1. Myers, Frank Edward III, MA, CIC

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Since the beginning of early medication, precautions against infectious diseases existed, including the "leper bell," or later the quarantine of those with smallpox. Infectious disease precautions, although never 100% effective, have remained a cornerstone of containing and reducing the spread of contagious pathogens. As the understanding of how diseases are spread has increased, the precautions have become more refined and less severe for the patient, as well as more reflective of the modes of transmission.

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Several recent papers have further redefined how the infection prevention community is thinking about contact precautions, specifically around the issues of methicillin-resistant Staphylococcus aureus (MRSA). Contact precautions have long been known to have a negative impact on the patients placed in them and the facilities utilizing them. Papers have shown contact precautions are associated with less direct care provided to the patient, greater chances of medication errors and injuries, and a greater chance of patient depression.1,2 Additionally, the costs of increased gown and glove usage have been noteworthy.3


Today, the decreased patient satisfaction scores associated with being in contact precautions could add real costs to an institution's bottom line because of Value-Based Purchasing.4 Some attempts to mitigate these costs, such as red lines on a patient's floor, have reduced spending, but these interventions were never measured for their impact on compliance or maintenance rates of the pathogens. Additionally, and ironically, some small unpublished studies have suggested that cleaning in contact precaution rooms may be inferior to that in noncontact precaution rooms possibly because of environmental service employees' fears of the pathogens.


Taking precaution

Despite the identified negative impact of contact precautions on the patient experience, its use has exploded over the past 20 years. The reason for this is multifactorial. First, certain pathogens exploded in its prevalence. A MRSA epidemic took off, driven not by increased transmission in acute care facilities but from transmission in the community. The strain that became epidemic hadn't "escaped" hospitals but had always been a community strain. Second, an epidemic of Clostridium difficile and multidrug-resistant Gram-negative infections took off and these were driven largely by acute care facility acquisition. Third, no science was identified that allowed institutions to determine when it was appropriate to discontinue precautions because the patient was no longer colonized and couldn't act as a reservoir for infection. Fourth, in response to the growing MRSA epidemic that some incorrectly assumed was driven by acute care facilities, legislation was introduced in a number of states mandating that a "search and destroy" approach for MRSA be developed. This approach identified more colonized patients with MRSA and caused an even greater percentage of patient's being placed on contact precautions.


New research

With a greater percentage of patients being placed on contact precautions, a team of researchers decided to test the hypothesis that actively finding patients colonized and infected with MRSA and placing them on contact precautions was the best approach to reducing MRSA.5 The researchers did a large multifacility study where some patients were only tested for MRSA colonization, another group was tested for MRSA and given chlorhexidine gluconate (CHG) baths and mupirocin for decolonization, and the third group was never screened for MRSA but were given decolonization and CHG baths regardless of their MRSA status. The last group still used contact precautions for known MRSA patients, but because researchers weren't looking for MRSA as aggressively as in the other two arms of the study, there were fewer patients on precautions.


The study arm with the fewest patients on contact precautions had the greatest reduction of MRSA transmission. Simply put, bathing patients and reducing nasal colonization appeared to be more effective than searching for MRSA patients and putting them on precautions, or searching for MRSA patients and attempting to decolonize the ones identified, and then placing them on contact precautions. This finding wasn't entirely surprising to some who had argued that (1) finding MRSA-colonized patients is very difficult as some have nasal colonization, perirectal, axillary, or other body regions. This makes the sensitivity of screening for MRSA poor. (2) More general approaches to controlling all infections tend to have a better yield than narrow targeted approaches. Given the difficulty in finding MRSA patients, a holistic approach to its control would be more effective.6 (3) CHG bathing reduced a number of infections and its gain in reducing MRSA and other infections could be easily extrapolated from the literature.7 This refocus on basic patient hygiene may also improve patient satisfaction scores.


This single paper reversed the argument, largely quelling the "search and destroy" believers with its inherent increase in the use of contact precautions. Nevertheless, because state mandates for active surveillance for MRSA weren't reversed, C. difficile and multidrug-resistant Gram-negative rates weren't dropping; in some cases, the rates were increasing and more patients were being placed on contact precautions.


Reaching the tipping point

A second study was published in the last year suggesting this growth in the percentage of patients on contact precautions may have a "tipping point;" that is, a point where contact precautions fail to be effective. To understand this, one needs to understand that contact precautions are a reminder to follow standard precautions. MRSA is transmitted no differently than methicillin-sensitive Staphylococcus aureus (MSSA), yet, for one, contact precautions are used and for the other standard precautions are used. Why? Because the implications of failing to follow standard precautions and allowing transmission of MRSA are much greater than MSSA, which means that following contact precautions will likely ensure compliance with standard precautions. But if all of your patients are on contact precautions, then effectiveness may degrade.


That was the question posited in the article "Contact Precautions, More Is Not Necessarily Better."8 The authors of this study looked at various percentages of patients being placed on contact precautions and concluded that once 40% or more of the patients were on contact precautions, compliance with those precautions degraded substantially. So although the cost to an institution of placing more of its patients on contact precautions increased due to material costs and patient satisfaction scores, the precautions were becoming less effective.


Institutions have reached a decision point. How best to maintain contact precautions for organisms whose control is essential, such as emerging pathogens, while not overusing contact precautions to the point where they're ineffective and it degrades the control of all critical pathogens. For those institutions that aren't mandated by regulatory bodies to conduct active surveillance for MRSA, the choice appears to be clear: abandon a "search and destroy" method for MRSA for adults and focus instead on basic patient hygiene with CHG bathing. Some facilities, such as the University of California, San Francisco, abandoned contact precautions for MRSA many years ago and reported no increase in MRSA transmission. Instead, the organization reaped the benefits of lower gown and glove costs and higher patient satisfaction.




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