Contact Precautions for Resistant Organisms

To evaluate if discontinuing systematic VRE surveillance and contact isolation of colonized patients affects the incidence of vancomycin-resistant enterococcus (VRE) faecium bacteremia

• N = 2,319   
• AGE = 5–94 years
• MALES: 58/59%, FEMALES: 42/41%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Hematologic malignancies: leukemia, lymphoma, BMT
• OTHER KEY SAMPLE CHARACTERISTICS: Underlying malignancies were ALL/AML, CML/MDS/MPD, HL/NHL/CLL, and plasma cell malignancies. No significant differences existed in either group.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Buffalo, NY

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Pediatrics, elder care, palliative care

Prospective nonrandomized observational study comparing the incidence of VRE faecium bacteremia in colonized patients with hematologic malignancies during the period of active surveillance/contact precautions versus no active surveillance/contact precautions

Comparing study periods, no significant difference existed in incidence of VRE bacteremia, MRSA bacteremia, and C-diff. Antibiotic utilization was not significantly different between study periods. Levofloxacin prophylaxis had no affect on the incidence of VRE bacteremia. Daily chlorhexidine bathing showed no effect on VRE colonization/bacteremia. No significant difference existed in aggregate antibiotic use and incidence of bacteremia ≤ 30 days prior between study periods. Nursing hours/patient day was not significantly different during study periods. No significant difference existed in patient demographics, patients per service, or underlying hematologic malignancies between study groups/periods.

In a single-site institution (with sporadic molecular epidemiology of VRE faecium in patients with hematologic malignancies), the incidence of VRE faecium bacteremia was not significantly different comparing study periods—active surveillance/contact precaution per institutional policy and after discontinuation of policy. Incidence of MRSA bacteremia and C-Diff remained stable.

• Baseline sample/group differences of import
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• Single-site study
• Only hematologic malignancies, not generalizable to other cancer types
• Predictive ability limited because of different sequential groups rather than the same group with time matched controls
• Nursing hours/day does not clearly estimate care burden/nurse/patient ratio
• Rates of colonization comparing groups not provided
• Treatment phase or types not collected comparing groups
• Lack of data on compliance with hand hygiene and lack of molecular epidemiologic data on VRE isolates from the second study period
• Role of active surveillance and contact precautions was not examined in clonal outbreaks, so the study may not be applicable to other patient populations with cancer or in outbreaks with different molecular data

A single-site study revealed that VRE bacteremia incidence in hematologic malignancy inpatients was not affected by VRE surveillance/contact precautions. Nursing practice measured as hours/patient day was not an effective measure for influencing nursing-sensitive infection-related outcomes. Larger multisite trials that include nursing-sensitive measures are needed to identify the most effective practices essential to prevent/control VRE bacteremia in high-risk patients.

To evaluate the effectiveness of implementing the new methicillin-resistant Staphylococcus aureus (MRSA) control measures in a tertiary care unit in Japan

The study was conducted in Japan, where the rate of MRSA was the second highest in the Asia-Pacific region—69.5%—in 2002. Although Japan was following infection control practices, the rate was not going down because its survey for the incidence of MRSA was not standardized. In 2003, according to the Society for Healthcare Epidemiology of America (SHEA), Japan started to strictly follow the evidence-based infection control guidelines, which included wearing gowns, masks, and gloves, in addition to implementing contact isolation in a separate room and conducting nasal swab cultures for colonization before discontinuing isolation. Two basic metrics also have been included to conduct surveys on the basis of SHEA and the Infection Control Practices Advisory Committee. To conduct this study, the authors have reviewed patients' data from January 2003–December 2010.

• N = 1,000
• AGE: No specific age noted
• MALES, FEMALES: Not noted
• KEY DISEASE CHARACTERISTICS: MRSA

• SITE: Single site           
• SETTING TYPE: Inpatient           
• LOCATION: Tertiary care center in Japan

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

• Quasi-experimental cohort study conducted to evaluate the changes of MRSA incidence and MRSA bloodstream infection (BSI) incidence after implementation of the infection control practices in the tertiary care center

•  SAS (version 9.2)

The study showed a significant reduction in MRSA infection or colonization and MRSA BSI (p < .0001) after strongly implementing the new infection control practices in the tertiary setting.

