Discontinuing Contact Precautions Research Articles

Nonsterile Glove Use

In acute care settings with low-risk of infection transmission, discontinuing contact precautions (i.e., gloves and gown) may result in similar rates of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) and may lower the risk of hospital-acquired vancomycin-resistant enterococci (VRE), compared to scenarios in which such precautions were employed. Rates of late-onset infections in a neonatal intensive care unit were similar when standard infection control precautions were used compared with universal glove use. Two guidelines recommend that nonsterile gloves should be worn for nonsterile procedures when it is anticipated that there will be contact with blood, body fluids, non-intact skin, mucous membranes, lesions, or hazardous drugs and chemicals; for environmental cleaning; and when contact precautions for infection control are in effect.

Discontinuing MRSA and VRE contact precautions: Defining hospital characteristics and infection prevention practices predicting safe de-escalation.

To define conditions in which contact precautions can be safely discontinued for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Interrupted time series. 15 acute-care hospitals. Inpatients. Contact precautions for endemic MRSA and VRE were discontinued in 12 intervention hospitals and continued at 3 nonintervention hospitals. Rates of MRSA and VRE healthcare-associated infections (HAIs) were collected for 12 months before and after. Trends in HAI rates were analyzed using Poisson regression. To predict conditions when contact precautions may be safely discontinued, selected baseline hospital characteristics and infection prevention practices were correlated with HAI rate changes, stratified by hospital. Aggregated HAI rates from intervention hospitals before and after discontinuation of contact precautions were 0.14 and 0.15 MRSA HAI per 1,000 patient days (P = .74), 0.05 and 0.05 VRE HAI per 1,000 patient days (P = .96), and 0.04 and 0.04 MRSA laboratory-identified (LabID) events per 100 admissions (P = .57). No statistically significant rate changes occurred between intervention and non-intervention hospitals. All successful hospitals had low baseline MRSA and VRE HAI rates and high hand hygiene adherence. We observed no correlations between rate changes after discontinuation and the assessed hospital characteristics and infection prevention factors, but the rate improved with higher proportion of semiprivate rooms (P = .04). Discontinuing contact precautions for MRSA/VRE did not result in increased HAI rates, suggesting that contact precautions can be safely removed from diverse hospitals, including community hospitals and those with lower proportions of private rooms. Good hand hygiene and low baseline HAI rates may be conditions permissive of safe removal of contact precautions.

Impact of discontinuing contact precautions and enforcement of basic hygiene measures on nosocomial vancomycin-resistant Enterococcus faecium transmission

Vancomycin-resistant Enterococcus faecium (VREfm) has emerged as a pathogen of major concern for public health. Although definitive evidence is lacking, contact precautions have been a crucial element in infection prevention and control (IPC) strategies designed to limit nosocomial VRE transmission. This study investigated the effect of discontinuing contact precautions while enforcing basic hygiene measures, including hand hygiene, environmental cleaning and antiseptic body washing, for patients with VRE in intensive care units (ICUs) on the prevention of nosocomial VRE transmission causing bacteraemia. Contact precautions were discontinued in January 2018. In total, 96 VREfm isolates from 61 patients with VREfm bacteraemia and/or colonization hospitalized in eight ICUs in a tertiary care hospital in 2016 and 2019 in were characterized by whole-genome sequencing. VRE transmission was investigated using patient movement data and admission screening for reliable identification of nosocomial acquisition. Discontinuation of contact precautions did not increase VREfm transmission events (eight in 2016 vs one in 2019). While the rate of endogenous VREfm was similar in both years (38% vs 31%), the number of non-colonized patients prior to VREfm bacteraemia was 16 (16/29, 55%) in 2019, which was significantly higher than in 2016 (8/32, 25%). The mean incidence density for VREfm bacteraemia was similar for both years (0.26 vs 0.31 per 1000 patient-days in 2016 and 2019, respectively). Discontinuation of contact precautions while enforcing basic hygiene measures did not lead to an increase in nosocomial bloodstream infection rates due to VREfm transmission in a hyperendemic ICU setting.

