Even NFL Stars LOVE Contact Precautions

What do we love most of all on this blog? Yup - contact precautions. Humor!

Well, I do have respect for the utility of gloves in preventing HAIs and MDRO transmission- but I've never been sure of gowns. It's just that they are pretty annoying to don and doff and little evidence supports any additional benefit above wearing just gloves. I mean, if Rob Gronkowski from the almost champion New England Patriots can't even put on a gown correctly, what chance do we mere mortals have, seriously. Maybe that's the reason why the benefits of gowns and gloves for preventing MRSA and VRE are so hard to estimate?

There are many other reasons why the benefits of contact precautions for endemic MDRO are so hard to quantify, of course. In this week's JAMA, Mike Rubin, Matt Samore and Anthony Harris have written a very nice Viewpoint acknowledging the limitations in the current literature.  In addition, they point out why studying infection prevention interventions is so tricky and suggest a path forward. They should be commended for their thoughtfulness and honesty - something those of us (including me) who support other policies with even weaker evidence bases should remember. If Gronk is having trouble with contact precautions, it's OK if some of the rest of us do too.

Universal gloving (+/-gowning) is a horizontal intervention

Years ago, Wenzel and Edmond described horizontal vs vertical infection control interventions. Horizontal interventions were defined as those where "all infections at any site are reduced" and vertical interventions were where "only specific organisms are targeted." It always seemed to me that universal gloving and universal gowning/gloving interventions were horizontal interventions, just like hand hygiene.

Thus, why is it that when we analyze and make a case against the universal gowns and gloves intervention (or trial) we only include MRSA outcomes? Put another way, why was it designed and critiqued as a vertical intervention and not a horizontal intervention? Shouldn't we also explore potential reductions in MSSA, GNR, MDR-GNR and CDI?  Of course, a critique of this approach would be that the BUGG study didn't look at pathogens beyond MRSA and VRE (yet), so we can't.  My response is then we shouldn't do studies of horizontal interventions unless they are properly funded to collect data on all pathogens possibly reduced through the intervention. These studies should also have high construct validity including tracking of post-discharge infections. Look what happens when hand hygiene's impact is limited to just healthcare-associated S. aureus bacteremia.

If we complete underpowered and underfunded studies with poor construct validity, they might come back to haunt us. And they could harm our field - infection control. More importantly, they might even harm our patients.

I hope I live long enough

Mike has had his say regarding universal gloves and gowns. I'm a huge fan of Mike's push for horizontal interventions like hand hygiene, but I was surprised when I read that he is pushing universal chlorhexidine bathing in his hospital. I will keep this post short so you can quickly move down to read his post, but I have a couple comments. First - chlorhexidine is an "antibiotic" and resistance already exists.  Second, if there is one thing we know about overuse (i.e. universal use) of antibiotics is that it leads to resistance. Third, I know that CHG is fashionable (like antibiotic cycling once was) and you can't fight fashion. Finally, if we really want clean hands, when you add the BUGG study's gloving+hand-hygiene compliance this would equal ~95% hand cleanliness.

In the meantime, I will sit on the sidelines and wait for CHG resistance to rise and the many MDR-acinetobacter and other GNR outbreaks that will occur secondary to it's overuse. Despite the title of my post, I suspect I won't have to wait too long.

Addendum: looking through the twitter chatter after the BUGG study was released, I noticed a disturbing trend of HCW complaining more about the burden of wearing contact precautions than the burden of HAI.

Don't BUGG me!

JAMA has just published the BUGG (Benefits of Universal Glove and Gown) study online (free full text here). This important, well-designed study was led by Anthony Harris (nice video of Anthony discussing the study here). It's a 9-month, multicenter, cluster randomized study in 20 medical and surgical ICUs that compares universal contact precautions (i.e., gowns and gloves for all patient care) to "standard" contact precautions (i.e., gowns and gloves for the care of patients with epidemiologically important organisms). The primary outcome evaluated was acquisition of MRSA or VRE. Patients were cultured for both organisms on admission and discharge from the ICU.

In a nutshell, the findings were as follows:

• There was no significant difference in the rate of acquisition of MRSA and VRE combined.
• When MRSA and VRE were evaluated separately, there was no difference in the acquisition of VRE, but there was a significant reduction in MRSA acquisition in the universal contact precautions group with an incremental benefit of 3 fewer MRSA acquisitions per 1,000 patient days.
• There was no difference in device-related infections (CLABSI, CAUTI, or VAP) between the two groups and no difference in mortality.
• There was no difference in adverse events between the two groups when evaluated by the IHI Global trigger tool (for what that's worth...).
• Hand hygiene rates were higher in the universal gowns/gloves study arm.
• As might be expected, there were fewer patient visits by healthcare workers in the universal gown/glove study arm.

So, how do we put this study into perspective? Should the study entice hospitals to begin universal gloving and gowning in the ICU setting? 

Let's assume you have a 15-bed ICU that admits 1,250 patients yearly with an average length of stay of 4 days (i.e., 5,000 patient-days annually). Assuming 10.5% of patients require contact precautions (this proportion comes from the control arm in the BUGG study), 131 patients would require isolation. Alternatively, under universal contact precautions, all 1,250 patients would be isolated. So by isolating an additional 1,119 patients we would prevent an additional 15 patients from acquiring MRSA (i.e., 3 per 1,000 patient days). Assuming 20% of the colonized patients go on to develop infection, 3 additional MRSA infections would be prevented with universal contact precautions. Bottom line: to prevent 3 additional infections we needed to isolate an additional 1,100 patients. Given that I'm a utilitarian and that I believe that the burden of contact precautions on patients is high, my assessment is that the benefit of universal gloves and gowns is outweighed by the overall burden on patients. Now it's true that MDR-GNRs and C. difficile weren't evaluated in the study so we may not be evaluating the full benefit of the intervention. But for now, don't BUGG me--I'm still pushing universal chlorhexidine bathing, high rates of hand hygiene compliance, and no isolation of patients with MRSA or VRE.

Addendum (10/6/13):  More on this study in Time.

Photo: Duke Infection Control Outreach Network (DICON)