The Importance of Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci

Implementation of contact precautions for multidrug-resistant organisms in the post-COVID-19 pandemic era: An updated national Emerging Infections Network (EIN) survey

OBJECTIVE

To understand how healthcare facilities employ contact precautions for patients with multidrug-resistant organisms (MDROs) in the post-coronavirus disease 2019 (COVID-19) era and explore changes since 2014.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Emerging Infections Network (EIN) physicians involved in infection prevention or hospital epidemiology.

METHODS

In September 2022, we sent via email an 8-question survey on contact precautions and adjunctive measures to reduce MDRO transmission in inpatient facilities. We also asked about changes since the COVID-19 pandemic. We used descriptive statistics to summarize data and compared results to a similar survey administered in 2014.

RESULTS

Of 708 EIN members, 283 (40%) responded to the survey and 201 reported working in infection prevention. A majority of facilities (66% and 69%) routinely use contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) respectively, compared to 93% and 92% in 2014. Nearly all (>90%) use contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter baumannii. More variability was reported for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing gram-negative organisms. Compared to 2014, fewer hospitals perform active surveillance for MRSA and VRE. Overall, 90% of facilities used chlorhexidine gluconate bathing in all or select inpatients, and 53% used ultraviolet light or hydrogen peroxide vapor disinfection at discharge. Many respondents (44%) reported changes to contact precautions since COVID-19 that remain in place.

CONCLUSIONS

Heterogeneity exists in the use of transmission-based precautions and adjunctive infection prevention measures aimed at reducing MDRO transmission. This variation reflects a need for updated and specific guidance, as well as further research on the use of contact precautions in healthcare facilities.

The Impact of Universal Glove and Gown Use on Clostridioides Difficile Acquisition: A Cluster-Randomized Trial

BACKGROUND

Clostridioides difficile is the most common cause of healthcare-associated infections in the United States. It is unknown whether universal gown and glove use in intensive care units (ICUs) decreases acquisition of C. difficile.

METHODS

This was a secondary analysis of a cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from 4 January 2012 to 4 October 2012. After a baseline period, ICUs were randomized to standard practice for glove and gown use versus the intervention of all healthcare workers being required to wear gloves and gowns for all patient contact and when entering any patient room (contact precautions). The primary outcome was acquisition of toxigenic C. difficile determined by surveillance cultures collected on admission and discharge from the ICU.

RESULTS

A total of 21 845 patients had both admission and discharge perianal swabs cultured for toxigenic C. difficile. On admission, 9.43% (2060/21 845) of patients were colonized with toxigenic C. difficile. No significant difference was observed in the rate of toxigenic C. difficile acquisition with universal gown and glove use. Differences in acquisition rates in the study period compared with the baseline period in control ICUs were 1.49 per 100 patient-days versus 1.68 per 100 patient-days in universal gown and glove ICUs (rate difference, -0.28; generalized linear mixed model, P = .091).

CONCLUSIONS

Glove and gown use for all patient contact in medical and surgical ICUs did not result in a reduction in the acquisition of C. difficile compared with usual care.

CLINICAL TRIALS REGISTRATION

NCT01318213.

Examining the impact of ICU population interaction structure on modeled colonization dynamics of Staphylococcus aureus

Background

Complex transmission models of healthcare-associated infections provide insight for hospital epidemiology and infection control efforts, but they are difficult to implement and come at high computational costs. Structuring more simplified models to incorporate the heterogeneity of the intensive care unit (ICU) patient-provider interactions, we explore how methicillin-resistant Staphylococcus aureus (MRSA) dynamics and acquisitions may be better represented and approximated.

Methods

Using a stochastic compartmental model of an 18-bed ICU, we compared the rates of MRSA acquisition across three ICU population interaction structures: a model with nurses and physicians as a single staff type (SST), a model with separate staff types for nurses and physicians (Nurse-MD model), and a Metapopulation model where each nurse was assigned a group of patients. The proportion of time spent with the assigned patient group (γ) within the Metapopulation model was also varied.

Results

The SST, Nurse-MD, and Metapopulation models had a mean of 40.6, 32.2 and 19.6 annual MRSA acquisitions respectively. All models were sensitive to the same parameters in the same direction, although the Metapopulation model was less sensitive. The number of acquisitions varied non-linearly by values of γ, with values below 0.40 resembling the Nurse-MD model, while values above that converged toward the Metapopulation structure.

