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

Abstract

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.

A Discrete Event Simulation Model of Patient Flow in a General Hospital Incorporating Infection Control Policy for Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE)

“…Non-colonized patients cohorted with colonized or infected patients have an increased risk of acquisition from their roommate. 27 Further, given recent reports of facilities choosing to forgo implementation of contact precautions for flagged patients, 33–35 our findings highlight the potential for such policies to result in undetected colonization and transmission.…”

“…Non-colonized patients cohorted with colonized or infected patients have an increased risk of acquisition from their roommate. 27 Further, given recent reports of facilities choosing to forgo implementation of contact precautions for flagged patients, [33][34][35] our findings highlight the potential for such policies to result in undetected colonization and transmission. Clinical studies in which patients with MRSA/VRE flags have been screened for persistent colonization have demonstrated that the administrative flag is a poor surrogate for colonization for both.…”

Patient contact is the main risk factor for vancomycin-resistant Enterococcus contamination of healthcare workers’ gloves and gowns in the intensive care unit

“…Our finding that 15% of HCWs are contaminated with VRE after patient care should add to the debate regarding whether or not to discontinue Contact Precautions for VRE. 20–22 Our findings contribute to the evidence for the use of Contact Precautions and hand hygiene for HCWs whose activities involve touching the patient.…”

Duration of Contact Precautions for Acute-Care Settings

“…34 Additionally, 18% of the respondents to a survey administered to physicians in the Emerging Infections Network (EIN) reported that the duration of isolation for MRSA at their hospital was indefinite once a patient was positive. 9 Shenoy et al 36 also conducted a randomized control trial of individuals with a history of MRSA colonization or infection at least 90 days prior to enrollment in the study and compared standard hospital practice of clinician-initiated screening using 3 sequential cultures (ie, "passive screening") to study initiated screening for discontinuation of CP (ie, "active screening"). In the active screening arm, research staff obtained 3 sets of surveillance nasal cultures performed at least 24 hours apart, processed by both culture and PCR.…”

“…A survey of 55 hospitals administered by Hospital Corporation of America (HCA, Inc.), a large healthcare system in the United States, found that 68% of ICUs had a policy for discontinuing CP for MRSA 34 . Additionally, 18% of the respondents to a survey administered to physicians in the Emerging Infections Network (EIN) reported that the duration of isolation for MRSA at their hospital was indefinite once a patient was positive 9 …”