Reconsidering Contact Precautions for Endemic Methicillin-Resistant <i>Staphylococcus aureus</i> and Vancomycin-Resistant <i>Enterococcus</i>

Morgan, Daniel J.; Murthy, Rekha; Munoz-Price, L. Silvia; Barnden, Marsha; Camins, Bernard; Johnston, BL; Rubin, Zachary; Sullivan, Kaede V.; Shane, Andi L.; Dellinger, E. Patchen; Rupp, Mark E.; Bearman, Gonzalo

doi:10.1017/ice.2015.156

Cited by 117 publications

(122 citation statements)

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“…Despite increasing evidence of the negative impact of CP, routine CP for MRSA and VRE remains commonplace. Our findings are similar to those reported by Morgan et al 14 Although their sampled population was smaller and varied slightly from ours, both surveys reveal a high percentage of respondents using CP (more than 90%) yet expressing interest in alternative approaches. Variation in the way CP is used was evident and likely driven by these factors: institutional (eg, infection rates, facility experience, workplace culture), patient (eg, population served), scientific (eg, evidence regarding duration of colonization), and regulatory (eg, state requires active surveillance testing for MRSA, so hospitals use CP).…”

Section: Discussionsupporting

confidence: 91%

Routine Use of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: Which Way Is the Pendulum Swinging?

Russell

Beekmann

Polgreen

et al. 2015

Infect. Control Hosp. Epidemiol.

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BACKGROUND Studies have suggested that contact precautions (CP) for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus may have risks that outweigh the benefits. These risks, coupled with more widespread use of horizontal interventions such as daily bathing with chlorhexidine gluconate, have brought into question the value of routine CP for these organisms. OBJECTIVE To assess the state of utilization of CP as well as adjunctive measures to reduce the risk of transmission in US hospitals. DESIGN Cross-sectional survey. PARTICIPANTS Total of 751 physician members of the Emerging Infections Network. METHODS An 8-question electronic survey distributed by email. RESULTS A total of 426/751 (57%) responded to the survey; 337/364 (93%) of respondents use routine CP for methicillin-resistant S. aureus and 335/364 (92%) use routine CP for vancomycin-resistant enterococcus. The most widely used trigger for initiation of CP for both pathogens was positive clinical culture. Practices for discontinuation of isolation varied widely. We found that 325/354 (92%) perform routine chlorhexidine gluconate bathing and 236/353 (67%) perform S. aureus decolonization with mupirocin for 1 or more subsets of inpatients, and 82/356 (23%) reported using either hydrogen peroxide vapor or ultraviolet-C room disinfection at discharge. Free text responses noted frustration and variation in the application, practice, and process for initiation and discontinuation of CP. CONCLUSIONS Use of CP for methicillin-resistant S. aureus and vancomycin-resistant enterococcus remains commonplace, although horizontal interventions such as chlorhexidine gluconate bathing are increasingly used. The heterogeneity of practices and policies was striking. Evidence-based guidelines regarding CP and horizontal interventions are needed. Infect. Control Hosp. Epidemiol. 2015;37(1):36-40.

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Section: Discussionsupporting

confidence: 91%

Routine Use of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: Which Way Is the Pendulum Swinging?

Russell

Beekmann

Polgreen

et al. 2015

Infect. Control Hosp. Epidemiol.

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“…Current data suggests if standard precautions are well adhered to, the incremental benefit of contact precautions is small. 56 It is not surprising then that there is marked variation in the utilisation of contact precautions for VRE colonised patients between institutions, with some hospitals having discontinued routine contact precautions for VRE and occasionally MRSA for non-critical wards. 56,57 Nonetheless, the presence of VRE and MRSA in the hospital environment is problematic.…”

Section: Contact Precautionsmentioning

confidence: 99%

“…56 It is not surprising then that there is marked variation in the utilisation of contact precautions for VRE colonised patients between institutions, with some hospitals having discontinued routine contact precautions for VRE and occasionally MRSA for non-critical wards. 56,57 Nonetheless, the presence of VRE and MRSA in the hospital environment is problematic. Improving environmental cleaning, particularly in high-risk units, as a 'horizontal' approach that focuses prevention strategies and impacts on all environmental MRO, is likely a more effective measure to reduce MRO exposure.…”