Discussion

Inclusion of complex population interactions within a modeled hospital ICU has considerable impact on model results, with the SST model having more than double the acquisition rate of the more structured metapopulation model. While the direction of parameter sensitivity remained the same, the magnitude of these differences varied, producing different colonization rates across relatively similar populations. The non-linearity of the model’s response to differing values of a parameter gamma (γ) suggests simple model approximations are appropriate in only a narrow space of relatively dispersed nursing assignments.

Conclusion

Simplifying assumptions around how a hospital population is modeled, especially assuming random mixing, may overestimate infection rates and the impact of interventions. In many, if not most, cases more complex models that represent population mixing with higher granularity are justified.

Improving mathematical modeling of interventions to prevent healthcare-associated infections by interrupting transmission or pathogens: How common modeling assumptions about colonized individuals impact intervention effectiveness estimates

Mathematical models are used to gauge the impact of interventions for healthcare-associated infections. As with any analytic method, such models require many assumptions. Two common assumptions are that asymptomatically colonized individuals are more likely to be hospitalized and that they spend longer in the hospital per admission because of their colonization status. These assumptions have no biological basis and could impact the estimated effects of interventions in unintended ways. Therefore, we developed a model of methicillin-resistant Staphylococcus aureus transmission to explicitly evaluate the impact of these assumptions. We found that assuming that asymptomatically colonized individuals were more likely to be admitted to the hospital or spend longer in the hospital than uncolonized individuals biased results compared to a more realistic model that did not make either assumption. Results were heavily biased when estimating the impact of an intervention that directly reduced transmission in a hospital. In contrast, results were moderately biased when estimating the impact of an intervention that decolonized hospital patients. Our findings can inform choices modelers face when constructing models of healthcare-associated infection interventions and thereby improve their validity.

Elastic Nanofibrous Membranes for Medical and Personal Protection Applications: Manufacturing, Anti-COVID-19, and Anti-Colistin Resistant Bacteria Evaluation

Herein, in the present work two series of thermoplastic polyurethane (TPU) nanofibers were manufactured using the electrospinning techniques with ZnO and CuO nanoparticles for a potential use as an elastic functional layer in antimicrobial applications. Percentages of 0%, 2 wt%, and 4 wt% of the nanoparticles were used. The morphological characterization of the electrospun TPU and TPU/NPs composites nanofibers were observed by using scanning electron microscopy to show the average fiber diameter and it was in the range of 90-150 nm with a significant impact of the nanoparticle type. Mechanical characterization showed that TPU nanofiber membranes exhibit excellent mechanical properties with ultra-high elastic properties. Elongation at break reached up to 92.5%. The assessment of the developed nanofiber membranes for medical and personal protection applications was done against various colistin resistant bacterial strains and the results showed an increment activity by increasing the metal oxide concentration up to 83% reduction rate by using TPU/ZnO 4% nanofibers against K. pneumoniae strain 10. The bacterial growth was completely eradicated after 8 and 16 h incubation with TPU/ZnO and TPU/CuO nanofibers, respectively. The nanofibers SEM study reveals the adsorption of the bacterial cells on the metal oxides nanofibers surface which led to cell lysis and releasing of their content. Finally, in vitro study against Spike S-protein from SARS-CoV-2 was also evaluated to investigate the potent effectiveness of the proposed nanofibers in the virus deactivation. The results showed that the metal oxide concentration is an effective factor in the antiviral activity due to the observed pattern of increasing the antibacterial and antiviral activity by increasing the metal oxide concentration; however, TPU/ZnO nanofibers showed a potent antiviral activity in relation to TPU/CuO.

Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.

Does high adherence to contact precautions lead to low in-hospital transmission of multi-drug-resistant micro-organisms in the endemic setting?

BACKGROUND

Conflicting results have been published on the impact of contact precautions (CPs) on reduction of transmission of multi-drug-resistant micro-organisms (MDROs) in the endemic setting. Ambiguous definitions coupled with low adherence partly explain these differences.

AIM

We prospectively monitored the level of adherence to CPs and aimed to relate it to in-hospital transmission of MDROs.

METHODS

Between January 2016 and March 2018, all patients under CPs underwent continuous monitoring of adherence to CPs by routine on-site visits on days 0, 3 and 7 after initiating CPs using a standardized checklist. The protocol included 10 interventions that were routinely checked such as CP sign at the door as well as wearing of gowns and gloves upon entry to the patient room. Patients requiring CPs were defined as colonized or infected with MDROs (meticillin-resistant Staphylococcus aureus (MRSA), non-Escherichia coli extended-spectrum beta lactamase (ESBL) Enterobacterales, vancomycin-resistant enterococci (VRE) and carbapenem-resistant Gram-negative micro-organisms (CRGN)) as well as patients infected with respiratory viruses, norovirus, scabies and hypervirulent strains of Clostridioides difficile.

