Rethinking contact precautions
I'm working on a talk entitled "Rethinking Contact Precautions" for the Winter Course in Infectious Diseases. If you've never been to the Winter Course, it's a great conference in a casual setting with state-of-the-art lectures on a wide variety of ID topics. And there's lots of skiing. This year, we'll be at Big Sky, Montana, February 14-18.
This weekend, I ran across a brand new paper in Infection Control and Hospital Epidemiology on discontinuing contact precautions. This one comes from Roswell Park Cancer Center where active surveillance (weekly perianal cultures) for VRE was discontinued in March 2011. At the same time contact precautions for VRE infection and colonization were also discontinued. The investigators compared VRE bacteremia rates for the 3-year period before and the 3-year period after discontinuing active surveillance and contact precautions. The 6-year period of the study included over 1,300 patients with hematologic malignancies, bone marrow transplant and lymphoma. Over the study period there were no changes in antibiotic utilization, nurse-to-patient ratio, age, gender, underlying malignancies or length of stay. Importantly, via interrupted time series analysis, there was no significant change in the rate of VRE bacteremia (2.32 infections/1,000 patient days before vs. 1.87 after). This is the third published study (see the others here and here) and there are two more studies in abstract form all showing no change in infection rates after contact precautions were discontinued.
I also re-read Kathy Kirkland's thoughtful paper, Taking Off the Gloves: Toward a Less Dogmatic Approach to the Use of Contact Isolation (free full text here). Kathy was way ahead of the curve with her thinking on this topic. Below is a table from her paper that summarizes the likelihood of benefit for contact precautions:
As I thought more about where we are in infection prevention in 2016, it seems to me that contact precautions is a decrepit concept. When introduced 50 years ago, contact precautions made sense. At that time hand hygiene rates were abysmal, alcohol-based handrubs were not available, patients weren't bathed with chlorhexidine, there were few single-bed hospital rooms, and there was no enhanced technology for environmental disinfection.
Putting it all together, there's little evidence that contact precautions are effective in the non-outbreak setting, and we're learning that nothing bad happens when contact precautions are stopped. At the University of Iowa, we're focusing on hand hygiene, stethoscope wipe down and bare below the elbows. And the list of hospitals forgoing the plague doctor suit for MRSA and VRE grows ever longer.
Nice study and analysis. I noticed a couple things - one, they said "Another limitation relates to lack of data on compliance with hand hygiene." How could this be? How could a cancer center not have this data, especially if they are so advanced to be thinking about stopping contact precautions for VRE?
ReplyDeleteThe second is this statement in the Methods: "We continued contact precautions and mandatory hand hygiene for patients colonized by methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Gram-negative bacteria; we also continued contact precautions along with mandatory hand washing with soap and water for patients with Clostridium difficile infection."
I'm happy they continued CP for MRSA, MDR-GNR and CDI since the data is strongest there and since they are far more significant pathogens. Stopping CP for MRSA is very risky since it is driven by three non-sustainable facts (1) The worldwide decline in MRSA - an ecological trend that will likely be reversed in the next decade and the related (2) rise in use of anti-MRSA antibiotics (e.g. linezolid) and (3) The false belief that hand hygiene compliance is over 50%, which it certainly isn't. Everywhere we've looked, hospitals that are reporting compliance over 90% have compliance rates closer to 40-60%, when using proper surveillance methods.
Interesting comments. I agree about not relaxing CP for MRSA, MRGN and Cdiff without good evidence, since these are much more significant pathogens. I am however interested in your belief that the recent worldwide decrease in MRSA is likely to be reversed in the next decade. Why is that? I am also interested to know what you define as "proper surveillance methods" for hand hygiene?
ReplyDeleteReferring back to the paper mentioned in this post, I would have thought that just using VRE bacteraemia as the outcome measure gives little indication of whether there was any change in the acquisition rate - a much better measure of infection transmission. Because VRE is relatively non-pathogenic, the ratio of infected to colonised is likely to be very low.