Infection Control Today - 03/2004: OR Topics

March 1, 2004

Experts Explore the Resistance to Contact Precautions, Barrier Protection

By John Roark

Since 1983, the Centers for Disease Control and Prevention (CDC) guidelines
for barrier protection have recommended that patients infected or colonized with
epidemiologically important pathogens should be placed under contact
precautions. In spite of these published guidelines, incidence of
antibiotic-resistant pathogens like MRSA and VRE continue to escalate.

In 1980, methicillin-resistant Staphylococcus
(MRSA) accounted for 2 percent of all of all staph infections, says
Barry M. Farr, MD, professor of internal medicine in the Department of Internal
Medicine within the University of Virginia Health System. Now its 50
percent, maybe higher. The problem of MRSA is out of control. It seems to be clear
that the reason its out of control is weve been looking the other way,
hoping that something really bad wouldnt happen. In northern European
countries, where theyve taken a different approach, theyve controlled MRSA
to less than 1 percent of staph aureus infections, and they keep doing it year
after year after embarrassing year. These countries battle the same MRSA strains
that are spreading in our communities (including new mec-4 strains found
spreading in prisons, in some sports teams and Native American communities)
containing increased numbers of virulence genes. Theyre nasty and can kill a
completely healthy young person in short order, and have done so, Farr
continues. Theyve done it in the United States, and theyve done it in
those northern European countries, but guess what? Our rate in the hospital
keeps going higher and higher, and theirs doesnt. Theirs may be creeping up a
tiny bit, but its still less than 1 percent.

If we were trying to control antibiotic-resistant pathogens
like MRSA, and if we had patients coming in who were high-risk for MRSA, then it
would be a smart thing to do a culture and know who has it in order to prevent
spread, says Farr. Its been shown and published, and more studies are
still coming out that are confirming that theres a high relative risk of
spread from patients who are merely colonized. The tradition in this country has
been to look the other way, says Farr. I think that is why we have not
controlled it.

Inertia is a powerful force in physics, and tradition is
powerful in human systems. Were all human beings, and in healthcare we
tend to do what others are doing, says Farr. We just keep networking and
doing what the others are doing. If everybody else was doing it, and your
hospital was the only one that wasnt, your policy would change so fast that
peoples heads would spin, so that they could keep up with the others. But if
the others are doing nothing, taking no responsible action to control it, then
theyre not going to do it, even if they see the data that shows that it works
better the way the northern Europeans do it. There are now more than 70 studies
that show you can control MRSA and VRE that way in healthcare settings. But most
people in this country keep on doing what they have been doing and what others
are doing.

Doing the Math

If you take a look at the studies on the reduction of
exposure risk, the costs involved in reducing that exposure are almost always
offset by not having to deal with problems on the back side when it comes to
employees and/or patients who might be exposed and seroconvert in the healthcare
facility, says Carolyn Twomey, a clinical nurse consultant for Regent
Medical. I think that overwhelmingly, people realize that theres a payoff
for good barrier protection. Its just a matter of finding the right barrier
protection that works for everybody and getting everyone to comply with it.

Normally, if a person comes into the hospital waiting room
and theyre coughing and sneezing, nobody does anything, says Jay Sommers,
PhD, director of clinical and scientific documentation for Kimberly-Clark. Now
theres a big concern, not only for the other patients, but for the healthcare

On our posters, weve basically mimicked the guidelines
of the CDC on respiratory etiquette, Sommers continues. For example,
someone with upper respiratory symptoms anybody with a runny nose, cough,
sneeze, headache, fever give them a mask, show them how to put it on and
take it off. If theres no mask available, give them tissues. We are supportive of those guidelines theyre key because of
the unknown. The fact that weve run out of flu vaccine exacerbates the
situation. We have people running around who havent been inoculated. Theres
the concern that if they do come down with something, you dont know whether
its flu or SARS.

People dont really know what to do. They see someone
come in and they think, are they symptomatic? Are they asymptomatic? What do
they have? Theres a thought process that goes into it, but unfortunately,
they dont have a lot of time to think. Thats why some of the infection
control guidelines have caused problems in the past what do we do? Who makes
that decision?

One of the topics being talked about are the new Society for
Healthcare Epidemiologists of America (SHEA) guidelines on precautions with
regard to MRSA and VRE. They want to do active surveillance, which means you
test the patient coming in, says Sommers. And they want to use gowns,
gloves and face masks for the symptomatic. Theres enough evidence out, if
someone has VRE or MRSA, it can be airborne or droplets, and the healthcare
worker should wear a face mask in dealing with these people.

It all adds up. Can cost-conscious hospital administrators see
the forest for the trees when faced with upfront expenses?

