Mitigating Risk of Endemic MRSA and VRE Transmission with the Discontinuation of Contact Precautions: Looking at the Issue
The recommendation of the Centers for Disease Control (CDC) for patient management of endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) with contact precautions is controversial and has been debated at multiple professional meetings.1,2 The major concern is: Does the removal of contact precautions for management of endemic MRSA and VRE have a negative impact on healthcare-associated infection (HAI) rates?
Recent publications are adding to a compelling body of literature that the discontinuation of contact precautions does not have a negative impact on HAI rates in conjunction with implementing robust infection prevention interventions. A retrospective, multicenter, interrupted time series analysis of the cumulative experience of 3 academic centers before and after discontinuation of contact precautions and the subsequent deployment of multiple horizontal infection prevention strategies—that included evidence-based bundles, hand hygiene programs, and chlorhexidine bathing3—found a downward trend in overall central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and mediastinal surgical site infection at each facility, which was attributed to the broad adoption of evidence-based bundle practices. The authors concluded that there were no statistically significant increases in these infections due to MRSA or VRE or any organisms after the discontinuation of contact precautions for patients with contained body fluids.
A systematic review and meta-analysis of 17 studies evaluating discontinuation of contact precautions found no significant difference between rates of healthcare-onset (HO) MRSA infection and decreased rates of HO-VRE infection before and after removing contact precautions.4 A subgroup analysis of studies that used chlorhexidine did not demonstrate a difference in HO-MRSA infection with discontinuation of contact precautions. Although these studies have methodological issues (e.g., use of the before and after design, small sample sizes, issues with outcomes examined, and examination of contact precautions as part of a bundle of interventions making it difficult to assess the impact of individual interventions), the findings are especially important in the current context of the COVID-19 pandemic when gowns have been difficult to procure. It is likely that many healthcare settings have transitioned away from routine contact precautions for MRSA and VRE as a necessity to increase the availability of gowns for managing COVID-19 patients and will view these studies as timely evidence that the practice can safely continue.
The wider acceptance of discontinuing contact precautions for management of endemic MRSA and VRE elevates the need for optimal implementation of evidence-based prevention strategies aimed at reducing transmission of these organisms.
Be sure to look for Part II (coming soon).
1Hebden J, and Pogorzelska-Maziarz M. Journal club: Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: An interrupted time series analysis. Am J Infect Control (2020); 48:1562-63.
2Morgan DJ, Diekema DJ, Sepkovitz K, Perencevich EN. Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control.2009;37:85–93.
3Haessler S, Martin EM, Scales ME, et al. Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: an interrupted time series analysis. Am J Infect Control. 2020;48:1466–1473.
4Kleyman R, Cupril-Nilson S, Robinson K, et al. Does the removal of contact precautions for MRSA and VRE infected patients change healthcare-associated infection rate? A systematic review and meta-analysis. Am J Infect Control.2020; in press.