Duration of carbapenemase-producing Enterobacteriales carriage among ICU patients in Miami, FL: A retrospective cohort study

Current recommendations by the Centers for Disease Control and Prevention suggest placing patients with carbapenem-producing Enterobacteriales (CPE) in contact precautions, but there is no consensus on the appropriate duration of precautions. We aimed to evaluate predictors for prolonged CPE carriage and median clearance time. Patients with first isolated CPE identified from 2012-2016 were followed for clearance of CPE using at least two rectal or tracheal aspirate surveillance cultures and clinical cultures during intensive-care-unit admission. Predictors associated with prolonged CPE carriage were assessed using Cox proportional-hazards. Out of 75 eligible patients, 25 (33%) cleared their CPE-carrier status; median time to clearance was 80 days (Range, 16-457). Patients who were immunocompromised, had mechanical ventilation exposure, or exposure to carbapenems had 66%, 66%, and 86% (HR, 0.34, 0.34, and 0.14, respectively [P-value <.05]) lower probability of clearing compared to those immunocompetent of without such exposures. Patients with CPE isolated from more than one body site had a 5.3 times higher probability of clearing their CPE-carrier status (P-value <.001). Patients immunocompromised, with mechanical ventilation exposure, or exposure to carbapenems had higher risk for prolonged CPE carriage. Infection prevention programs should consider these predictors as part of their assessment of discontinuing contact precautions among CPE carriers to prevent horizontal transmission and outbreaks within healthcare facilities.

Taking off the gown: Impact of discontinuing contact precautions for extended-spectrum β-lactamase (ESBL)-producing organisms.

Contact precautions are used to prevent the spread of extended-spectrum β-lactamase (ESBL)-producing organisms in acute-care hospitals, but supporting data are lacking. We discontinued such precautions for ESBL Escherichia coli and Klebsiella spp and found no increased prevalence of these organisms with our change in practice.

Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None

Discontinuing Contact Precautions for Vancomycin-Resistant Enterococcus (VRE) Is Associated With Rising VRE Bloodstream Infection Rates in Ontario Hospitals, 2009-2018: A Quasi-experimental Study.

In Ontario, Canada, since 2012, some hospitals discontinued contact precautions for vancomycin-resistant Enterococcus (VRE). Between 2009 and 2018, there was an associated rise in VRE bloodstream infections in hospitals where contact precautions were discontinued but not in hospitals that maintained contact precautions. These data suggest contact precautions are important for hospital VRE control programs.

527. Project “Isolation Zero”: Discontinuing Contact Precautions for Patients Colonized/Infected with Multidrug-Resistant Organisms through Community-Level Follow-Up in Spain

BackgroundIn an effort to prevent and control the spread of multidrug-resistant organisms (MDROs), hospitals implement contact precautions (CP) for patients colonized/infected with MDROs. All agencies related to the prevention and control of infections recommend this practice, but they also recognize that is not exempt from unintended consequences. In 2017, SHEA published an expert guideline where they provide recommendations for discontinuation of CP. Currently, the most accepted recommendation is to perform at least one microbiological culture prior to discontinuing CP. The main objective of this project is to implement and evaluate a novel community -level approach to safely discontinue CP in patients with a history of colonization/infection with an MDRO.MethodsThe “Isolation Zero” project (IZ) was rolled out in November 2018 in the healthcare area of A Coruña, Spain. All clinical records of patients included in the MDROs alert system between 2005–2012 in A Coruña were reviewed. Patients included in the study were those who reside in the healthcare area of A Coruña and did not have any positive microbiological culture for MDROs in the last 2 years (Figure 1). Those who met the inclusion criteria were sent a letter suggesting that they obtain a nurse consultation in the next 2 months and that they provide specific MDRO cultures (Figure 2). Finally, the Department of Preventive Medicine (PM) reviewed all the results and identified patients for which CP could be safely discontinued in future hospitalizations.ResultsA total of 792 clinical records were reviewed (Table 1). 184 patients met the inclusion criteria. The response rate was 60.3% (111 patients). The most frequent MDRO tested was MRSA (84.8%), followed by MDR Acinetobacter (7.6%). CP were withdrawn for a total of 83 patients, while 15 patients continued to test positive (Table 2).ConclusionThese results suggest that even after more than 2 years without a positive result, 13,5% of patients remain positive for MDROs. Therefore, in order to safely minimize the use of CP, we conclude that an approach similar to that used in IZ is a good option for PM Departments. Follow-up at the community -level can help reduce the number of hospital isolations required and can help improve the overall quality of care. Disclosures All authors: No reported disclosures.

The impact of discontinuing contact precautions for multidrug resistant organisms at a less than 400-bed level II teaching hospital and a community hospital: A 3-month pilot study

The impact of discontinuing contact precautions (CPs) for patients with select multidrug-resistant organisms on bacteremia infection rates was evaluated in this quality improvement project. The removal of use of CPs, with increased focus on standard precautions, for all patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization/infection was piloted via a quality improvement project over a 3-month period. CP was discontinued in December 2018. Comparing 3 months pre- and postchange, the overall incidence density rate decreased for hospital-onset (HO) laboratory-identified (LabID) MRSA bacteremia (0.07 vs 0.02; P = .52), whereas HO LabID VRE bacteremia rates remained the same (0.00 vs 0.00). Overall estimated financial savings, including personal protective equipment ($15,375) and staff time ($17,165), was $32,540 for the project period, with annualized estimated savings of $130,160. In this pilot study evaluating the discontinuance of CPs, there was no evidence of an increase in HO MRSA or VRE LabID bacteremia incidence density rates. This practice change may be safely implemented at similar health care facilities.

