MRSA: Isolation and Contact Precautions Still Needed?
Authors of new study argue there is clear evidence of harm from such practices
The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, as well as the Centers for Disease Control and Prevention (CDC), all continue to recommend infection control contact precautions (CP) for patients with methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization. However, even in our immediate area, while several acute care hospitals continue to isolate and apply CP for such patients, others have chosen to apply CP only for those patients with MRSA infection and not colonization, and a few have abandoned this practice altogether.
In California, it is a regulatory requirement to provide nares MRSA screening for high-risk individuals, which can be variously defined but at the least includes all admissions to the intensive care unit (ICU). Our facility also provides nares screening for all patients admitted from skilled nursing facilities (SNFs) or long-term care, and those on hemodialysis. About 11% are colonized on admission. Once recognized, they are isolated, infection control flags their chart, and CP are implemented.
Our facility even has extended this practice to pre-emptively place patients admitted from several high-risk SNFs known to be “endemic” for MRSA/multidrug-resistant organisms (MDRO)/carbapenem-resistant Enterobacterales (CRE) in isolation until the results of admitting screening studies have been completed.
The authors of a new study question the merits of isolation and CP for patients with MRSA.1 They identified studies that support this practice, usually combined with other measures, but also identified studies that could not definitively demonstrate a benefit for the use of gown and gloves in the prevention of MRSA transmission. Part of the problem is that many studies employ a bundle of infection prevention practices for patients with recognized MRSA colonization, including enhanced hand hygiene and environmental cleaning, regular chlorhexidine bathing, and sheet changes, and, thus, teasing out the specific benefit of gowns/gloves is not possible.
An argument against the need for isolation and CP for hospitalized patients with recognized MRSA colonization or infection is the fact that, even with routine nares screening, many such patients escape detection, and yet MRSA transmission or outbreaks in facilities are not commonly observed. Nares MRSA screening (by any method) identifies only about two-thirds of patients with colonization.
Because of the expediency and more limited resources during COVID, our facility abandoned isolation and CP practices for MRSA for two years and did not observe an increase in MRSA transmission. Of course, many patients were in isolation for COVID.
In contrast to any purported benefit of CP, the authors argue there is clear evidence of harm from such practices, including reduced staff-patient interactions, with detrimental effects on patient experience and well-being. Some facilities have more limited resources, and this practice may not be as valuable as other interventions, as well as the general unnecessary waste of gowns and gloves, and the added impact to the environment.
Instead of the routine isolation of MRSA-positive patients, the authors argue that isolation and CP should be employed only when increased transmission is observed.
We have debated these issues ourselves, recognizing that we do not observe much evidence of MRSA transmission in our facility. Most cases of hospital-onset MRSA infection are presumed to have had unrecognized colonization, and in-hospital transmission has not been a significant problem. On the other hand, staff “fatigue” with infection control practices is a real problem. Perhaps it is best to focus preventive efforts on more worrisome organisms with a greater potential for risk, such as CRE and Candida auris. But for now, as long as CP continue to be recommended by the CDC, many facilities will continue this practice.
REFERENCE
- Diekama DJ, Nori P, Stevens MP, et al. Are contact precautions “essential” for the prevention of healthcare-associated methicillin-resistant Staphylococcus aureus? Clin Infect Dis 2023; Sep 21:ciad571. doi: 10.1093/cid/ciad571. [Online ahead of print].
The authors of a new study question the merits of isolation and contact precautions for patients with methicillin-resistant Staphylococcus aureus.
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