Contact precautions are recommended by the Centers for Disease Control and Prevention (CDC) for all patients known to be infected with or carrying multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Yet, the use of contact precautions--which require a patient to be isolated in a single hospital room and health care providers to wear a gown and gloves when caring for patients--is widely debated in the medical community.
To help inform best practices, a group of epidemiologists and infection prevention specialists led by Daniel Morgan, MD, MS, an associate professor of Epidemiology & Public Health at the University of Maryland School of Medicine, set out to review current practice and existing literature to build a framework for decision-making based on all available evidence. The conclusion: there are no high-quality data to support or reject the use of contact precautions and much variability in individual hospital practices; therefore, a standard rule for all acute-care hospitals is not feasible. Until more definitive data are recorded, the use of contact precautions should be individualized to fit a hospital's specific needs and resources.
"Theoretically, contact precautions make sense," says Dr. Morgan. "Isolating patients and using gloves and gowns should prevent the spread of bacteria, but studies have not shown these practices have a measurable effect on reducing infection rates."
However, they do have an effect on patient satisfaction, Dr. Morgan adds. "Studies show that patients on contact precautions receive fewer visits from healthcare workers, which can be associated with lower patient satisfaction, depression and anxiety. Perhaps because donning and doffing gowns and gloves can be a labor-intensive and time-consuming process," Dr. Morgan notes.
With up to 25 percent of all hospitalized patients on contact precautions, there is an obvious need to address the value of the practice. In addition to reviewing more than 90 published studies on contact precautions, Dr. Morgan and colleagues also administered a survey to epidemiologists and infection prevention specialists. Most respondents (63 percent) were in favor of implementing contact precautions in a different way.
"We critically assessed the practice of contact precautions for the control of endemic pathogens and found that much of our practice was not supported by robust data," says co-author Gonzalo Bearman, MD, MPH, FACP, FSHEA, chair of the Division of Infectious Diseases at Virginia Commonwealth University (VCU) and hospital epidemiologist, VCU Medical Center. "We feel that local needs and resources, not mandates, should drive infection prevention practices, particularly with respect to the use of contact precautions for MRSA and VRE in non-outbreak conditions."
While most hospitals in the U.S. use contact precautions as recommended by the CDC, there are some hospitals, including VCU Medical Center, that employ different approaches. These include a greater focus on horizontal infection control methods (hand hygiene, bathing patients with chlorhexidine, environmental cleaning and disinfection), the use of gowns and gloves for patients with certain syndromes associated with greater contamination (diarrhea, open wounds), and/or active surveillance combined with decolonization.
More studies of these "alternative" methods are needed, but anecdotal reports from these institutions suggest that their infection rates are stable or declining.
"It's clear that nationally we need to do a better job of preventing hospital-acquired infections," says Dr. Morgan, who notes that one-quarter of hospital-acquired infections are caused by MRSA or VRE. "Contact precautions may provide a small benefit, but their use needs to be thoughtfully considered on a hospital by hospital basis. For example, if a hospital has a reputation for treating the sickest of the sick--those most at risk for infection--that institution may wish to employ all available methods of infection control, including contact precautions. But every hospital should incorporate the patient experience into their decision-making process."
"As a research institution devoted to raising standards of care for patients everywhere, I applaud Dr. Morgan and his colleagues for providing us with invaluable perspective on the use of contact precautions," says E. Albert Reece, MD, PhD, MBA, the John Z. and Akiko K. Bowers Distinguished Professor and Dean of the University of Maryland School of Medicine. "Dr. Morgan has presented us with an objective overview that can be referenced by infection control decision-makers across the nation as we in the medical community continue to evaluate the best interventions to reduce hospital-acquired infections."
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