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: Discontinuation of contact precautions for patients colonized or infected with either MRSA or VRE is associated with a decrease in rates of noninfectious adverse events.

SOURCE: Martin EM, Bryant B, Grogan TR, et al. Noninfectious hospital adverse events decline after elimination of contact precautions for MRSA and VRE. Infect Control Hosp Epidemiol 2018 May 10:1-9. doi: 10.1017/ice.2018.93. [Epub ahead of print].

In 2016, Martin and colleagues at UCLA and the Santa Monica Hospital reported that elimination of routine contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) infection or colonization was not associated with an increase in detection of these organisms, but was associated with considerable cost savings. Others have confirmed a lack of adverse outcomes resulting from discontinuation of contact precautions in response to these organisms,^1,2 indicating that this strategy is safe. The same group now reports that this approach is not only safe, but it is associated with a reduction of noninfectious adverse events.

In a before-and-after study, the investigators compared hospital reportable adverse events for single years prior to and after discontinuation of contact precautions for VRE and MRSA. During the year before, chlorhexidine bathing for almost all inpatients was implemented. The noninfectious adverse events that were considered were postoperative respiratory failure, hemorrhage/hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma. The comparison was analyzed using segmented and mixed-effects Poisson regression models.

Approximately 12% of 24,732 admissions in the pre-intervention period resulted in isolation for MRSA and/or VRE, while no patient was isolated for this reason post-intervention. Meanwhile, there was an overall 19% decrease in noninfectious adverse events from pre- to post-intervention from 12.3 per 1,000 admissions to 10.0 per 1,000 admissions (P = 0.022). There was no significant change in overall infectious adverse events. Limiting the analysis to MRSA/VRE admissions, the rate of noninfectious adverse events decreased from 21.4 per 1,000 to 6.08 per 1,000 admissions (P < 0.001) — a 72% reduction.

COMMENTARY

The authors of several studies have reported that patients may suffer from a wide variety of adverse events as a result of being placed in contact precautions. However, recent studies have contradicted these findings. This study has some of the usual drawbacks of most infection prevention research, including its quasi-experimental before-and-after design and other changes such as the implementation of almost universal chlorhexidine bathing during the pre-intervention period.

Several studies indicate that the elimination of routine contact precautions for patients with MRSA and/or VRE colonization or infection is safe (i.e., not associated with increased rates of detection of affected patients). Martin and colleagues have found that such discontinuation is not just safe regarding infection, but it actually appears to enhance patient safety as evidenced by a decrease in noninfectious adverse effects.

REFERENCES

1. 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.
2. 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.
3. Martin EM, Russell D, Rubin Z, et al. Elimination of routine contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: A retrospective quasi-experimental study. Infect Control Hosp Epidemiol 2016;37:1323-1330.