FINDINGS

Overall, data from 13,756 CP records from 1378 visits of 812 patients were analysed. Adherence varied between 93% and 100% for each intervention, except for "separate space for contaminated material" with an adherence of 5.3-6.1%. The incidence of in-hospital transmission during the study period was extremely low for MRSA, VRE, non-E.coli ESBL Enterobacterales and CRGN with 0.00-0.064 cases/1000 patient days.

CONCLUSION

High adherence coupled with continuous monitoring of CPs correlated with a very low in-hospital transmission rate. These results indicate that CPs are highly effective if routine monitoring of adherence is implemented.

Acquisition of Antibiotic-Resistant Gram-negative Bacteria in the Benefits of Universal Glove and Gown (BUGG) Cluster Randomized Trial

Background

The Benefits of Universal Glove and Gown (BUGG) cluster randomized trial found varying effects on methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus and no increase in adverse events. The aim of this study was to assess whether the intervention decreases the acquisition of antibiotic-resistant gram-negative bacteria.

Methods

This was a secondary analysis of a randomized trial in 20 hospital intensive care units. The intervention consisted of healthcare workers wearing gloves and gowns when entering any patient room compared to standard care. The primary composite outcome was acquisition of any antibiotic-resistant gram-negative bacteria based on surveillance cultures.

Results

A total of 40 492 admission and discharge perianal swabs from 20 246 individual patient admissions were included in the primary outcome. For the primary outcome of acquisition of any antibiotic-resistant gram-negative bacteria, the intervention had a rate ratio (RR) of 0.90 (95% confidence interval [CI], .71–1.12; P = .34). Effects on the secondary outcomes of individual bacteria acquisition were as follows: carbapenem-resistant Enterobacteriaceae (RR, 0.86 [95% CI, .60–1.24; P = .43), carbapenem-resistant Acinetobacter (RR, 0.81 [95% CI, .52–1.27; P = .36), carbapenem-resistant Pseudomonas (RR, 0.88 [95% CI, .55–1.42]; P = .62), and extended-spectrum β-lactamase–producing bacteria (RR, 0.94 [95% CI, .71–1.24]; P = .67).

Conclusions

Universal glove and gown use in the intensive care unit was associated with a non–statistically significant decrease in acquisition of antibiotic-resistant gram-negative bacteria. Individual hospitals should consider the intervention based on the importance of these organisms at their hospital, effect sizes, CIs, and cost of instituting the intervention.

Clinical Trials Registration

NCT01318213.

Molecular Characterization of Staphylococcus aureus Obtained from Blood Cultures of Paediatric Patients Treated in a Tertiary Care Hospital in Mexico

Purpose

Staphylococcus aureus is one of the main causative agents of hospital-acquired (HA) infections. In Mexico, information about the characteristics of clinical S. aureus isolates is limited. Our aim was to characterize S. aureus strains obtained from blood cultures of paediatric patients treated in a tertiary care hospital.

Materials and Methods

We analysed 249 S. aureus isolates over the period from 2006 to 2019, and their resistance profiles were determined. The isolates were classified into methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA). Staphylococcal cassettes chromosome mec (SCCmec) were detected. Virulence genes (cna, clfA, clfB, eta, etb, fnbA, fnbB, hla, pvl, sec, and tsst) were amplified, and their clonal relationships were established by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST) and clonal complex (CC) typing. We reviewed one hundred medical files to collect clinical information.

Results

Thirty-eight percent of the isolates were MRSA and showed an expanded profile of resistance to other non-beta-lactam antibiotics, while MSSA strains presented a reduced resistance profile. SCCmec-II was the most frequent element (86.3%). Eight virulence factors were detected in MSSA and six in MRSA. The pvl gene was detected in four MRSA-SCCmec-IV isolates (P≤0.0001). MRSA isolates were distributed among 14 clones and were classified into 15 sequence types (ST); the most frequent was ST1011 (17%). The most common CC in MRSA was CC5 (69%, P≤0.0001), and in MSSA, it was CC30 (30%, P≤0.0001). Eighty-seven percent of MRSA isolates were HA-MRSA, and 13% were community-acquired MRSA (CA-MRSA). Of 21 HA-MRSA isolates, 17 had SCCmec-II, while two CA-MRSA isolates had SCCmec-IV. Of MSSA isolates, 77% were derived from HA infections and 23% from CA infections.

