Questions for Contact Precautions Eliminators

Over the past eight years, I've been the lone supporter of contact precautions on the blog. Of course, Tom and Hilary haven't publicly committed either way, at least on this blog. And to clarify my position, I'm greatly in favor of more studies examining the role of isolation strategies and how/where to best implement them. For example, do we need gowns or would gloves alone suffice? And should we isolate uncolonized patients instead of colonized patients since we're most interested in preventing transmission from contaminated healthcare worker to uncolonized patients? This latter question is why I currently favor exploring the benefits of universal gloving strategies. But of course, there is a growing number of studies that explore the discontinuation of contact precautions, which have led to places like Iowa eliminating contact precautions for MRSA/VRE colonized or infected patients. So with that in mind, I have a few questions for folks who are in favor of eliminating contact precautions. Specifically, I want to understand the who/what/when/where/why behind their recommendations.

Question #1: Are hospitals no longer a source for MDRO-bacterial acquisition? Do acute care hospitals or subpopulation (ICUs, hemodialysis) remain sites for patient-to-patient transmission or have we completely eliminated transmission in these settings?

Question #2: If transmission has been eliminated, how would we know? Are you aware of data that proves patients who are uncolonized on admission remain uncolonized by the time of discharge? Does your hospital do discharge surveillance cultures for sentinel organisms like MRSA, CRE?

Question #3: If you don't do surveillance culturing on discharge, do you follow patients post discharge to make sure they don't develop an MDRO infection at a subsequent point? Do patients no longer develop MDRO infections linked to a prior hospital stay suggesting that all transmission is now occurring in the community setting?

Question #4: If transmission in acute-care settings has been eliminated, how has that happened? Is it that hand hygiene compliance of 34 to 57% is enough to halt all transmission? Is it that the environment is so sparkling clean these days that clinicians can't even pick up bad bacteria on their hands?

Question #5: Perhaps you agree that hospitals (or ICUs) are still engines powering the emergence of MDRO in human populations and your hospital might even be a source for patient acquisition. Is it that you think hands are not a source of transmission and contact precautions just don't work? Do you feel similarly about hand hygiene - does hand hygiene not reduce transmission? Since we know that when caring for patients that healthcare workers gloves/gowns become contaminated 8-39% of the time, where do these bacteria go? Do they just disappear?

Question #6: Finally, even if transmission is occurring via the hands of healthcare workers maybe you're convinced it's not your problem? If you can't see the benefits directly in your hospital, it's not important. Tragedy of the commons? - meh. Perhaps, it's up to me to detect all MRSA colonized patients in my clinic or on admission to my hospital and decolonize them?


  1. Interesting post, Eli!

    Since I’m a hospital epidemiologist at Iowa (where we still use contact precautions (CP), but just not for those patients who have MRSA or VRE as part of their microbiota), I feel like you’re “calling me out”. So I’ll answer your questions, hoping to spur others to do the same.

    (1a) no (1b) yes, no (2a) N/A, hasn’t been eliminated (2b) Yes, limited data suggest that most remain uncolonized; acquisition (or unmasking, in case of VRE) rates vary (2c) no (3a) yes, but only if they are readmitted for infection to our hospital (3b) no (4a) N/A, hasn’t been eliminated (4b) no (4c) no (5a) no and no (these questions are very confusing!) (5b) no, HH does reduce transmission (see Mortimer, et al. Am J Dis Child 1962;104:289-95) (5c) gowns or other clothes that drape over contaminated fields transiently carry organisms (MDRO and non-MDRO), which persist for varying time periods prior to becoming non-viable (probably due to environmental conditions, ambient UV exposure, etc. (5d) no, see 5c. (6a) definitely my (our) problem, (6b and 6C) not sure I understand these questions, we are all committed to reducing healthcare-associated infections.

    Finally, I’ll make a larger (and more important) point—I don’t know of any “CP Eliminators”. That locution is a straw man. Every hospital epidemiologist I know, including those who have stopped using CP for endemic MRSA/VRE carriers, believes that CP (and related barrier precautions) is an important component in the transmission-prevention toolbox. The argument is over a very narrow (in the big picture) application of CP—specifically: are CP as we currently apply them to those patients we’ve found to carry MRSA or VRE, effective in preventing infections? My review of the literature, focused on trials with concurrent control groups, suggests that the answer is “no”. Other applications (including universal barriers (gloves +/- gowns) in selected high risk populations) may end up being more appropriate applications.

    And yes, I know I’ve blogged plenty about how much I hate CP—I also hate amphotericin B and aminoglycosides, but sometimes they are the correct choices.

    I’ll expand on this in a post next week, along with how we plan to approach CP at my institution going forward.

  2. Yikes. I certainly didn't mean to call you out. I was primarily focusing my questions on folks that have completed these studies and (mostly) ignored these questions in their study design and discussion. I also didn't mean to set up a straw man and was clear that Iowa only eliminated CP for MRSA/VRE in my post. Of course practically, many providers have taken the elimination for CP as a signal that CP don't work. I'm very confused by your use of the word endemic for MRSA/VRE and not for clearly endemic CDI. I wonder how you define endemic and how that is even important for discussions of CP use? I will expand on those questions in my next post - and again, this was not targeting you or Mike or anyone at Iowa - of course, maybe I needed to explain up front that I wasn't focusing on you - although I thought saying this wasn't calling out Iowa would have done more to call out Iowa than not saying anything.

  3. No worries, Eli, it is cool even if you do mean to call me out--this is a Controversies blog, and I ought to be able to explain and/or defend an infection prevention approach that is taken in the institution where I practice!

    As for endemic, I probably tossed that off too informally, but I meant it to distinguish from an outbreak setting--where we would apply CP. And though we continue to use CP for CDI, Andreas Widmer might suggest we stop (CID 2017;64:393). I can go into why I support taking different approaches to CDI and MDR-GNR in a later post.

  4. Good article, thought provoking questions.


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