By Kelly M. Pyrek
Can aggressive isolation practices and contact precautions make a significant impact on infection rates? Should these stringent interventions be applied to all patients merely colonized with multidrug-resistant organisms (MDROs)? Those are the questions facing infection preventionists as they struggle with translating evidence into practice in the real world, where textbook scenarios aren’t the norm and healthcare epidemiology may not have all of the answers.
While contact precautions have been traditionally applied to patients infected with MDROs, this intervention has been expanded to include those colonized with all MDROs in many healthcare facilities. Although numerous recommendations and guidelines promote the use of contact precautions, the data dictating this practice remain resolute to some and ambiguous to others. At the Fifth Decennial International Conference on Healthcare-Acquired Infections held in Atlanta in March, experts David Pegues, MD, and Kathryn Kirkland, MD, reviewed the scientific data supporting use of contact precautions and attempted to reconcile differences in an informal debate.
Pegues, of Ronald Reagan UCLA Medical Center, and Kirkland, of Dartmouth-Hitchcock Medical Center, discussed whether "all patients colonized with multidrug resistant organisms should be placed in contact precautions." Before the onset of the debate, a select number of attendees were queried as to what they believed about this aforementioned statement and were allowed to respond using an automated polling device; 49 percent responded "definitely yes," 22 percent said "perhaps yes," 6 percent were "neutral," 9 percent said "perhaps no" and 14 percent said "definitely no." After both sides of the issue were presented, Decennial audience members voted again on the statement, "all patients colonized with multidrug resistant organisms should be placed in contact precautions." This time, 31 percent said a "definite yes" while 18 percent said a "definite no" and 4 percent remained neutral on the topic.
That practitioners were able to be persuaded to change their minds on the issue suggests an ongoing struggle with the degree to which some interventions must be implemented, and potential ramifications for patients.
"I think people are struggling with the potential benefits and the potential risks in increased isolation," says Pegues. Regarding the impact of contact precautions on patients, Pegues acknowledged that it can decrease healthcare worker/patient contact, trigger delays in care and lower patient satisfaction overall. Mitigation strategies would include better staff education and using strategies to reduce the feeling of social isolation. "I believe the potential benefit is a direct one for all patients in a healthcare facility, but maybe only an indirect one for a patient who is colonized with an MDRO; the direct benefit is that others presumably will have a decreased risk of acquisition of the MDRO and a decreased risk of developing subsequent infection. The potential risk is felt more directly by the patient who is placed in contact isolation with increased possibility of social isolation and decreased contact with caregivers. The broader perspective suggests it’s a valuable strategy because it’s going to protect a greater number of people. The individual perspective suggests there may be deleterious effects of isolation. As a public health practitioner, my perspective supports the good of the many over the good of the few; however, I do think there are ways to mitigate the potential deleterious effects of isolation on patients."