Conclusion

MSSA isolates had more virulence factors. MRSA isolates were resistant to more non-beta-lactam antibiotics, and those with SCCmec-IV expressed a greater variety of virulence factors. Most S. aureus isolates belonged to CC5.

Association Between Contact Precautions and Transmission of Methicillin-Resistant Staphylococcus aureus in Veterans Affairs Hospitals

IMPORTANCE

The effectiveness and importance of contact precautions for endemic pathogens has long been debated, and their use has broad implications for infection control of other pathogens.

OBJECTIVE

To estimate the association between contact precautions and transmission of methicillin-resistant Staphylococcus aureus (MRSA) across US Department of Veterans Affairs (VA) hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used mathematical models applied to data from a population-based sample of adults hospitalized in 108 VA acute care hospitals for at least 24 hours from January 1, 2008, to December 31, 2017. Data were analyzed from May 2, 2019, to December 11, 2020.

EXPOSURES

A positive MRSA test result, presumed to indicate contact precautions use according to the VA MRSA Prevention Initiative.

MAIN OUTCOMES AND MEASURES

The main outcome was the association between contact precautions and MRSA transmission, defined as the relative transmissibility attributed to contact precautions. A contact precaution effect estimate (<1 indicates a reduction in transmission associated with contact precautions) was estimated for each hospital and then pooled over time and across hospitals using meta-regression.

RESULTS

In this cohort study of 108 VA hospitals, more than 2 million unique individuals had over 5.6 million admissions, of which 14.1% were presumed to have contact precautions with more than 8.4 million MRSA surveillance tests. Pooled estimates found associations between contact precautions and transmission to be stable from 2008 to 2017, with estimated transmission reductions ranging from 43% (95% credible interval [CrI], 38%-48%) to 51% (95% CrI, 46%-55%). Over the entire 10-year study period, contact precautions reduced transmission 47% (95% CrI, 45%-49%), and the intrafacility autocorrelation coefficient estimate was 0.99, suggesting consistent estimates over time within facilities. Larger facilities and those with higher admission screening compliance observed additional reductions in transmission associated with contact precautions (relative rate, 0.84; 95% CI, 0.74-0.96 and 0.74; 95% CI, 0.58-0.96, respectively) compared with smaller facilities and those with lower admission screening compliance. Facilities in the southern US had a smaller transmission reduction attributable to contact precautions (relative rate, 1.14; 95% CI, 1.01-1.28) compared with facilities in other regions in the US.

CONCLUSIONS AND RELEVANCE

In this cohort study of adults in VA hospitals, transmissibility of MRSA was found to be reduced by approximately 50% among patients with contact precautions. These results provide an explanation for decreasing acquisition rates in VA hospitals since the MRSA Prevention Initiative.

Effectiveness of Contact Precautions to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci in Intensive Care Units

BACKGROUND

Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are under increasing scrutiny, in part due to limited clinical trial evidence.

METHODS

We retrospectively analyzed data from the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial to model the use of contact precautions in individual intensive care units (ICUs). Data included admission and discharge times and surveillance test results. We used a transmission model to estimate key epidemiological parameters, including the effect of contact precautions on transmission. Finally, we performed multivariate meta-regression to identify ICU-level factors associated with contact precaution effects.

RESULTS

We found that 21% of admissions (n = 2194) were placed on contact precautions, with most for MRSA and VRE. We found little evidence that contact precautions reduced MRSA transmission. The estimated change in transmission attributed to contact precautions was -16% (95% credible interval, -38% to 15%). VRE transmission was higher than MRSA transmission due to contact precautions, but not significantly. In our meta-regression, we did not identify associations between ICU-level factors and estimated contact precaution effects. Importation and transmission were higher for VRE than for MRSA, but clearance rates were lower for VRE than for MRSA.

CONCLUSIONS

We found little evidence that contact precautions implemented during the STAR*ICU trial reduced transmission of MRSA or VRE. We did find important differences in the transmission dynamics between MRSA and VRE. Differences in organism and healthcare setting may impact the efficacy of contact precautions.

Risk factors for transmission of carbapenem-resistant Enterobacterales to healthcare personnel gloves and gowns in the USA

BACKGROUND

Hospitals are sources for acquisition of carbapenem-resistant Entero-bacterales (CRE), and it is believed that the contamination of healthcare personnel (HCP) hands and clothing play a major role in patient-to-patient transmission of antibiotic-resistant bacteria.

