert.1 I concluded the commentary at that time in the following way: “Overall, a reasonably firm conclusion can be reached that routine contact isolation for endemic MRSA and VRE is unnecessary (and may be harmful) when there is active maintenance of hand hygiene, environmental cleaning, and chlorhexidine bathing.” The results examined here, which are consistent with those of several other recently published studies, strongly confirm this conclusion. Thus, a 2018 systematic review and meta-analysis concluded that discontinuation of contact precautions for MRSA and VRE has not been associated with increases in infection rates.2 I believe it is time to accept the evidence and act accordingly.
- Deresinski S. VRE and MRSA: Should we stop routine contact precautions? Infect Dis Alert 2016;36:31-32.
- Marra AR, Edmond MB, Schweizer ML, et al. Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis. Am J Infect Control 2018;46:333-340.