Section: Contact Precautionsmentioning

confidence: 99%

Healthcare‐acquired infections: prevention strategies

Fernando

Gray

Gottlieb

2017

Internal Medicine Journal

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Healthcare‐acquired infections (HAI) impact on patient care and have cost implications for the Australian healthcare system. The management of HAI is exacerbated by rising rates of antimicrobial resistance (AMR). Health‐care workers and a contaminated hospital environment are increasingly implicated in the transmission and persistence of multi‐resistant organisms (MRO), as well as other pathogens, such as Clostridium difficile. This has resulted in a timely focus on a range of HAI prevention actions. Core components include antimicrobial stewardship, to reduce overuse and ensure evidence‐based antimicrobial use; infection prevention strategies, to control MRO – particularly methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin‐resistant Enterococcus spp. (VRE) and, more recently, multi‐resistant Gram‐negative bacteria; enhanced institutional investment in hand hygiene; hospital cleaning and disinfection; and the development of prescribing guidelines and standards of care. AMR surveillance and comparisons of prescribing are useful feedback activities once effectively communicated to end users. Successful implementation of these strategies requires cultural shifts at local hospital level and, to tackle the serious threat posed by AMR, greater co‐ordination at a national level. HAI prevention needs to be multi‐modal, requires broad healthcare collaboration, and the strong support and accountability of all medical staff.

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“…30 In addition, some hospitals perform surveillance cultures during hospitalization in predefined units to identify cases of MRSA acquisition. 30 Because colonization with MRSA can be persistent, 31 especially in high-risk populations, some previously published guidance documents recommend automatically placing patients on CP during hospitalization if they have a history of MRSA colonization or infection during prior hospital admissions, 5,30 thereby increasing the population in healthcare facilities who are on CP for MRSA. 5 There are no national guidelines pertaining to discontinuation of MRSA CP.…”

Section: Shea Research Network Surveymentioning

confidence: 99%

Duration of Contact Precautions for Acute-Care Settings

Banach

Bearman

Barnden³

et al. 2018

Infect. Control Hosp. Epidemiol.

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purposeThis expert guidance document (EG) provides recommendations regarding discontinuation of contact precautions (CP) at the individual patient level in acute-care hospitals employing CP for 1 or more of the following organisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile, and multidrug-resistant Enterobacteriaceae (MDR-E), including carbapenem-resistant Enterobacteriaceae (CRE) and extended-spectrum β-lactamase (ESBL)-producing organisms. This document also provides a review of the role of molecular testing in guiding decisions pertaining to duration of CP for patients with these organisms. The guidance does not address decisions regarding the initiation of CP for any specific organism.Previously published guidelines describe components of CP and identify situations in which CP should be used; currently, however, few publications address the issue of how long CP should be maintained. At the time of publication, decisions related to implementation of CP for select, endemic organisms are made by individual facilities based on factors such as institutional epidemiology, resources, organizational priorities, and previously published guidance, and these vary widely. The SHEA Guidelines Committee (GLC) selected this topic to address when CP should be discontinued for individual patients in acute-care settings that employ CP for the aforementioned organisms.Although the organisms addressed are frequently encountered in other settings (eg, nursing homes, long-term acute-care facilities, rehabilitation centers, outpatient medical care settings), additional considerations may affect the application of these recommendations outside the acute-care hospital environment. authorsThe authors consist of current and past members of the SHEA Guidelines Committee (GLC), who serve as volunteers. All authors are involved at their respective institutions in the development of policies pertaining to CP, either directly or in an advisory role. intended useSpecial-topic EG documents are developed to address areas of relatively narrow scope that lack the level of evidence required for a formal guideline but are important for the provision of safe and effective healthcare. As such, systematic grading of evidence level is not provided for individual recommendations. Each EG is based on a synthesis of limited evidence, theoretical rationale, current practices, practical considerations, the opinion of the writing group, and consideration of potential harms where applicable. Within the EG, a summary list of recommendations is provided, along with their respective rationales. We also conducted a survey of the SHEA Research Network (SRN).No EG can anticipate all situations and this EG is not meant to be a substitute for individual judgment by qualified professionals. methods Expert Guidance DevelopmentThis EG follows the process outlined in the Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents. 10 The topic of duration of CP was among those proposed and ...

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Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus

Abstract: Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.

Cited by 117 publications

References 65 publications

Routine Use of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: Which Way Is the Pendulum Swinging?

Routine Use of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: Which Way Is the Pendulum Swinging?

Healthcare‐acquired infections: prevention strategies

Duration of Contact Precautions for Acute-Care Settings

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