Abstract
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. To estimate the association between contact precautions and transmission of methicillin-resistant Staphylococcus aureus (MRSA) across US Department of Veterans Affairs (VA) hospitals. 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. A positive MRSA test result, presumed to indicate contact precautions use according to the VA MRSA Prevention Initiative. 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. 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. 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.
Highlights
Antibiotic-resistant pathogens are a serious public health concern, and the association between the coronavirus disease 2019 pandemic and personal protective equipment supply availability has strained infection control programs across the country
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%)
In this cohort study of adults in Veterans Affairs (VA) hospitals, transmissibility of methicillin-resistant Staphylococcus aureus (MRSA) was found to be reduced by approximately 50% among patients with contact precautions
Summary
Antibiotic-resistant pathogens are a serious public health concern, and the association between the coronavirus disease 2019 pandemic and personal protective equipment supply availability has strained infection control programs across the country. The Centers for Disease Control and Prevention (CDC) released updated guidelines recommending use of gloves and gowns when caring for all patients infected or previously identified as colonized with target antibioticresistant bacteria.[10] In October 2007, the US Department of Veterans Affairs (VA) implemented a MRSA Prevention Initiative in all hospitals. The initiative included 4 elements: (1) universal surveillance for MRSA colonization; (2) contact precautions for patients identified as carriers of MRSA; (3) an emphasis on hand hygiene; and (4) an institutional culture change that placed responsibility for infection control on everyone with patient contact.[4] Implementation of these guidelines, which have been recommended by the CDC as recently as July 2019,11 provides a natural context for assessing the effectiveness of contact precautions across a large and geographically diverse population of hospitals
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