Blog | Monday, July 10, 2017

Questions for contact precautions eliminators

Over the past eight years, I've been the lone supporter of contact precautions on the blog. Of course, Tom and Hilary haven't publicly committed either way, at least on this blog. And to clarify my position, I'm greatly in favor of more studies examining the role of isolation strategies and how/where to best implement them.

For example, do we need gowns or would gloves alone suffice? And should we isolate uncolonized patients instead of colonized patients since we're most interested in preventing transmission from contaminated healthcare worker to uncolonized patients? This latter question is why I currently favor exploring the benefits of universal gloving strategies. But of course, there is a growing number of studies that explore the discontinuation of contact precautions, which have led to places like Iowa eliminating contact precautions for methicillin-resistant Staphylococcus aureus (MRSA)/vancomycin-resistant Enterococci (VRE)-colonized or infected patients.

So with that in mind, I have a few questions for folks who are in favor of eliminating contact precautions. Specifically, I want to understand the who/what/when/where/why behind their recommendations.

Question #1: Are hospitals no longer a source for multidrug resistant organism-bacterial acquisition? Do acute care hospitals or subpopulation (ICUs, hemodialysis) remain sites for patient-to-patient transmission or have we completely eliminated transmission in these settings?

Question #2: If transmission has been eliminated, how would we know? Are you aware of data that proves patients who are uncolonized on admission remain uncolonized by the time of discharge? Does your hospital do discharge surveillance cultures for sentinel organisms like MRSA or carbapenem-resistant Enterobacteriaceae (CRE)?

Question #3: If you don't do surveillance culturing on discharge, do you follow patients post discharge to make sure they don't develop an MDRO infection at a subsequent point? Do patients no longer develop MDRO infections linked to a prior hospital stay suggesting that all transmission is now occurring in the community setting?

Question #4: If transmission in acute-care settings has been eliminated, how has that happened? Is it that hand hygiene compliance of 34% to 57% is enough to halt all transmission? Is it that the environment is so sparkling clean these days that clinicians can't even pick up bad bacteria on their hands?

Question #5: Perhaps you agree that hospitals (or ICUs) are still engines powering the emergence of MDRO in human populations and your hospital might even be a source for patient acquisition. Is it that you think hands are not a source of transmission and contact precautions just don't work? Do you feel similarly about hand hygiene - does hand hygiene not reduce transmission? Since we know that when caring for patients that healthcare workers gloves/gowns become contaminated 8%-39% of the time, where do these bacteria go? Do they just disappear?

Question #6: Finally, even if transmission is occurring via the hands of healthcare workers maybe you're convinced it's not your problem? If you can't see the benefits directly in your hospital, it's not important. Tragedy of the commons? Meh. Perhaps, it's up to me to detect all MRSA colonized patients in my clinic or on admission to my hospital and decolonize them?

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.