AIM

The aim of this study was to determine which HCP types, HCP-patient interactions, and patient characteristics are associated with greater transmission of CRE to HCP gloves and gowns in the hospital.

METHODS

This was a prospective observational cohort study that enrolled patients with recent surveillance or clinical cultures positive for CRE at five hospitals in four states in the USA. HCP gloves and gown were cultured after patient care. Samples were also obtained from patients' stool, perianal area, and skin of the chest and arm to assess bacterial burden.

FINDINGS

Among 313 CRE-colonized patients and 3070 glove and gown cultures obtained after patient care, HCP gloves and gowns were found to be contaminated with CRE 7.9% and 4.3% of the time, respectively. Contamination of either gloves or gowns occurred in 10.0% of interactions. Contamination was highest (15.3%) among respiratory therapists (odds ratio: 3.79; 95% confidence interval: 1.61-8.94) and when any HCP touched the patient (1.52; 1.10-2.12). Associations were also found between CRE transmission to HCP gloves or gown and: being in the intensive care unit, having a positive clinical culture, and increasing bacterial burden on the patient.

CONCLUSION

CRE transmission to HCP gloves and gown occurred frequently. These findings may inform evidence-based policies about what situations and for which patients contact precautions are most important.

Multidrug-Resistant Organisms in Palliative Care: A Systematic Review

Background: Multidrug-resistant organisms (MDROs) are an important health care issue. Patients in Western societies often present an increased morbidity of chronic conditions accompanied by poor immune status and the use of devices. In particular, patients in palliative care (PC) are at greater risk of MDRO colonization, due to accompanying special devices and being hospitalized. Objective: To gain an overview of the literature regarding MDROs in PC. Design: Systematic review Data sources: On the 19th of October 2019 the databases " PubMed" and " CINAHL" were used to identify studies reporting on MDROs in PC; the search was updated on 16th of May 2020. Results: Seventeen out of 486 articles were included. Six represent qualitative data, 10 quantitative data, and one a mixed methods approach. Prevalence data range from 4.0% to 18%. MDRO colonization has a negative impact on patients and families. It leads to uncertainties and higher workload by staff members. Strategies for the management of MDROs in the field of PC are predominantly available for methicillin-resistant Staphylococcus aureus. Not even half of institutions utilize existing protocols. Recommendations for dealing with MDROs indicate required staff and time resources as well as information, communication, and specific knowledge. Conclusion: There is a great need for studies examining the prevalence of all MDROs in the PC setting. Additionally, not only patients but also a public enlightenment on MDROs should be provided to decrease knowledge gaps and therefore reduce transmission on MDROs.

Model-based Assessment of the Effect of Contact Precautions Applied to Surveillance-detected Carriers of Carbapenemase-producing Enterobacteriaceae in Long-term Acute Care Hospitals

BACKGROUND

An intervention that successfully reduced colonization and infection with carbapenemase-producing Enterobacteriaceae (CPE) in Chicago-area long-term acute-care hospitals included active surveillance and contact precautions. However, the specific effects of contact precautions applied to surveillance-detected carriers on patient-to-patient transmission are unknown, as other, concurrent intervention components or changes in facility patient dynamics also could have affected the observed outcomes.

METHODS

Using previously published data from before and after the CPE intervention, we designed a mathematical model with an explicit representation of postintervention surveillance. We estimated preintervention to postintervention changes of 3 parameters: β, the baseline transmission rate excluding contact precaution effects; δb, the rate of a CPE carrier progressing to bacteremia; and δc, the progression rate to nonbacteremia clinical detection.

RESULTS

Assuming that CPE carriers under contact precautions transmit carriage to other patients at half the rate of undetected carriers, the model produced no convincing evidence for a postintervention change in the baseline transmission rate β (+2.1% [95% confidence interval {CI}, -18% to +28%]). The model did find evidence of a postintervention decrease for δb (-41% [95% CI, -60% to -18%]), but not for δc (-7% [95% CI, -28% to +19%]).

CONCLUSIONS

Our results suggest that contact precautions for surveillance-detected CPE carriers could potentially explain the observed decrease in colonization by itself, even under conservative assumptions for the effectiveness of those precautions for reducing cross-transmission. Other intervention components such as daily chlorhexidine gluconate bathing of all patients and hand-hygiene education and adherence monitoring may have contributed primarily to reducing rates of colonized patients progressing to bacteremia.

