The “horizontalists”

Contact precautions, blah, blah, blah. Regular readers know that this is one of the topics we revisit often. Yet in my decade as a hospital epidemiologist, I never suggested we stray from the current CDC guidance on use of CP in healthcare settings. Why? For one thing, I was a VA hospital epidemiologist--but VA or not, it is a real challenge to convince colleagues and hospital administrators to make such a major practice change, especially if it is not consistent with existing authoritative guidance. No one wants to be an outlier on an issue like this, perhaps fearing not only increased infection rates but also repercussions from JCAHO or other surveyors. Or maybe I just don’t have the courage of my convictions (one of those convictions being that “horizontal” population-based approaches are more effective overall, and in the long run, than are pathogen-based “vertical” approaches). Not everyone has been so hesitant to put this theory to the test, however. Below are excerpts from a current thread on our Emerging Infections Network listserve:

We are looking into getting rid of isolation gowns, exclusively for MRSA and VRE in a relatively small teaching hospital. We are planning on focusing more on handwashing and glove use when appropriate, as well as monitoring for any changes in the rate of HAI. I have heard through the grapevine that there are other institutions that gave up on MRSA and VRE contact isolation. At this point we are not using active surveillance with swabs, but we do isolate MRSA and VRE based on finding them in any clinical cultures or based on historical data from previous admissions, which does not make much sense to me. I am interested to hear opinions from the forum, especially from people who went through a similar process. What are the barriers that you encountered? What are people thinking of the 2 papers that came out in April in NEJM? (neither of which apply to what we are doing now, since we are not swabbing noses regularly, but still....we are going completely opposite way of what the VA did).

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Date: Mon 15 Aug 2011 11:37 We do not isolate MRSA or VRE. Our area has an exceptionally high incidence on CA-MRSA, and the Dept of Public Health has endorsed this approach as well. I think, when you examine any "bundled" approach, hand hygiene is the key factor, tho often it is difficult to break out. I am as concerned about transmission from the patients we don't know are colonized as much as those we know about, so support a "universal" approach.
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Date: Mon 15 Aug 2011 12:53 Hi - At [ ] Medical Center we are 9 months into our change to the policy you describe emphasizing vigorous adherence to standard precautions and eliminating contact precautions for VRE and MRSA. We are currently analyzing the data but do not have any change in infection rates to report. We will also be looking at bed flow and additional quality of care factors in respect to the change.

My own opinion on the discrepancies seen in the literature in regards to the topic are that where hand hygiene improvements were possible interventions such as the VA study make an impact but places such as the Swiss study released a few years ago where hand hygiene was in place there is no or minimal added benefit from applying the contact precautions.

I like our current approach where the emphasis is on preventing transmission in all patients regardless of their known colonization/ infection status as opposed to raising the alarm and isolating a subset of the population who may or may not be the true culprits in terms of current/active shedding of resistant organisms.