Use of contact precautions by healthcare workers for all ICU patient contact did not reduce the combined incidence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus, although there was a lower risk of MRSA acquisition alone, according to a study.
Antibiotic resistance is associated with considerable illness, death and costs, and MRSA and VRE are primary causes of healthcare-associated infections, according to background information in the study, which was published Oct. 4 on the website of the Journal of the American Medical Association and presented at IDWeek 2013 in San Francisco.
The estimated cost of antibiotic resistance in the United States is more than $4 billion per year, the study authors wrote. Healthcare-associated infections are the most common complication of hospital care, affecting an estimated one in every 20 inpatients. Numerous studies have shown that healthcare workers acquire bacteria on their hands and clothing by touching patients.
The CDC recommends use of contact precautions when caring for patients colonized or infected with antibiotic-resistant bacteria. However, colonization with MRSA, VRE or other antibiotic-resistant bacteria often is not detected and contact precautions, therefore, are not applied. It has not been known whether wearing gloves and gowns for all patient contact, not just for patients with known colonization, decreases acquisition of antibiotic-resistant bacteria in the ICU.
Study methodology and results
Anthony D. Harris, MD, MPH, of the University of Maryland School of Medicine in Baltimore, and colleagues assessed whether wearing gloves and gowns for all patient contact in the ICU compared with the use of contact precautions only for patients with known antibiotic-resistant bacteria reduces acquisition rates of MRSA and VRE.
The randomized trial was conducted in ICUs in 20 U.S. hospitals from January 2012 to October 2012. In the intervention ICUs, all healthcare workers were required to wear gloves and gowns for all patient contact and when entering any patient room. The primary outcome was acquisition of MRSA or VRE based on surveillance cultures (92,241 swabs) collected on admission and ICU discharge from 26,180 patients.
The researchers found a decrease in both the intervention and control ICUs in the composite rate of MRSA or VRE acquisition over the study periods, but the difference in change was not statistically significant. There was a borderline statistically significant reduction in MRSA that was greater in the intervention group, according to the news release.
The intervention did not reduce VRE acquisition, but did reduce MRSA acquisition, the authors thus wrote. Better hand hygiene compliance on room exit occurred in the intervention ICUs. The intervention led to fewer healthcare worker-patient visits and did not increase the frequency of adverse events.
Preeti N. Malani, MD, MSJ, of the University of Michigan Health System and Veteran Affairs Ann Arbor Healthcare System, wrote that although the study results failed to demonstrate an overall benefit of universal use of gloves and gowns to reduce acquisition of MRSA or VRE, this approach may be worth considering in some high-risk settings such as surgical ICUs, wherein MRSA transmission is high among patients with newly implanted medical devices.
If implemented, gloving and gowning should be just part of an overall strategy that includes efforts to optimize hand hygiene and prudent use of antimicrobials. Although it is appealing to believe there is a simple approach to what should and should not be done to prevent infection in the ICU, best practices are more nuanced and unfortunately one size does not fit all.
The final approach must be adapted to fit the epidemiology of specific ICUs and should also consider the type of resources available. The study by Harris et al serves as a poignant reminder that many questions remain for what constitutes best practice in the care of critically ill patients. Ongoing investment in these sorts of resource-intensive trials is essential for continued progress.