Barrier Precautions in the Era of Multidrug Pathogens

Purpose of review

There is a continuing debate regarding contact precaution (CP) usage for endemic multidrug-resistant organisms (MDROs). In this review, we examine current recommendations for CP and highlight differences in CP use between endemic and non-endemic MDROs.

Recent findings

The discontinuation of CP had no effect on the incidence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci. The evidence regarding CP for extended-spectrum beta-lactamase producing Enterobacteriaceae is inconclusive, highlighting the need for more research to determine best infection control strategies. Carbapenem-resistant Enterobacteriaceae maintains a sporadic pattern in the USA, supporting current recommendations to use CP for colonized and infected patients. MDR Acinetobacter baumannii (MDR-AB) is extremely virulent and responsible for outbreaks in healthcare settings, emphasizing the need for CP use with MDR-AB infected patients. Candida auris (C. auris) is often misdiagnosed; it is resistant to UV light and quaternary ammonium low-level disinfection. Because little is known about the transmission of C. auris, significant caution and CP use are necessitated. There is little research on vancomycin-resistant S. aureus (VRSA) control strategies due to its rarity; thus, CP is strongly recommended.

Summary

Contact precautions are frequently part of a bundled infection control approach that involves meticulous hand hygiene, patient decolonization, chlorhexidine gluconate bathing, and reducing the use of invasive devices. Healthcare facilities should continue to utilize CP for non-endemic MDROs and the presence of endemic MDROs; however, CP may not add benefit to the current infection prevention bundle approach.

Prevalence of device use and transmission based precautions in nineteen large Australian acute care public hospitals: Secondary outcomes from a national healthcare associated infection point prevalence survey

BACKGROUND

The use of invasive devices increases the risk of healthcare associated infections (HAI). The recent national HAI point prevalence survey secondary outcomes aimed to estimate the prevalence of patients with an indwelling urinary catheter device and vascular access devices; and also identify prevalence of those managed under transmission based precautions (TBP); and those colonised or infected with a multi drug resistant organism (MDRO).

METHODS

A point prevalence study was conducted in large acute care Australian public hospitals. All data were collected by two trained Research Assistants. Surveillance methodology was based on the European Centre for Disease Prevention and Control PPS Protocol. Data was also collected on prevalence of TBPs and MDROs.

RESULTS

A total of 2767 acute adult inpatients were sampled across 19 hospitals. The prevalence of peripheral vascular, central vascular and urinary catheters devices was 55.2% (95%CI: 53.3%-57.1%), 14.8% (95%CI: 13.5%-16.1%) and 20.7% (95%CI: 19.2%-22.3%) respectively. Of the 2767 patients sampled 285 (10.3%, 95%CI: 9.2%-11.5%) were documented as either being infected or colonised with a MDRO, and 781 (11.8%) patients were being managed under the hospital TBP policy.

CONCLUSION

This is the first national study to describe the prevalence of devices, TBPs and MDROs in Australian healthcare settings. In an era where device use should be constantly reviewed to minimise risk of HAI, and the increasing challenges of managing patients with MDROs, this data can serve as a benchmark for future studies.

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

OBJECTIVE

Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions.

DESIGN

Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls.

SETTING

All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases.

INTERVENTION

A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE.

RESULTS

We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance (P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions (P = .008). PPE use was not significantly different before versus after the intervention (P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently.

CONCLUSIONS

HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.

A qualitative study of factors affecting personal protective equipment use among health care personnel

BACKGROUND

Health care personnel (HCP) use of personal protective equipment (PPE) reduces infectious disease transmission. However, PPE compliance remains low. The objective of this study was to better understand how HCP perceptions factor into PPE decision making as well as how organizational processes and the environment impact behavior.

METHODS

This qualitative study used observation and focus groups at 2 medical centers. Data were analyzed using thematic analysis.

RESULTS

The decision to use PPE and to follow precaution practices was influenced by risk perception as well as organizational and environmental factors. Perceived risk, related to certain organisms and work tasks, was considered by HCP when deciding to use PPE. Organizational processes, such as policies that were not applied uniformly, and environmental factors, such as clean versus contaminated space, also played a role in HCP PPE use.

DISCUSSION

Because HCP seemed focused on organisms and work tasks, education on specific organisms and helping HCP think through their workflow may be more effective in conveying the importance of PPE in reducing transmission. Additionally, isolation practices should be compared across disciplines to ensure they complement, rather than contradict, one another. Assessment of the environment may help protect HCP and patients from infectious organisms.