A culture costs something, a gown costs something, gloves
cost something, says Farr. For the past 11 or 12 years, people have been
trying to have healthcare as cheap as they can get it. Thats sort of a
national imperative we had to lower our costs. They keep trying to be cheap,
but they dont look at the studies that show that if you control these
infections, which are more expensive and more deadly, then you actually have
lower costs. Its sort of penny-wise and pound-foolish. Theyre not looking
at the entire picture; theyre just looking at what their purchase costs are
for the materials. Theyre not looking at the downstream effect of controlling
it. Thats like saying, Im not going to invest anything, because that
would cost money. Theyre not looking at the long-term outcome of having
invested at the end of the day you have dividends. Theyre ignoring the
dividends part of the picture.

It does cost more, and it takes more time. You look at cost
vs. benefits, reasons Sommers. Whats it going to cost a box of
tissues, a face mask? But the benefit is youre preventing that infection from
spreading, even assuming somebody may have just the flu. If you can contain it,
the costs are insignificant compared with what may happen. Another equation you
can use is cost vs. risk. Whats the risk of not doing the respiratory
etiquette? Its almost the same thing. The benefit is the protective
part, the avoidance part, but then theres the risk also. What is the cost vs.
the risk of not doing it?

Why exactly, arent adequate precautions being effectively
taken? I think a lot of people wait until the CDC says Thou
shalt do this, says Farr. The CDC started saying in 1983 that we should
isolate the cases that were suspected or confirmed, whether infected or
colonized. But people have not read between the lines and thought:
colonization is invisible. To know theyre colonized, we would have to do a
culture, and we probably should to do it in the high-risk patients like they do
in northern Europe. People here have not really gotten that message, partly, I
think, because theyve never seen it in black and white. I hate to say that,
but the CDC has never said that in black and white. So, people may just be
waiting to see that.

Which raises the question, why doesnt the CDC take a
definitive stand on this issue?

Well, theyre people too, says Farr. The CDC has
those same forces of tradition and doing what others do, and not rocking the
boat, and not making waves. If its their tradition, and they think that they
would make a lot of waves, or it would cost a lot of money, then maybe they
shouldnt go there: Maybe we just have to let this stay out of control and
hope it doesnt get too bad. I heard about a hospital where 80 percent of
their staph infections are now MRSA. So it can get worse. Were heading there. The voyage has begun.

Farr believes that we are on the way to bigger, badder bugs. There is the next threat, which is VRE and MRSA getting
together late at night and exchanging genetic information, and creating the
godzilla of the microbial world that can be more of a problem because its
more antibiotic resistant. There have been two of those that have been seen.
There have been some more that had intermediate susceptibility, and a study by
the CDC shows that the strains that were MRSA with intermediate susceptibility
to vancomycin were more deadly than infections due to plain MRSA. Now we know
that we can have strains that are highly vancomycin-resistant, by the two
getting together and exchanging genetic information. The prospects are not real
good if we continue the present course. As Dickens said in A Christmas Carol,
If these shadows remain unaltered, the child will die. Many Tiny Tims
are going to die from antibiotic-resistant infections in U.S. healthcare. And
many elderly Tims are going to die of this as well.

Problem Pathogen Partnership

In an effort to reduce and control the rates of MRSA and VRE
in hospital facilities, Farr created the Problem Pathogen Partnership, a
voluntary program for facilities interested in helping protect their patients.

I was talking to Bill Jarvis, who was the head of the
outbreak investigations section at CDC for 17 years in the hospital infections
program, says Farr. Jarvis had written an article in the New England
Journal of Medicine
detailing how the Siouxland health district was able to
control VRE for three years. They had an epidemic going on in this health
district, and people were worried and wanted to know what to do. Jarvis said if
youre having a problem with this you should probably do some surveillance
cultures, see who has it, and then use contact precautions, as the CDC has
recommended. They did, and all 32 facilities (28 nursing homes and four
hospitals) agreed to participate. They identified who had it, they started
controlling it, and it got better year after year. At the end of three years,
they had significantly reduced or eliminated VRE in all 32 facilities. It was
very impressive, says Farr. Its the only place that has tried that for
VRE in the U.S. Just think, what if an entire state was doing this what
would the effect be?

Farr worked at setting up a partnership among area hospitals.
We didnt have tons of money, being just barefoot doctors as we are, he
says. We tried to share the data, showed them Jarvis studies and other
studies. What if we all tried it? A number of hospitals in Virginia and North
Carolina started joining, a website was created, inviting people to share data
about how this approach could work, included algorithms to tell people who we
would culture and when we would do it, and some basic recommendations.

Everybody basically should start a program and then modify
it as local conditions dictate to control the problem. Use the method to control
it. There are 300 hospitals in the two states, and probably 25 or
so not quite 10 percent joined. They were not ordered to do that by the
CDC; they did it because they wanted to help protect their patients. A number of
them showed improvements.

Caution, vigilance and attention published guidelines are the
first steps on the road to lower rates of infection. I honestly think that
you have to remind people that its a jungle out there, says Sommers The
most basic of the infection control practices that are recommended are the most
important things you can do. That will help a lot of situations. Wash your
hands. Use a tissue. Dont touch a problematic area and then touch something
else, even if youve got gloves on. We work really hard to make sure that you
remind people that its those kinds of behaviors that are going to make the
biggest difference.