Expand contact precautions? NO!!!!!!!
The Associated Press has an article today on infection prevention efforts at the University of Maryland Medical Center (Eli's old stomping ground). One of the interventions noted is universal contact precautions in the surgical intensive care unit. My thinking on control of multidrug-resistant pathogens is actually moving in the opposite direction. I think that high rates of hand hygiene compliance (particularly if coupled with standard precautions and a bare-below-the-elbows approach) will be shown to be as effective as contact precautions. Another useful approach may be universal gloving (we have found that to be as effective as contact precautions in the ICU setting). And I really don't think it's reasonable for family members to be required to wear gowns if they are not visiting other patients. However, the article's description of the white coat as a "walking germ" was great!
The data suggests that with Acinetobacter, your approach won't work. The idea that one size fits all, be that ADI or just HH etc, will be successful has been continuously debunked in the literature. At UMMC we practiced a variety of approaches depending on the unit-specific problems with great success. When you have Acinetobacter cases, as we did, you can't just hope HH works. Our published data in ICHE this year suggested that you would need ACTUAL HH compliance during the day, night, weekends to be greater than 95% to have a chance preventing transmission. I am not saying your approach doesn't work in Richmond but our data suggests that it won't work in Baltimore.
ReplyDeleteBefore transmission-based precautions, there was organism-based precautions, which your approach somewhat resembles. I agree that for hand hygiene to be effective, compliance must be very high. I'm not arguing that universal contact precautions can't or won't work, but it isn't the only way to control MDROs, and I don't think that we have ever really given hand hygiene a chance.
ReplyDeleteEvery hospital is different, but when we say that intervention x works here and not there, it may be that the old effectiveness vs efficacy argument is really what we are describing. In infection control, most of the interventions require high levels of compliance to have impact, which is why the central line bundle looks so good in Peter Pronovost's hands and less good in some others'.
And none of these interventions are stand-alone--they are being implemented on top of a platform of other interventions (e.g., antimicrobial stewardship, chlorhexidine bathing, line & ventilator bundles, etc), each of which is impacting the local MDR scene.
Contact precautions is one of our older interventions and it's uncomfortable for family members and healthcare workers. So it seems to me that we should try to maximize other interventions, and reserve it for instances where the others are not effective. Perhaps if there is an organism/setting where clothing contamination is extensive and is playing a role in transmission, then CP may be the answer.
The ultimate question is this: given a setting where hand hygiene compliance is >90%, patients are bathed daily with chlorhexidine, and the usual bundles are adhered to, what are the incremental benefits and burdens of (1) contact precautions and (2) universal contact precautions?
Apart from what you said Mike, which I tend to agree with, this really begins and ends with Acinetobacter. HH is not enough even at high levels and I don't think CHG should be used in settings with high levels of Acinetobacter, so there is not much left. Contact precautions are not perfect but Acinetobacter is highly transmissible, far more than MRSA and VRE, so we put up with wearing gowns/gloves to protect the patients from Acinetobacter.
ReplyDeleteMike. One question for you. Given the explosive use of chg, how long until we see chg-resistant strains? Is the widespread appearance of Acinetobacter evidence of chg resistance? My concern with chg is that we are trading one type of resistance for another.
ReplyDeleteWe began chlorhexidine bathing of all ICU patients in 2007. We have not had a device-related Acinetobacter infection in any of our ICUs for the past 2 years. While I am aware of some in vitro data on acquisition of chlorhexidine resistance in Acinetobacter, I'm not aware of outbreaks associated with chlorhexidine use. We also use the chlorhexidine biopatch on all central lines throughout the hospital, and will soon roll out a plan for chlorhexidine bathing outside the ICUs.
ReplyDeleteI suspect that you aren't doing testing for CHG resistance in GNR, so you might not identify an emergent resistant pathogen. In fact, I am not sure studies have been done that prove exposure to a specific antibiotic leads to development of resistant clones. Generally, whether it is triclosan or CHG or antibiotics, we should suspect that they select for resistance and enter that into our decision making My guess is that CHG resistance will increase. I think glove use and HH compliance will have a longer-term benefit for our patients.
ReplyDeleteLack of outbreaks is some evidence, but emergence of resistant clones might not lead to outbreaks as other factors such as poor HH compliance must also be in place.