Impact of Discontinuing Contact Precautions for MRSA and ESBLE in an Intensive Care Unit: A Prospective Noninferiority Before and After Study

Abstract

OBJECTIVE To compare incidence densities of methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE) acquisition in the intensive care unit (ICU) before and after discontinuation of contact precautions (CP) and application of standard precautions (SP). DESIGN Prospective noninferiority before-and-after study comparing 2 periods: January 1, 2012, to January 31, 2014 (the CP period) and February 1, 2014, to February 29, 2016 (the SP period). SETTING A 16-bed polyvalent ICU in France with only single-bed rooms with dedicated equipment and reusable medical devices. PATIENTS All patients admitted to the ICU during the CP and SP periods were included: 1,547 and 1,577 patients, respectively. METHODS Incidence densities of ICU-acquired MRSA or ESBLE were determined per 1,000 patient days. Other studied factors included (1) patient characteristics, (2) incidence densities of MRSA or ESBLE carried at admission, (3) compliance with hand hygiene protocols, and (4) antibiotic consumption. RESULTS Incidence densities of ICU-acquired MRSA were 0.82 (95% confidence interval [CI], 0.31-1.33) and 0.79 (95% CI, 0.30-1.29) per 1,000 patient days during the CP and SP periods, respectively. For ESBLE, values were 2.7 (95% CI, 1.78-3.62) and 2.06 (95% CI, 1.27-2.86) per 1,000 patient days. These rates were significantly nonsuperior during the SP period compared to CP period, with a margin of 1 per 1,000 patient days for both MRSA (P=.002) and ESBLE (P=.004). Other factors were comparable during the 2 periods. Only ESBLE carried at admission was inferior during the SP period. We observed a high level of compliance to hand hygiene protocols. CONCLUSIONS Discontinuing CP did not increase acquired MRSA and ESBLE in our ICU with single rooms with dedicated equipment, strict application of hand hygiene, medical and paramedical leadership, and good antibiotic stewardship. Infect Control Hosp Epidemiol 2017;38:1342-1350.

Effects of Discontinuing Contact Precaution on Control of Extended-Spectrum β-lactamase-producing Enterobacteriaceae Nosocomial Acquisition: An Interrupted Time Series Analysis

“…The patients were signi cantly older in the post-intervention period, but studies who aimed to investigate the risk factors associated with acquisition of ESBL-producing bacteria did not report the age as one. (21,22) The fact that our study was conducted not only in ICUs (ICUs LOS are 8 days on average) can explained that the LOS observed (12 days throughout both periods) is slightly higher than in others (22). Taking account that the LOS could increase the risk to acquired MDRO (23), our acquisition ID was still comparable to previous ndings (24).…”

Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase–producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies

“…These patients would be missed by a policy of targeted screening; nonetheless, and as discussed above, the hazard of cross-transmission from such unidentified carriers of ESBL-producing E. coli is probably negligible, provided that standard precautions are strictly applied. More pragmatically, in 2 recent studies conducted in ICUs with a relatively low prevalence of ESBL-E, high compliance to standard precautions, and only single-bed rooms, no change was observed in the incidence densities of ICU-acquired ESBL-E colonization and infection following the complete discontinuation of ASC and CP [26,27], further raising doubt regarding the relevance of these measures in the absence of an outbreak. Still, ASC may be warranted for transferred or repatriated patients at high risk of carriage of carbapenemase-producing Enterobacteriaceae or other extensively drug-resistant Gram-negative bacteria (GNB), such as pan-resistant Acinetobacter spp.…”

Effectiveness of a multisite personal protective equipment (PPE)–free zone intervention in acute care

“…Currently, contact precautions as an infection prevention policy is controversial, with some arguing for discontinuing its use in specific settings and organisms. [9][10][11]20 However, as others have noted, 12 there remain significant unanswered questions on safety and the effect on transmission rates of discontinuing contact precautions. The PPE-free zone, which does not appear to have any negative effect on HCP compliance with contact precautions or entry hand hygiene, may be a viable approach for reducing HCP burden while maintaining contact precautions use until the controversy is better studied and resolved.…”

“…[6][7][8] As a result, some facilities have discontinued the use of contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycinresistant Enterococcus. [9][10][11] However, there is limited evidence to-date demonstrating that the elimination of contact precautions is safe. 12 In light of these challenges, strategies termed "safe zones" or "red box" have been proposed that require PPE use only during higher-risk encounters with patients on contact precautions.…”