CONCLUSION

Preventing the spread of infectious organisms should not depend solely on PPE use, but should also be recognized as an organizational responsibility.

Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk

Background

The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge.

Methods

We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection.

Results

The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge.

Conclusions

MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.

Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures

OBJECTIVE

To assess potential transmission of antibiotic-resistant organisms (AROs) using surrogate markers and bacterial cultures.

DESIGN

Pilot study.

SETTING

A 1,260-bed tertiary-care academic medical center.

PARTICIPANTS

The study included 25 patients (17 of whom were on contact precautions for AROs) and 77 healthcare personnel (HCP).

METHODS

Fluorescent powder (FP) and MS2 bacteriophage were applied in patient rooms. HCP visits to each room were observed for 2-4 hours; hand hygiene (HH) compliance was recorded. Surfaces inside and outside the room and HCP skin and clothing were assessed for fluorescence, and swabs were collected for MS2 detection by polymerase chain reaction (PCR) and selective bacterial cultures.

RESULTS

Transfer of FP was observed for 20 rooms (80%) and 26 HCP (34%). Transfer of MS2 was detected for 10 rooms (40%) and 15 HCP (19%). Bacterial cultures were positive for 1 room and 8 HCP (10%). Interactions with patients on contact precautions resulted in fewer FP detections than interactions with patients not on precautions (P < .001); MS2 detections did not differ by patient isolation status. Fluorescent powder detections did not differ by HCP type, but MS2 was recovered more frequently from physicians than from nurses (P = .03). Overall, HH compliance was better among HCP caring for patients on contact precautions than among HCP caring for patients not on precautions (P = .003), among nurses than among other nonphysician HCP at room entry (P = .002), and among nurses than among physicians at room exit (P = .03). Moreover, HCP who performed HH prior to assessment had fewer fluorescence detections (P = .008).

CONCLUSIONS

Contact precautions were associated with greater HCP HH compliance and reduced detection of FP and MS2.

[Analysis of the predictive value of preventive isolation criteria in the intensive care unit]

OBJECTIVE

To assess the diagnostic accuracy of the criteria used to detect patients carrying multiresistant microorganisms (MRMs).

DESIGN

A prospective observational study was carried out from May 2014 to May 2015.

SETTING

Polyvalent Intensive Care Unit.

PATIENTS

A cohort of consecutively admitted patients meeting the following criteria for preventive isolation according to the "Zero Resistance" project: hospital length of stay>4 days in the last three months ("hospital"); antibiotherapy during one week in the last month ("antibiotic"); institutionalized patients or recurrent contact with healthcare ("institution or care"); MRM carrier in the last 6 months ("previous MRM").

VARIABLES

Demographic data, culture results and isolation time. A multivariate analysis was performed using multiple logistic regression between each of the risk factors and patient MRM carrier status.

RESULTS

During the study period, 575 patients were admitted, of which 28% met the isolation criteria (162). Fifty-one (31%) were MRM carriers. Of the patients who did not meet the criteria, 29 (7%) were carriers. In the multivariate analysis, the only variable independently associated to carrier status was "previous MRM", with OR=12.14 (95%CI 4.24-34.77).

CONCLUSIONS

The only criterion independently associated with the ability to detect patients with MRMs upon admission to the ICU was the existence of "previous MRM".

Improving the Use of Personal Protective Equipment: Applying Lessons Learned

Unrecognized transmission of pathogens in healthcare settings can lead to colonization and infection of both patients and healthcare personnel. The use of personal protective equipment (PPE) is an important strategy to protect healthcare personnel from contamination and to prevent the spread of pathogens to subsequent patients. However, optimal PPE use is difficult, and healthcare personnel may alter delivery of care because of the PPE. Here, we summarize recent research from the Prevention Epicenters Program on healthcare personnel contamination and improvement of the routine use of PPE as well as Ebola-specific PPE. Future efforts to optimize the use of PPE should include increasing adherence to protocols for PPE use, improving PPE design, and further research into the risks, benefits, and best practices of PPE use.

The discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: Impact upon patient adverse events and hospital operations

BACKGROUND

Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are a resource-intensive intervention to reduce healthcare-associated infections, potentially impeding patient throughput and limiting bed availability to isolate other contagious pathogens. We investigated the impact of the discontinuation of contact precautions (DcCP) for endemic MRSA and VRE on patient outcomes and operations metrics in an acute care setting.

