Blog | Thursday, November 14, 2013

Don't BUGG me!


The Journal of the American Medical Association has just published the BUGG (Benefits of Universal Glove and Gown) study online (free full text here). This important, well-designed study was led by Anthony Harris (nice video of Anthony discussing the study here). It’s a 9-month, multicenter, cluster randomized study in 20 medical and surgical ICUs that compares universal contact precautions (i.e., gowns and gloves for all patient care) to “standard” contact precautions (i.e., gowns and gloves for the care of patients with epidemiologically important organisms). The primary outcome evaluated was acquisition of methicillin-resistant Staphylococcus aureus MRSA or vancomycin-resistant enterococci (VRE). Patients were cultured for both organisms on admission and discharge from the ICU.

In a nutshell, the findings were as follows:
• There was no significant difference in the rate of acquisition of MRSA and VRE combined.
• When MRSA and VRE were evaluated separately, there was no difference in the acquisition of VRE, but there was a significant reduction in MRSA acquisition in the universal contact precautions group with an incremental benefit of 3 fewer MRSA acquisitions per 1,000 patient days.
• There was no difference in device-related infections (central line-associated bloodstream infection, catheter-associated urinary tract infections, or ventilator-associated pneumonia) between the two groups and no difference in mortality.
• There was no difference in adverse events between the two groups when evaluated by the IHI Global trigger tool (for what that’s worth).
• Hand hygiene rates were higher in the universal gowns/gloves study arm.
• As might be expected, there were fewer patient visits by health care workers in the universal gown/glove study arm.

So, how do we put this study into perspective? Should the study entice hospitals to begin universal gloving and gowning in the ICU setting?

Let’s assume you have a 15-bed ICU that admits 1,250 patients yearly with an average length of stay of 4 days (i.e., 5,000 patient-days annually). Assuming 10.5% of patients require contact precautions (this proportion comes from the control arm in the BUGG study), 131 patients would require isolation. Alternatively, under universal contact precautions, all 1,250 patients would be isolated. So by isolating an additional 1,119 patients we would prevent an additional 15 patients from acquiring MRSA (i.e., 3 per 1,000 patient days). Assuming 20% of the colonized patients go on to develop infection, 3 additional MRSA infections would be prevented with universal contact precautions.

The bottom line is that to prevent 3 additional infections we needed to isolate an additional 1,100 patients. Given that I’m a utilitarian and that I believe that the burden of contact precautions on patients is high, my assessment is that the benefit of universal gloves and gowns is outweighed by the overall burden on patients. Now it’s true that multi-drug resistant Gram-negative rods and Clostridium difficile weren’t evaluated in the study, so we may not be evaluating the full benefit of the intervention. But for now, don’t BUGG me; I’m still pushing universal chlorhexidine bathing, high rates of hand hygiene compliance, and no isolation of patients with MRSA or VRE.

Addendum (10/6/13): More on this study in Time.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.