The burden of contact precautions
A perspective published in JAMA today (free full text here) takes another whack at contact precautions. In this piece, Dan Morgan, Dick Wenzel, and Gonzalo Bearman nicely lay out the arguments against the use of contact precautions for endemic MRSA and VRE.
One thing this paper did was to stimulate me to think about using the gloved/gowned encounter as the unit of analysis rather than the number of days of isolation, or the number of patients impacted. Doing so highlights the burden for healthcare workers. To that end, I looked at the data cited in the perspective and did some calculations.
In the paper, they note that universal gowns and gloves in the BUGG Study resulted in a decrease of 1 acquisition of MRSA for every 336 patient-days of the intervention. There were 4 room entries per hour (96/day) in the BUGG Study in the intervention arm. They also note that 19% of S. aureus acquisitions represent transmission events when analyzed by whole genome sequencing. And 1 in 3 patients who acquire MRSA will become infected.
Doing the math, we find that in order to prevent 1 MRSA infection in the ICU setting using universal gowns and gloves requires 514,449 "protected" (gowned/gloved) encounters. Now using contact precautions for patients with targeted pathogens only (as opposed to universally) would greatly reduce the burden of the intervention, but even if it were reduced by a factor of 10, or even 20, the burden would remain extraordinarily high.
When you combine high burden with questionable effectiveness and the current focus on alternative interventions (like hand hygiene and chlorhexidine bathing), it's not surprising that contact precautions is increasingly viewed as a decrepit concept.
In the paper, they note that universal gowns and gloves in the BUGG Study resulted in a decrease of 1 acquisition of MRSA for every 336 patient-days of the intervention. There were 4 room entries per hour (96/day) in the BUGG Study in the intervention arm. They also note that 19% of S. aureus acquisitions represent transmission events when analyzed by whole genome sequencing. And 1 in 3 patients who acquire MRSA will become infected.
Doing the math, we find that in order to prevent 1 MRSA infection in the ICU setting using universal gowns and gloves requires 514,449 "protected" (gowned/gloved) encounters. Now using contact precautions for patients with targeted pathogens only (as opposed to universally) would greatly reduce the burden of the intervention, but even if it were reduced by a factor of 10, or even 20, the burden would remain extraordinarily high.
When you combine high burden with questionable effectiveness and the current focus on alternative interventions (like hand hygiene and chlorhexidine bathing), it's not surprising that contact precautions is increasingly viewed as a decrepit concept.
I found this a very confusing Viewpoint. They had a subtitle: "Time to Retire Legal Mandates" and then conclude "Legal mandates and metrics for active surveillance cultures should be retired." However, 90% of their references and discussion center around contact precautions. Your comment on their Viewpoint is focused on the universal gowning and gloving (BUGG) study and not contact precautions, as they are typically applied in hospitals - either after active surveillance or passive surveillance, when patients are identified through clinical cultures. So I am not sure exactly how it relates - but it is a huge number. Wouldn't active surveillance reduce this burden? Are you in favor of active surveillance - is that the new argument ! (humor)
ReplyDeleteOf note, Maryland ended mandatory active surveillance years ago - thus only 4 states are left. This seems focused on VA, where they have been very successful reducing MRSA.
In any case, I don't find this Viewpoint very convincing; it is mostly confusing.
Did the BUGG trial (along with Dr. Bearman's research on universal gloving) monitor HOW gloves and gowns were actually being used? Our research (Burdsall et al.,2017 in press), along with Matthieu Eveillard's, Emmanuelle Girou's, Jennie Wilson's and Heather Loveday's research), and a lot of single shot case QA and anecdotal observations of mine over 25 years might suggest that in the same way that there are issues with how hand hygiene is performed, observed, and reported, the same goes for glove use. (Think about where you will put your bare hands vs. where you put gloved hands). And when PPE use has been observed, it seems many of the research studies extrapolate glove use and hand hygiene from behind curtains. How can that be accurate? Is it that the PPE is not useful in preventing cross-contamination, or is the issue HOW the PPE is being used? In precautions, how likely are you to change gloves after touching contaminated surfaces, objects, or items? How people USE PPE is important. The Glove Use Surveillance Tool (GUST) (c) helps quantify observations, and it does drill down to the gloved encounter. I would be careful not to throw the baby out with the bath water. Gloves and other PPE are useful if used correctly. So that needs active surveillance (yes Eli!). Needs a lot more study. Check out the Protection Motivation Theory and think about how it applies to PPE use.
ReplyDeleteCompliance with gowns/gloves was measured in the BUGG Study and for gloving in the universal gloving study by Bearman.
ReplyDelete