Impact of discontinuing contact precautions against vancomycin resistant Enterococcus: Multicenter study in Argentina

Background: Contact precautions (CP) are widely recommended to prevent multidrug-resistant organism (MDRO) transmission avoiding colonization and infection. However, conflicting data exist regarding their effectiveness. Recent studies suggest that for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococcus (VRE), standard measures and decolonization for MRSA could be effective. In Argentina there is no formal recommendation, however, most centers implement CP and only a few discontinue them. Our purpose is to evaluate the impact on the EVR infections after discontinuing CP in centers located in Buenos Aires. Methods & Materials: Multicenter, retrospective, quasi-experimental study of patients admitted to acute care facilities in Buenos Aires. We included centers that perform health care associated infections surveillance according to NHSN definitions and discontinued CP for more than 1 year. The CP included the use of gloves, gowns, personnel items or their subsequent disinfection and individual or cohort rooms. EVR infection was defined as the presence of signs and symptoms associated with EVR isolation in clinical samples 48 hours after admission. We compared the number of cases of VRE infections/1000 discharges 1 year before and after discontinuing CP. P 0 .05 was considered statistically significant. During the study, CP were continued for other MDRO (MRSA, multidrug resistant gram-negative bacilli and Clostridium difficile) in addition with the hand hygiene program. Results: Five institutions were included (4 tertiary acute care University Private - 1 Public), 4 polyvalent. Total beds 1308, only 2 centers have shared rooms. One institution reported UCI data. In the preintervention period occurred 27 infections / 61099 discharges (rate 0.44 / 1000 discharges), after CP discontinuation there were 32 infections / 61668 discharges (rate 0.52 / 1000 discharges) (p0.62). The average adherence to hand hygiene in the initial period was 58% and post-intervention 66%. Conclusion: This experience, in different centers, shows that discontinuation of CP was not associated with a significant increase of VRE infections and should be accompanied by cross-sectional measures such as Hand Hygiene. The prevalence of different MDRO infections should be considered to evaluate the cost effectiveness of CP.

Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis.

Single-center, quasi-experimental study conducted between 2011 and 2016.METHODSWe employed an interrupted time series design to evaluate the impact of 7 horizontal infection prevention interventions across intensive care units (ICUs) and hospital wards at an 865-bed urban, academic medical center. These interventions included (1) implementation of a urinary catheter bundle in January 2011, (2) chlorhexidine gluconate (CHG) perineal care outside ICUs in June 2011, (3) hospital-wide CHG bathing outside of ICUs in March 2012, (4) discontinuation of contact precautions in April 2013 for MRSA and VRE, (5) assessments and feedback with bare below the elbows (BBE) and contact precautions in August 2014, (6) implementation of an ultraviolet-C disinfection robot in March 2015, and (7) 72-hour automatic urinary catheter discontinuation orders in March 2016. Segmented regression modeling was performed to assess the changes in the infection rates attributable to the interventions.RESULTSThe rate of HAI declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 (P=.76) and 6.25 (P=.21) per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days (P=.23) for device-associated HAI following discontinuation of contact precautions.CONCLUSIONThe discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. This approach may represent a safe and cost-effective strategy for managing these patients.Infect Control Hosp Epidemiol 2018;39:676-682.

Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis

Several single-center studies have suggested that eliminating contact precautions (CPs) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) control in nonoutbreak settings has no impact on infection rates. We performed a systematic literature review and meta-analysis on the impact of discontinuing contact precautions in the acute care setting. We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Embase through December 2016 for studies evaluating discontinuation of contact precautions for multidrug-resistant organisms. We used random-effect models to obtain pooled risk ratio estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled risk ratios for MRSA and VRE were assessed separately. Fourteen studies met inclusion criteria and were included in the final review. Six studies discontinued CPs for both MRSA and VRE, 3 for MRSA only, 2 for VRE only, 2 for extended-spectrum β-lactamase-producing Escherichia coli, and 1 for Clostridium difficile infection. When study results were pooled, there was a trend toward reduction of MRSA infection after discontinuing CPs (pooled risk ratio, 0.84; 95% confidence interval, 0.70-1.02; P = .07) and a statistically significant reduction in VRE infection (pooled risk ratio, 0.82; 95% confidence interval, 0.72-0.94; P = .005). Discontinuation of CPs for MRSA and VRE has not been associated with increased infection rates.

