Killing contact precautions one study at a time
They looked at the rate of positive clinical cultures for MRSA and VRE one year before and after contact precautions were stopped on July 1, 2014. Importantly, at around the same time they expanded daily chlorhexidine bathing from ICU patients to all inpatients.
Comparing the pre- and post-intervention periods in this quasi-experimental study, here are the key findings:
- There was no difference in the rate of clinical cultures for MRSA or VRE.
- There was no difference in C. difficile infection rates (a nonequivalent dependent variable).
- There was no difference in MRSA colonization rates (active surveillance cultures were performed on high-risk patients).
- An annual cost savings of $730,000 in isolation gowns, and $5 million in nursing time associated with donning personal protective equipment was demonstrated.
Now one could argue that the benefit of contact precautions was replaced by the beneficial effect of chlorhexidine bathing. That doesn't bother me. I'd gladly trade 24 hours of gowns, gloves and confinement to a small space for a 5-minute wipedown with chlorhexidine.
This is the fourth paper that shows a consistent finding of no increase in MDRO infections after contact precautions are stopped. The others can be found here, here, and here. And there are two more studies in abstract form. It seems to me that we simply don't need contact precautions for MRSA and VRE given newer developments in infection prevention (chlorhexidine bathing, better compliance with hand hygiene, private patient rooms, and enhanced environmental disinfection). Hopefully, the addition of this new study will convince other hospitals that the world doesn't end when contact precautions are retired.
Photo: Dan Uslan MD, UCLA
interesting to see outcomes, particularly that most "clinical cultures" represent urinary colonisation rather than actual infection.
ReplyDeleteMost Australian hospitals abandoned contact precautions for MRSA some time ago, and after some consideration, our hospital took a similar approach to VRE a few years ago.
https://www.mja.com.au/journal/2015/202/5/should-we-continue-isolate-patients-vancomycin-resistant-enterococci-hospitals
A few years ago, there was a public dispute between the provincial public health authority and several Canadian hospitals that wanted to abandon contact precautions for VRE.
https://www.sjhc.london.on.ca/our-performance/patient-safety-indicators/vancomycin-resistant-enterococci-vre
http://www.publichealthontario.ca/en/eRepository/PIDAC-IPC_VRE_Evidence-based_Review_2012_Eng.pdf
While I see the point and the ease on the workload ... is it just me still wondering what all the chlorhexidine use will bring. Not only with regard to CHX-resistance, but in addition in bacterial resistance by "chaired" pumps? Time will tell. Haven't looked up the article, but 5 mil in nursing time just for downing and gloving? That is about 30 FTE!
ReplyDeleteI know this may seem like a very basic question, but do we have a sense for which infection control practices are actually having a measurable impact? Bundled line insertion protocols for instance? Or is the decline in MRSA thought to be more due to pathogen specific evolution or population immunity factors?
ReplyDelete