As we saw in part one of this two-part series, the topic of active surveillance cultures (ASC) is a controversial one, with critics of the practice pointing to its expense, tying scarce infection prevention resources to one pathogen and the potential for adverse outcomes when patients who test positive are placed in isolation with reduced contact with healthcare personnel. Some experts emphasize that conventional, common-sense infection prevention and control measures are more effective at reducing rates of methicillin-resistant Staphylococcus aureus (MRSA).
Scientists at the Virginia Commonwealth University Medical Center found compliance with non-pathogen specific infection control practices such as hand hygiene, efforts to reduce device-related infections, and chlorhexidine bathing, is successful for reducing rates of healthcare-associated MRSA. The findings were presented at the Fifth Decennial International Conference on Healthcare-Associated Infections in Atlanta March 18-22.
Beginning in 2004, the medical center instituted a series of non-pathogen specific initiatives to reduce HAIs including an increasingly aggressive hand hygiene program, a central line bundle, a ventilator bundle and chlorhexidine bathing of all adult ICU patients and a recommendation for bare below the elbows, along with compliance monitoring and feedback via unit-specific posters. Active surveillance cultures were not performed.
During this time, Michael Edmond, MD, MPH, MPA, and colleagues observed a 91 percent reduction in MRSA central line-associated bloodstream infections, a 62 percent reduction in MRSA catheter-associated urinary tract infections and a 92 percent reduction in MRSA ventilator-associated pneumonia. These outcomes were observed in a 16-bed medical ICU, 18-bed surgical ICU and 14-bed neuroscience ICU. Edmond cautioned this is an observational study using data from a single medical center and was observed in the ICU. Other healthcare facilities may have different results.
This study demonstrates that a broad focus on implementation of evidenced-based practices designed to reduce all healthcare-associated infections is effective at reducing MRSA infections, and will likely have a more beneficial impact on overall patient outcomes, said Neil Fishman, MD, president of SHEA. These study findings are consistent with guidelines for infection prevention and control in healthcare settings.
The Role of Isolation and Contact Precautions
Another component of the issue is the use of isolation and contact precautions. At the 2010 Decennial International Conference, the session, Controversies in Contact Precautions engaged infectious disease physicians David Pegues, MD, of Ronald Reagan UCLA Medical Center, and Kathryn Kirkland, MD, of Dartmouth-Hitchcock Medical Center, in a debate over 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.
In his pro-contact precautions presentation, Pegues declared that there was a scientifically sound rationale for contact precautions to protect against the transmission of multidrug-resistant organisms (MDROs). Pegues explained that there is consistent evidence that control strategies, including contact precautions, reduce the incidence of MDROs, such as that outlined in the 2006 MDRO guideline produced by HICPAC, and that since those guidelines were published, more than 30 additional studies support this intervention. In regard to the role of gowns and gloves, Pegues says that gowns and gloves are more effective than universal gloving in the transmission prevention of MRSA and VRE. He acknowledged researcher Charlie Huskins controversial STAR ICU study in which he determined that when looking at the incidence density of new colonization vs. infection, there is no additional benefit of active surveillance cultures and contact precautions for colonized patients. He said that there are limitations to quasi-experimental studies such as Huskins and that in nearly all studies reported that sufficient MDRO control required at least seven or eight different interventions concurrently or consecutively. 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.
In summary of his argument, Pegues noted the presence of unresolved issues relating to contact precautions, including when to use gowns and gloves vs. gowns or gloves alone; when to implement contact precautions in the active surveillance culture process; the duration of contact precautions and when to clear patients; universal gloving vs. contact precautions; and how to optimize contact precautions as an infection prevention and control intervention. At the very least, Pegues said, glove use and hand hygiene is the minimum of care.
In her opposing argument against excessive contact precautions, Kirkland made the point that in the statement, all patients colonized with multidrug-resistant organisms should be placed in contact precautions, the word all was too broad, the word resistant was too narrow, and that contact precautions was the wrong intervention. Instead, she asked Decennial attendees to consider the statement that all patients are colonized, all patients are managed in ways that reduce HAIs, and that some patients should be placed on contact precautions. As a reminder, Kirkland reiterated the indications of contact precautions as a private room, gowns and gloves worn by the healthcare worker as a barrier, and applied to one patient to protect another. Kirkland noted the evidence that contact precautions are necessary, but asserted that many are weak studies with potential biases and mixed conclusions making it easy to use them to argue for contact precautions. She said that at best, the evidence for contact precautions was weak and ambiguous. Instead, she pointed to evidence that contact precautions are not always necessary, and asked the audience to consider that contact precautions for colonized patients are not needed in some settings.
For patients not yet colonized with an MDRO, Kirkland noted that a private room can prevent transmission from shared equipment, that gloves can prevent transmission if healthcare worker apparel is contaminated, and that gloves can continue hand carriage of pathogens by healthcare workers. For colonized patients, Kirkland said that a private room cant isolate a patient from themselves; that a gown could transmit infection, and that gloves are as likely as hand to be a source of contamination and cross-infection. She added that at least 18 percent of gloved hands become contaminated during patient care, and that dirty gloves are at least as dangerous as dirty hands. A healthcare worker with clean hands may actually be safer than one with gloved hands, she said. Regarding the impact of contact precautions on patients, Kirkland noted that the jury is still out on whether healthcare workers more easily pass by isolation rooms and that these patients receive less care than those who are not in isolation.
Kirkland also addressed the problem of putting a focus on MDROs to the exclusion of all other pathogens. She said that studies point to a smaller number of infections caused by MDROs and that if only MRSA or VRE is targeted, what happens to everything else? She said that after all, all patients are colonized with organisms that could trigger an outbreak at any time. She advised that clinicians put contact precautions in context and use them when they make sense only. A patient should be placed in a private room if there is strong likelihood that there could be widespread contamination (such as when a patient has diarrhea) or a long persistence of an organism; to use gloves only to protect the healthcare worker; and to use gowns when there is anticipated exposure to infectious material. Kirkland said it is essential to rephrase the question of what is appropriate, for whom, when and why, and acknowledged that it is a complex social and behavioral issue as well. Its time to reconcile our differences and move toward consensus, she said, adding that to do so, the issues of determining the added value of contact precautions and the impact of reduction vs. cost increases must be addressed.
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.