Transmissibility of Clostridium difficile Without Contact Isolation: Results From a Prospective Observational Study With 451 Patients.

Contact precautions are recommended by health authorities in Europe and the United States for patients with Clostridium difficile infection (CDI). Recently, the significance of nosocomial transmission has been challenged by screening on admission studies and whole-genome sequencing, providing evidence for an endogenous source of C. difficile. We discontinued contact precautions for patients with CDI, except for patients infected with hypervirulent ribotypes or with stool incontinence, to determine the rate of transmission. From January 2004 to December 2013, contacts of each index case with CDI were screened for toxigenic C. difficile by culturing rectal swabs. Transmission was defined as possible if toxigenic C. difficile was detected in contacts, as probable if the identical polymerase chain reaction ribotype was identified in index–contact pairs, and as confirmed if next-generation sequencing (NGS) revealed clonality of strains. Four hundred fifty-one contacts were exposed to 279 index patients nursed in 2-to 4-bed rooms. Toxigenic C. difficile was detected in 6.0% (27/451) after a median contact time of 5 days. Identical ribotypes were identified in 6 index–contact pairs, accounting for probable transmission in 1.3% (6/451). NGS was performed for 4 of 6 pairs with identical strains, and confirmed transmission in 2 contact patients. The rate of transmission of toxigenic, predominantly nonhypervirulent C. difficile, was low and no outbreaks were recorded over a 10-year period after discontinuing contact precautions for patients with CDI who were not severely incontinent and who used dedicated toilets. As contact precautions may lead to lower levels of care, their implementation needs to be balanced against the risk of nosocomial transmission.

Hospital based clearance of patients with skin and soft tissue methicillin resistant Staphylococcus aureus (MRSA): A systematic review of the literature

Objectives To systematically review the reported processes associated with hospital based screening and subsequent clearance of patients diagnosed with skin or soft tissue infection (SSTI) associated with methicillin-resistant Staphylococcus aureus (MRSA). Methods A systematic review of published and grey literature following the guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), between 2000 and 2015. Results The electronic search identified 1128 citations using CINAHL, Medline and the Cochrane library databases from which relevant studies were selected for review. The potential relevance for SSTI MRSA clearance was further evaluated and 1066 citations were excluded. The remaining 62 full text articles were reviewed with 10 meeting the primary inclusion discussing MRSA clearance (n = 9204 patient numbers). Of the ten full articles, intervention techniques employed for MRSA clearance swabbing included five studies employing Agar culture swabs, one using only polymerase chain reaction (PCR) swabbing, and three studies analysed both types of swabbing techniques. Nine articles were retrospective qualitative studies with evidence hierarchy III and IV, while one study was a randomised control trial (RCT) with evidence hierarchy II [1]. All of the articles reported using selective screening programs targeting SSTI of MRSA patients, however there was no consistency identified between MRSA screening techniques. Conclusion Current literature utilising SSTI MRSA clearance process delivers no irrefutable recommendations or guidelines for consistent and effective SSTI MRSA clearance procedures. The Australian Guidelines for the Prevention and Control of Infection in Healthcare [2] provides guidelines for the processes involved in patient MRSA clearance and discontinuing contact precautions (CP), however there is variability within individual Australian State interpretation of the guidelines and State managed infection control practices. To reduce cost associated with CP and prevent adverse events for patients, further studies are required to identify best practice in regards to SSTI MRSA clearance techniques, such as the swabbing process or the scheduling of the swabs.

The Impact of Discontinuing Contact Precautions for VRE and MRSA on Device-Associated Infections.

The impact of discontinuing contact precautions for patients with MRSA and VRE colonization/infection on device-associated hospital-acquired infection rates at an academic medical center was investigated in this before-and-after study. In the setting of a strong horizontal infection prevention platform, discontinuation of contact precautions had no impact on device-associated hospital-acquired infection rates.

"Bringing down the flag": removing the contact precautions label for non-hospitalized patients with prior methicillin-resistant Staphylococcus aureus infection or colonization.

A policy consensus has not been reached regarding discontinuing contact precautions in patients with a history of methicillin-resistant Staphylococcus aureus (MRSA). We found that as many as 72% of outpatients flagged for past MRSA were no longer carriers, and a single nasal PCR test provided a reasonable negative predictive value for removing contact precautions.