This was the first study conducted at a tertiary level in Japan. It was based on the evidence based-practice showing a significant reduction in MRSA spread and MRSA infection burden, which was proved after strictly following the new practices of MRSA control, including isolating the patient. Through this study, the authors also standardized in discontinuing the isolation of MRSA patients based on SHEA and the Infection Control Practices Advisory Committee.

• Measurement/methods not well described
• Measurement validity/reliability questionable
• Other limitations/explanation: This study implemented multifaceted interventions, and defining the relative effect of each intervention is impossible. The test used is only able to detect the outcomes and cannot detect changes in trends.

Nurses play an important role in implementing infection control practices, as nurses are the one who come into contact with patients first. Nurses can follow these guidelines and also advise other healthcare workers to do the same.

To examine infection measures to reduce the transmission of vancomycin-resistant enterococci (VRE).

VRE cultures were obtained from all 259 patients (100%) in 404 admissions to the unit during the use of enhanced infection control strategies and 167 of 184 patients (91%) in 210 admissions to the unit during the use of standard infection control practices.

Enhanced Infection Control

1. Inpatient surveillance: perianal cultures on admission and weekly
2. Hand washing before and after patient contact
3. Contact isolation for VRE-colonized and VRE-infected patients
4. Gown and glove use on entry of rooms of VRE-colonized and ​VRE-infected patients
5. Consultation with infectious disease specialists when infection is first suspected
6. Systematic recommendation by infectious disease specialists to discontinue empirical vancomycin use after 72 hours
7. Systematic recommendation by infectious disease specialists to use oral metronidazole rather than oral vancomycin for Clostridium difficile colitis
8. Spatial separation of patients into three cohorts: VRE-positive, VRE-negative, and VRE-unknown patients
9. Surveillance of perianal cultures taken for inpatients with cancer housed off the oncology unit
10. Gown and glove use on entry of rooms of VRE-unknown patients
11. Assignment of staff cohorts; nurses and nursing assistants assigned to VRE-positive patients or VRE-negative and VRE-unknown patients
12. Patient orientation about VRE with an explanatory brochure
13. Monitoring compliance by observational studies
14. Environmental cultures taken in VRE-positive patient rooms before and after patient discharge and room disinfection

Patients were evaluated during the use of enhanced infection control strategies (n = 259) and standard infection control practices (n = 184).

Eleven-room, 22-bed adult oncology unit in a 650-bed tertiary care hospital

This was a prospective cohort study.

Standard infection control versus enhanced infection control:

• VRE infection rates
• Colonization
• Changes in antimicrobial use.

• VRE colonization was significantly reduced: 8.6 patients per 1,000 days versus 13.2 patients per 1,000 days
• Compliance with enhanced strategies: 91.7% of individuals who entered rooms wore gowns and gloves
• Enhanced infection control strategies: The incidence of VRE bloodstream infections decreased significantly (1.4 patients per 1,000 days versus 3.2 patients per 1,000 days for the standard group).

• No conceptual model was described.
• Single unit where patients were not transferred
• No randomization
• Fifteen infection control measures were implemented simultaneously; therefore, the influence of each intervention is unknown.

There is an emerging problem of growing multi-drug resistant gram-negative rods (MDR-GNRs), and rapid and sensitive detection is difficult. There is no consensus regarding the list of drug-resistant bacteria to target for infection control and infection control policies for multi-drug resistant gram-negative organisms (DR-GNRs) often lack strong evidence to identify the minimum interventions needed to reduce their transmission. The authors were trying to determine if horizontal transmission can be prevented by detecting and appropriately controlling targeted drug-resistant bacilli before they acquire resistance.

In January 2005, a prevention policy against MDR-GNR infection was implemented. After isolating strains that met the defined criteria, contact precautions were implemented. Active interventions, including approval for specific antibiotics prior to use and regulating the prescription of certain antimicrobials, were not applied. The preintervention period (January 1, 2003 to December 31, 2004) was compared to intervention period (January 1, 2005 to December 31, 2010).

