reconsidering contact precautions for endemic 1169
VRE control that do not use CP generally fall into 3 categories: (1) focus on improved general or horizontal infection control methods without CP, (2) enhanced efforts on syndromic use of gowns and gloves for patients with syndromes correlated with greater contamination (eg, diarrhea, wounds), and (3) targeted decolonization of patients found to be positive for MRSA without CP (see Table 3). Several institutions (Table 3) focus on general horizontal
approaches to limiting transmission of MRSA and VRE, such as hand hygiene, bathing patients with chlorhexidine, or environmental cleaning and disinfection. These hospitals continue to apply CP for Clostridium difficile and multidrug- resistant gram-negative rods. There were multiple anecdotal reports from these institutions of stable or declining rates of infections with MRSA or VRE after foregoing CP.63–65 Three centers reported using CP for patients with specific
syndromes regardless of colonization status. These centers made a specific effort to use CP for all patients with diarrhea who were unable to self-toilet or with incontinence (including C. difficile or norovirus), open wounds that cannot be contained within a dressing, pneumonia or upper respiratory tract infection in patients unable to practice respiratory eti- quette, and patients with urinary tract infection unable to self- toilet65 or with incontinence.66 The limited reports from these hospitals noted no change in percentage of S. aureus that is methicillin-resistant, a low rate of MRSA during a prevalence survey, and stable or declining rates of ventilator-associated pneumonia, central line–associated bloodstream infection, and surgical site infection (both overall and due to MRSA).65 Given the importance of preventing infections with either
methicillin-susceptible and methicillin-resistant S. aureus, the Cleveland Clinic hospital system implemented surveillance cultures of patients for S. aureus upon admission to ICU with targeted decolonization with chlorhexidine bathing and intranasal mupirocin. They reported decreased S. aureus in a single medical ICU (6.28 vs 3.32 acquisitions/1,000 patient- days) and healthcare-associated infections (3.52 to 1.29 cases/ 1,000 patient-days).67 This policy has since been implemented at all 10 Cleveland Clinic hospitals with reported declining rates of MRSA. These hospitals continue to apply CP for C. difficile and multidrug-resistant gram-negative rods.
discussion
The literature does not provide strong evidence of benefit from CP over standard precautions for controlling endemic VRE or MRSA. To our knowledge, to date, no study has compared CP with standard precautions. Determining the optimal use of CP is an important issue because it affects 10%–25% of hospitalized patients, may have a negative impact on patient throughput, and may cause harm and decrease quality of care by reducing HCP-patient contact. Understanding the true benefits and harms of CP is important. Our survey of SHEA Research Network members found that most hospitals responding currently use CP for MRSA and VRE, but a high
proportion expressed interest in using CP in a different manner. Hospitals no longer using CP for MRSA or VRE paid special attention to collecting metrics focusing on processes and outcomes. Process measures generally focused on HCP compliance with policies related to hand hygiene and use of gloves and gowns, as well as compliance with other horizontal infection control strategies being employed at each institution (eg, hand hygiene improvement, line insertion checklists, chlorhexidine bathing, environmental cleaning, and anti- microbial stewardship). In addition, the availability of single patient rooms was reported by some facilities to factor in the decision to not routinely use CP for MRSA and VRE. Outcome measures focused on overall, hospital-wide rates of healthcare- associated infections, especially those due to MRSA or VRE. A few facilities conducted either limited or ongoing surveil- lance culturing for MRSA patient colonization to ensure that MRSA and VRE rates did not increase after foregoing CP. Surprisingly, hospitals not using CP for patients with MRSA
or VRE reported no negative feedback from the Joint Com- mission or the Centers for Medicare and Medicaid Services after hospital visits. Because not using CP for MRSA or VRE is uncommon, many respondents stated that they had been proactive in providing data to surveyors related to MRSA and VRE rates and having infection prevention policies that clearly stated the rationale for not using CP for MRSA or VRE. At all institutions it was important that staff be educated with regard to use of gowns and gloves so that they would be compliant with policies and could explain policies if asked by regulatory reviewers. Interestingly, some hospitals designed their pro- gram to forego CP with assistance from the local and state Departments of Health and reported that this step assisted with regulatory review. It is notable that many hospitals not using CP for MRSA or
VRE are in states with legislation mandating active surveillance culturing for MRSA. Despite mandating use of active surveil- lance, state laws often do not require use of CP for those identified with MRSA. This was not seen as a barrier to fore- going use of CP. Relevant questions for future research include when and
where CP may provide additional benefits over assiduous use of standard precautions, especially when hospitals are using horizontal control measures, such as chlorhexidine bathing, universal gloving, hand hygiene surveillance, and environmental cleaning. Additionally, a more rigorous examination of universal or targeted chlorhexidine bathing or syndromic use of CP compared with standard use of CP for MRSA or VRE would advance the field. Our findings suggest that a “one size fits all” approach to MRSA and VRE control in endemic settings is not supported by robust science. Across multiple healthcare systems, various strategies are reported for the control of endemic, hospital-acquired MRSA and VRE infections, suggesting that local factors, needs, and resources should drive the choice of optimal CP utilization.
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