1166 infection control & hospital epidemiology october 2015, vol. 36, no. 10
reporting the benefit of CP in terminating VRE outbreaks. As with theMRSA literature, CP as an intervention to decrease VRE acquisitionwas rarely studied separately fromother interventions or compared with standard precautions as the only intervention. Therefore, reviewers included studies that compared CP alone or with some other intervention with a defined control. The search for published studies examining use of CP for VRE control in non-outbreak settings identified 5 studies (Table 1b). Bearman et al6,34 conducted 2 quasi-experimental studies
where CP for patients with VRE was compared with universal glove use. The authors found no difference in VRE acquisition and higher healthcare-associated infection rates with universal glove use in one of the studies. In 2014, De Angelis et al35 published a systematic review and meta-analysis of measures taken to control VRE in ICU settings. They reported results from 3 studies6,12,36 that had application of CP as their only intervention. CP did not significantly reduce the VRE acqui- sition rate (pooled relative risk, 1.08 [95% CI, 0.63–1.83]). The remaining 3 studies were cluster-randomized trials that
examined the impact of CP on VRE acquisition in ICUs.11,12,16 Huskins et al12 used CP in the intervention group after ASC. The mean ICU-level incidence of colonization or infection with VRE/1,000 patient-days at risk did not differ between the 2groups (P=.53). In a cluster randomized trial among ICUs, HCP in intervention ICUs wore gowns and gloves for all patient contacts and room entries in comparison with control ICUs where CP was used only for patients with known antibiotic- resistant bacteria, and the researchers found no difference.16 Likewise, a study in the setting of universal chlorhexidine body washes and hand hygiene improvement identified no benefitto ASC for addressing VRE or other MDROs.11 In conclusion, the literature has not identified a benefitto
CP over standard precautions in acute care settings for controlling the spread of VRE. Unfortunately, no study has compared CP with standard precautions alone. Positive publication bias likely exists and study quality is generally low.
Studies in Children
Studies assessing the impact of CP for MRSA or VRE in chil- dren are limited to quasi-experimental studies in outbreak settings.20 A case-control study with 16 cases and 62 controls identified the absence of CP (odds ratio, 17.16 [95% CI, 1.49–198.21]) and the presence of a gastrointestinal device (4.03 [1.04–15.56]) as factors associated with VRE acquisi- tion.25 As with adult studies, the pediatric literature is limited to quasi-experimental studies that examined CP as part of a bundle, often in response to an outbreak.20
Potential Harms Associated With CP for MRSA and VRE
Studies exploring the negative consequences of CP have focused on the impact on HCP behavior, patient flow, adverse physical events, psychological harm, and patient satisfaction.
Various studies have examined the impact of CP on HCP behavior.3,37–41 CP has been associated with fewer bedside visits and physical examinations by HCP. In ICU and medical/ surgical wards at 4 hospitals, patients on CP were observed having fewer hourly HCP visits (2.78 vs 4.37; P<.001) and shorter contact time (14.0 vs 17.0 minutes/hour; P=.02).3 In surgical settings, patients on CP received 5.3 hourly visits compared with 10.9 among patients not on CP, and had a shorter contact time (29 vs 37 minutes/hour; P=.008).37 In a medical ICU, patients on CP had fewer contacts than those who were not on CP (2.1 vs 4.2 per hour; P=.03).38 Similarly, attending physicians examined patients on CP less frequently (35% vs 73%; P<.001).41 Studies suggest that CP may delay admission from emergency to inpatient settings. Duration of time for admis- sion from the emergency department to a CP room was 12.9 hours for patients with MRSA compared with 10.4 hours for a standard room.42 Average admission wait was 54 minutes longer in patients with a history of MDRO (298 minutes vs 244 minutes; P=.045).43 CP may also result in delayed discharge of patients. Patients on CP awaiting transfer to long- term care facilities experienced an average delay of 10.9 days compared with 4.3 days for similar patients not on CP.42–44 A retrospective study at 2 tertiary medical centers found
adverse event rates were higher in patients on CP (31/1,000 patient-days vs 15/1,000 patient-days; P<.001) as were preventable adverse event rates (20/1,000 patient-days vs 3/1,000 patient-days; P<.001).45 Karki et al46 studied inpatients before and after application of CP for positive VRE status and found no difference in rates of adverse events (incidence rate ratio, 1.04 [0.85–1.27]) but sub-analyses noted more injuries after CP were initiated (3.24 [1.16–11.17]).46 By contrast, in a case-control study, patients with MRSA (on CP) with heart failure or chronic obstructive pulmonary disease found no difference in complication rates with patients with- out MRSA (P=.40).40 Notably, 2 trials that randomly applied CP to patients regardless ofMDRO status found no increase in adverse events associated with use of CP.16,39 Additionally, 2 studies failed to find differences in morbidity or complica- tions in patients on CP and those that were not.39,40 There is a significant quantity of literature related to psychological and psychiatric outcomes in patients on CP but findings vary.47–56 Among inpatients at 3 general hospitals, patients on CP had higher Hospital Anxiety and Depression Scale scores (12.8 vs 8.2; P<.001).51 For patients on a spinal cord injury rehabilitation unit, those on CP had higher Beck Depression Inventory scale scores (16.5 vs 12.3; P=NS).52 Subsequent controlled studies by Day et al53,56 suggest that CP may not be associated with depression and anxiety. The issue of isolation is relevant to the care of pediatric patients, who may be unable to visit unit playrooms or schoolrooms in hospitals owing to their isolation status. Despite these potential concerns, one study in pediatrics found no difference in care.57
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