• N = 1,287,296 total inpatient days
• OTHER KEY SAMPLE CHARACTERISTICS: No exclusion criteria; active sampling from asymptomatic patients was not conducted; data included dates of detection, types of culture samples, inpatient or outpatient status, names of the detected strains, and results of susceptibility testing; inpatient days of care were defined as the sum of each daily inpatient census for the month

• SITE: Single site    
• SETTING TYPE: Multiple settings    
• LOCATION: Shizuoka Cancer Center, Nagakute, Aichi, Japan

• PHASE OF CARE: Multiple phases of care

Retrospective study (pre- and postintervention) based on the examination of a bacterial testing database

MDR-GNRs were defined as gram-negative bacilli that were insensitive to at least three of the specified classes of antimicrobials, metallo-beta-lactamase-producing bacilli, and extended spectrum beta-lactamase (ESBL)-producing bacilli. Strains of MDR-GNRs were isolated at least 48 hours after admission, and only newly detected stains were included and excluded cases in which the same strain was later detected in the same patients. Each species was included if multiple strains were isolated from the same patients.

The overall incidence density rate of all multi-drug resistant nonfermenting gram-negative bacilli over the eight-year study period (2003–2010) was 0.31 per 10,000 patient days. Rates did not increase significantly between the preintervention period (0.15 per 10,000 days) and the intervention period (0.35 per 10,000 days). The overall incidence rate of MDR enterobacteriaceae infections was 0.49 per 10,000 days. However, the preintervention period was 0.19 per 10,000 days, and the intervention was 0.56 per 10,000 days, representing a statistically significant decrease.

The study increased the detection of enterobacteriaceae bacteria with an increase in ESBL-producing organisms, but no significant change in detection rate of MDR non-glucose-fermenting bacilli was found. Contact precautions were implemented to limit the emergence of MDR-gram negative bacilli, but the efficacy of these policies was deemed uncertain.

• Retrospective study
• No active surveillance of asymptomatic patients
• Incidence measurements based solely on clinical cultures and may be insufficiently sensitive because asymptomatic patients may have been missed

MDR-GNRs are an emerging worldwide problem. Nurses have a significant responsibility to ensure proper precautions are taken as quickly as possible when these organisms are detected. Nurses should ensure that the patient is properly educated, but more importantly, should implement contact precautions and ensure that other healthcare providers are following these precautions. 

To evaluate the role of a multi-faceted infection control policy in decreasing the transmission of vancomycin-resistant enterococci (VRE).

A surveillance program was initiated. The use of empirical vancomycin was limited in patients with febrile neutropenia to four specific situations.

Infection control staff monitored isolation practices and educated staff and visitors.

• Tertiary hospital treating patients with cancer
• Cancer center with 417 beds

This was a prospective cohort study.

The total incidence of VRE infections declined from 0.437 in 1,000 patient days to 0.229 in 1,000 patient days.

• No conceptual model was described.
• Several measures were initiated at the same time.
• Limited to one institution
• Initiated after an outbreak
• Multiple strategies were used at once; therefore, determining which was most the effective in preventing transmission was difficult.

To determine whether cover gowns in addition to gloves decrease the nosocomial transmission of vancomycin-resistant enterococci (VRE) in an intensive care unit.

• Current practice studied first: gown and nonsterile, disposable gloves. Change in practice studied: gloves only.
• Private rooms and hand washing signs
• Equipment, such as blood pressure cuffs, thermometers, and stethoscope, dedicated to the patient

• Mean patient age was 54.6 years (SD = 16.2).
• Patients with at least two perirectal cultures
• For the gown and gloves study period, 141 patients (with 64 patients colonized on admission) were enrolled for 895 days.
• For the gloves only group, mean age was 55 years (SD = 15.1), and 173 patients (with 71 colonized) were enrolled for 945 days.

Medical intensive care unit (teaching hospital)

This was a prospective study.

Gown and Gloves

• 22% (11 of 49) of patients at risk developed VRE
• Acquisition rate: 1.80 cases per 100 days
• 23% of patients’ admission cultures grew VRE

Gloves Only

• 22% (21 of 51) of patients at risk developed VRE
• Acquisition rate: 3.78 cases per 100 days
• 20% of patients' admission cultures grew VRE

• Length of stay was a risk factor.
• No conceptual model was described.