In a recent review published in Clinical Infectious Diseases, a group of authors critically assessed the designation of contact precautions (CP) as an "essential practice" for methicillin-resistant Staphylococcus aureus (MRSA) prevention in acute care facilities.
They evaluated existing evidence on its benefits, harms, and effectiveness and proposed its implementation only under specific circumstances.
Study: Are contact precautions “essential” for the prevention of healthcare-associated methicillin-resistant Staphylococcus aureus? Image Credit: Olga Zarytska/Shutterstock.com
Background
The Society for Healthcare Epidemiology of America (SHEA), the Association of Professionals in Infection Control (APIC), and the Infectious Diseases Society of America (IDSA), compendium, endorsed by relevant bodies, is pivotal for guiding MRSA prevention in hospitals.
However, designating CP as "essential" raises concerns due to inadequate evidence and potential adverse consequences, suggesting a need for a more tailored, context-specific approach.
The compendium's authors hint at the non-universality of CP. Several epidemiologists favor a precision-based application of CP, emphasizing the need for further research to optimize its implementation in suitable circumstances, mitigating unintended repercussions and enhancing the precision in infection control efforts, particularly in instances of outbreaks or continuous transmissions.
Appraising the evidence
The studies referenced in the compendium do not provide conclusive evidence supporting CP as an essential practice for MRSA prevention.
While they offer insight into MRSA contamination of healthcare personnel and the environment, they fall short of proving the effectiveness of CP over other interventions like improved hand hygiene and environmental cleaning.
Observational studies and their implications
The multitude of observational studies and mathematical models presented show varying impacts of CP on MRSA transmission, neither conclusively supporting nor disputing CP as a preventative measure for MRSA.
The decline in MRSA infections and the national trend of reducing CP usage point towards the need for a better understanding of the role of CP in MRSA prevention within acute care hospitals.
Reflections on the VA MRSA initiative and CP implementation
The VA MRSA initiative successfully combined vertical and horizontal interventions, raising questions about the real contribution of active screening and CP.
With conflicting modeling studies and the absence of definitive controlled trials, the proportionate importance of CP in reducing MRSA infections remains ambiguous.
Assessing CP during the pandemic and beyond
The rise in MRSA infections during the coronavirus disease 2019 (COVID-19) pandemic and the myriad of changes in care practices make it challenging to evaluate the real impact of changes in CP use during this period.
The distinctions in infection prevention practices between different hospitals and the unprecedented stress on healthcare and infection prevention programs during the pandemic also cloud the understanding of the impact of CP on MRSA prevention.
Efficacy of CP in MRSA prevention
CP are crucial for preventing the spread of MRSA; however, no randomized trials decisively prove their efficacy for those colonized or infected with MRSA.
Several cluster randomized trials have analyzed the incorporation of CP, with most of the studies conducted in Intensive Care Unit (ICU) settings, rendering the results less generalizable to other care environments.
Insights from various studies
Studies like the Study on the Randomized Evaluation of Decolonization vs. Universal Clearance to Eliminate Methicillin-Resistant Staphylococcus aureus (REDUCE MRSA), Efficacy of Nosocomial Infection Control to Reduce the Incidence of Nosocomial Infection (STAR*ICU), and Mastering hospital Antimicrobial Resistance and its Spread into the Community (MOSAR) have provided insights into the effectiveness of CP.
Huskins et al.'s STAR*ICU study in 18 ICUs revealed that despite extensive use of CP, there was no notable reduction in MRSA acquisition or infection events. The REDUCE MRSA trial by Huang et al. showcased that universal decolonization was more effective than MRSA screening and CP in lowering MRSA clinical cultures and bloodstream infections.
Meanwhile, the MOSAR study observed no additional decline in MRSA with screening-guided CP after initial interventions showed a reduction in MRSA acquisition.
The amalgamation of results from these studies suggests that the increased use of CP does not notably enhance MRSA prevention compared to other common infection prevention interventions.
The benefits of universal gown and gloves (BUGG) Study: A differing perspective
Harris et al.'s BUGG study found benefits from the universal use of gowns and gloves in all ICU patients, particularly showcasing a statistically significant reduction in MRSA acquisition events in intervention units.
However, this study had limitations, such as uneven allocation in the randomization process and differing baseline MRSA acquisition rates between intervention and control units, necessitating further exploration to ascertain the effectiveness of CP.
Adverse impacts on patient care and satisfaction
Although deemed essential, CP can potentially lead to unintended adverse consequences. The practice has been linked to fewer clinician-patient interactions, longer hospital stays, and higher hospital costs.
Patients under isolation reportedly receive fewer visits and are less likely to be examined by attending physicians. Furthermore, implementing CP can cause "Personal Protective Equipment (PPE) fatigue," resulting in reduced time for actual patient care and possibly diminishing the adherence to CP.
Strain on healthcare providers and resources
The extensive implementation of CP places substantial pressure on healthcare providers. It stretches the already scarce resources of infection prevention programs, raising concerns regarding the feasibility and sustainability of CP in hospitals, especially those facing resource constraints.
Environmental implications of CP
CP has severe environmental repercussions, particularly due to the extensive use of single-use plastics in gowns and gloves. With the United States (U.S.) healthcare system contributing significantly to national greenhouse gas emissions, the environmental sustainability of extensive CP use is questioned, given its considerable contribution to waste generation and carbon dioxide emissions.
The wide-ranging negative impacts of plastics on health and the environment further accentuate the urgency to rethink the indiscriminate use of CP.
Reevaluation and future recommendations
It is essential to weigh the environmental externalities against the perceived cost and benefits of CP, especially considering that true environmental costs are borne disproportionately by vulnerable populations.
Future recommendations for MRSA CP must consider aligning with the objectives of reducing harm, waste, and environmental impact while enhancing patient safety.
There is a pressing need to re-evaluate the extensive use of CP, especially in settings where its value and supporting evidence base are low, and to seek harmonization with broader healthcare objectives and environmental sustainability.
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