METHODS

This is a retrospective, quasi-experimental analysis of the 12 months before and after DcCP for MRSA and VRE at an academic medical centre. The frequency for bed closures due to contact isolation was measured, and personal protective equipment (PPE) expenditures and patient satisfaction survey results were compared using the Wilcoxon signed-rank test. Using an interrupted time series design, emergency department (ED) admission wait times and rates of patient falls, pressure ulcers and nosocomial MRSA and VRE clinical isolates were compared using GEEs.

RESULTS

Prior to DcCP, bed closures for MRSA and/or VRE isolation were associated with estimated lost hospital charges of $9383 per 100 bed days (95% CI: 8447 to 10 318). No change in ED wait times or change in trend was observed following DcCP. There were significant reductions in monthly expenditures on gowns (-61.0%) and gloves (-16.3%). Patient satisfaction survey results remained stable. No significant changes in rates or trends were observed for patient falls or pressure ulcers. Incidence rates of nosocomial MRSA (1.58 (95% CI: 0.82 to 3.04)) and VRE (1.02 (95% CI: 0.82 to 1.27)) did not significantly change.

CONCLUSIONS

DcCP was associated with an increase in bed availability and revenue recovery, and a reduction in PPE expenditures. Benefits for other hospital operations metrics and patient outcomes were not identified.

Variation and trends in transmission dynamics of Methicillin-resistant Staphylococcus aureus in veterans affairs hospitals and nursing homes

Variation and differences of MRSA transmission within and between healthcare settings are not well understood. This variability is critical for understanding the potential impact of infection control interventions and could aid in the evaluation of future intervention strategies. We fit a Bayesian transmission model to detailed individual-level MRSA surveillance data from over 230 Veterans Affairs (VA) hospitals and nursing homes. Our approach disentangles the effects of potential confounders, including length of stay, admission prevalence, and clearance, estimating dynamic transmission model parameters and temporal trends. The median baseline transmission rate in hospitals was approximately four-fold higher than in nursing homes, and declined in 46% of hospitals and 9% of nursing homes, resulting in a median transmission rate reduction of 43% across hospitals and an increase of 2% in nursing homes. For first admissions into an acute care facility, the median (range) importation probability was 10.5% (5.9%–18.4%), and was nearly twice as large, 18.7% (9.2%–37.4%), in nursing homes. This analysis found differences within and between hospitals and nursing homes. The transmission rate declined substantially in hospitals and remained stable in nursing homes, while admission prevalence was considerably higher in nursing homes than in hospitals.

The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems

OBJECTIVE

To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside.

DATA SOURCES/STUDY SETTING

Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare.

STUDY DESIGN

Historical cohort study using data from admissions to VA hospitals between 2007 and 2012.

METHODS

We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates.

PRINCIPAL FINDINGS

Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs.

CONCLUSIONS

While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.

Patient contact is the main risk factor for vancomycin-resistant Enterococcus contamination of healthcare workers' gloves and gowns in the intensive care unit

OBJECTIVE

To determine which healthcare worker (HCW) roles and patient care activities are associated with acquisition of vancomycin-resistant Enterococcus (VRE) on HCW gloves or gowns after patient care, as a surrogate for transmission to other patients.

DESIGN

Prospective cohort study.

SETTING

Medical and surgical intensive care units at a tertiary-care academic institution.ParticipantsVRE-colonized patients on Contact Precautions and their HCWs.

METHODS

Overall, 94 VRE-colonized patients and 469 HCW-patient interactions were observed. Research staff recorded patient care activities and cultured HCW gloves and gowns for VRE before doffing and exiting patient room.

RESULTS

VRE were isolated from 71 of 469 HCWs' gloves or gowns (15%) following patient care. Occupational/physical therapists, patient care technicians, nurses, and physicians were more likely than environmental services workers and other HCWs to have contaminated gloves or gowns. Compared to touching the environment alone, the odds ratio (OR) for VRE contamination associated with touching both the patient (or objects in the immediate vicinity of the patient) and environment was 2.78 (95% confidence interval [CI], 0.99-0.77) and the OR associated with touching only the patient (or objects in the immediate vicinity) was 3.65 (95% CI, 1.17-11.41). Independent risk factors for transmission of VRE to HCWs were touching the patient's skin (OR, 2.18; 95% CI, 1.15-4.13) and transferring the patient into or out of bed (OR, 2.66; 95% CI, 1.15-6.43).

CONCLUSION

Patient contact is a major risk factor for HCW contamination and subsequent transmission. Interventions should prioritize contact precautions and hand hygiene for HCWs whose activities involve touching the patient.