1164 infection control & hospital epidemiology october 2015, vol. 36, no. 10


Publications focusing on outbreak settings were excluded. A survey was mailed electronically to all SHEA Research Network members. Hospitals not using CP for MRSA or VRE were identified from both the literature and an infection control listserv and queried on practice and experience; we summarize only reports previously published or with permis- sion from the institutions.


results


Guideline Recommendations for CP for MRSA and VRE in Acute Care Facilities


Multiple guidelines address strategies for preventing cross- transmission of MRSA and VRE in acute care settings that reference the use of CP. SHEA and the Infectious Diseases Society of America jointly recommend that CP be used for MRSA-infected and MRSA-colonized patients in acute care settings for the control of MRSA in both endemic and outbreak settings.4 More broadly, the Healthcare Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention recommend that CP be imple- mented routinely in “all patients infected with target MDROs [multidrug-resistant organisms] and for patients that have been previously identified as being colonized with target MDROs” without identifying explicitly whichMDROs are to be included.5


Impact of CP on Endemic MRSA


Forty-eight articles were reviewed by 2 individuals (Z.R. and B.C.C.) and final results discussed by all authors regarding MRSA. CP as an intervention to decrease MRSA acquisition was rarely analyzed separately from other interventions, and most studies were performed in outbreak settings where multiple control measures were initiated simultaneously. Initially, only studies that evaluated CP alonewereincludedinthereview. However, only 2 studies in endemic settings qualified for inclu- sion, one of which was a prospective quasi-experimental study6,7 andone arandomizedtrial.8 Given the paucity of studies evalu- ating the effect of CP alone, we then included other studies that evaluated the effect of active surveillance cultures (ASC) and resultant increase in use of CP9–15 or universal gown and gloves.16 Lower quality, quasi-experimental studies generally demon-


strated a decrease in transmission ofMRSA with CP. In a retro- spective analysis of interventions to decrease MRSA bacteremia, authors concluded that CP and ASC resulted in a 67% decrease in the incidence of MRSA bacteremia.13 MRSA acquisition decreased from 7.0% to 2.8% after implementation of similar interventions in another quasi-experimental study.14 In a larger quasi-experimental study, Robicsek et al15 instituted ASC and CP on all hospital admissions with a subsequent decrease in MRSA. This study included a decolonization regimen in its final phase. Marshall and colleagues10 performed a quasi-experimental study in an intensive care unit (ICU) with endemic MRSA and noted decreased rates of MRSAafter changing fromno-CP to CP-based


ASC. Another before-after study compared 4 different infection prevention strategies and demonstrated a decrease in MRSA bacteremia with CP.13 Finally, all hospitals of theUSDepartment of Veterans Affairs implemented a before-after bundle that included CP based on ASC, hand hygiene, and cultural change. This study found a small decrease in MRSA colonization and a larger decrease in MRSA healthcare-associated infections.17 In contrast to uncontrolled studies, prospective trials with


control groups largely failed to demonstrate a benefit of CP for MRSA. In a prominent controlled quasi-experimental study, Harbarth et al9 screened surgical patients for MRSA coloniza- tion at admission. Using a cross-over design in 12 surgical wards, they compared rapid ASC with CP to standard infection control measures, which included less frequent CP and decolonization for patients with MRSA by clinical cultures. They observed no difference in MRSA rates between the 2 periods (adjusted incidence rate ratio, 1.20 [95% CI, 0.85–1.69]; P=.29). Huskins et al12 conducted a multicenter cluster randomized controlled trial examining ASC and CP for MRSA-colonized patients and found no difference in the inci- dence of MRSA colonization or infection. A 2014 study con- ducted across 13 European ICUs evaluated multiple


interventions forMDROs in a quasi-experimental fashion. The final phase of the study evaluated ASC with application of CP for carriers.11 The authors found that colonization with MDROs (MRSA, VRE, and Enterobacteriaceae) decreased slightly during an earlier chlorhexidine and hand hygiene intervention phase of the study (relative risk, 0.98 [95% CI, 0.95–0.99]; P=.04) but did not decrease with subsequent addition of ASC.6 Studies examining the use of universal gloves or universal


gowns and gloves have identified mixed results, with the largest study identifying a decrease in MRSA transmission.16 How- ever, in units randomized to universal gowns and gloves, the number of patient interactions by healthcare personnel (HCP) was lower with better hand hygiene and thus the decreased transmission of MRSA may have been due only indirectly to gown and glove use.16 In a quasi-experimental study com- paring CP for MRSA versus universal gloving, Bearman et al6 showed no difference in MRSA acquisition. Harris and colleagues16 published a cluster randomized trial in which the use of universal gowns and gloves, regardless of colonization status, decreased MRSA acquisition by 40%. In summary, many studies suffer from methodologic lim-


itations, such as small sample size, interventions introduced simultaneously, and lack of comparison groups. Adherence to CP was often not monitored, and when assessed, adherence was poor (Table 1a). Although retrospective studies suggest that CP decreases MRSA acquisition, this was not observed in more rigorous studies.


Impact of CP on Endemic VRE


Forty-five articles were reviewed by 2 individuals (M.B. and B.L.J.) for VRE. The literature18–33 abounds with publications


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