Increased prevention efforts may not reduce spread of hospital-based bacteria

Expanded use of barrier precautions, such as gloves and gowns in conjunction with active surveillance for bacteria, did not reduce the transmission of methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococcus, according to a study recently published in the New England Journal of Medicine.

The prospective, randomized clinical trial was conducted at 18 intensive care units (ICUs) in the United States. The authors attributed the findings to incomplete compliance by health care providers with recommended hand hygiene procedures, and the use of gloves and gowns. There were also notable time lags in confirming the presence of bacteria in patients, they reported.

Data from 18 ICUs

W. Charles Huskins, MD, and colleagues at the Mayo Clinic performed a cluster-randomized trial wherein they evaluated the effect of ICU surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) colonization, and the impact of the expanded use of barrier precautions (intervention) on MRSA and VRE colonization compared with existing practices (control).

The team collected surveillance cultures from patients at the participating ICUs, with results reported only to the ICUs assigned to the intervention.

Patients colonized or infected with MRSA or VRE were assigned to care with contact precautions in intervention group ICUs, and the remaining patients were assigned to care with universal gloving until discharge or negative surveillance culture results.

Proper protocol not followed

The authors recorded 5,434 admissions to 10 intervention ICUs and 3,705 admissions to eight control ICUs during the 6-month intervention period.

According to the study findings, patients colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs. Patients spent a median of 92% of their intervention ICU days with either contact precautions or universal gloving compared with a median 38% of control ICU days spent with contact precautions.

The group found that health care providers at the intervention ICUs used clean gloves, gowns and hand hygiene protocols less frequently than required for interaction with patients who had been assigned to barrier precautions, according to the study abstract. Gloves were used for a median 82% of contacts, gowns 77% and hand hygiene after 69% of contacts when contact precautions were specified.

Furthermore, universal gloving specifications resulted in gloves being used for a median 72% of contacts and hand hygiene after 62% of contacts.

Decreasing transmission

Ultimately, the authors wrote, “mean ICU-level incidence of events of colonization or infection with MRSA or VRE per 1,000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs.”

“The intervention was not effective in reducing the transmission of MRSA or VRE,” they concluded, “although the use of barrier precautions by providers was less than what was required.”

To decrease the transmission of MRSA and VRE bacteria in health care settings, they noted, health care providers must demonstrate improved compliance with isolation precautions in conjunction with proper interventions to reduce the presence of bacteria on body sites and decrease environmental contamination.

Reference:

Huskins WC, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011; 364:1407-1418. doi: 10.1056/NEJMoa1000373 (2011).

Disclosure: Huskins receives consulting fees from Roche Diagnostics and serves on an advisory board for GlaxoSmithKline. Co-author Donald A. Goldmann, MD, receives consulting fees from Medegen and serves on an advisory board for BioNeutral Group.

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