Contact Precautions for Endemic Pathogens: Is There A Paradigm Shift in the Making?

In a riveting and somewhat controversial presentation at the SHEA 2018 Spring Conference, Gonzalo Bearman, MD, MPH, chair of the Division of Infectious Diseases, Richard P. Wenzel professor of internal medicine, and hospital epidemiologist at the Virginia Commonwealth University (VCU) Health System, homed in on the use of contact precautions for endemic pathogens.

“I realize that this is a controversial topic. I’m not here to tell you ‘the way.’ I’m not here to preach infection prevention salvation. I’m here to give you my perspective on contact precautions,” he told conference attendees. “How should we best use contact precautions for endemic pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE)?”

The philosophy behind how he and his colleagues approach the use of contact precautions at VCU dates back to 1978, when Herbert A. Simon, an American economist and political scientist said in his Nobel Prize speech that “…decision makers can satisfice either by finding optimum solutions for a simplified world or by finding satisfactory solutions for a more realistic world.” At VCU, Dr. Bearman and his colleagues are looking to do just that for day-to-day operations.

Citing a study published in 2008, where he and his colleagues posited that focusing resources on just a single pathogen as a sole approach to infection control is inherently flawed, Dr. Bearman and his team proposed that the new paradigm consists of multi-potent interventions designed to reduce risk from all pathogens transmitted in the same mechanism: contact.

“My question is, do we really need to be so aggressive in our approach to infection prevention?” he asked attendees. “I’m here to suggest that maybe with contact precautions more is not necessarily better.”

According to Dr. Bearman, there are 2 central approaches to infection prevention, one vertical and one horizontal. “The horizontal approach is the one that we advocate for vigorously at VCU,” he said. Examples of this approach include hand hygiene (HH), chlorhexidine bathing, central line insertion bundles, ventilator bundles, and a “Bare Below the Elbows” policy for health care workers.

Another study, published in JAMA in 2013 by Harris et al, provided some interesting findings on the concept of universal gloving and gowning (UGG). The cluster randomized trial was conducted across 20 medical and surgical intensive care units (ICUs) spanning 20 US hospitals. The primary outcome was MRSA and VRE on admission and discharge, while the secondary outcomes included individual MRSA acquisition/VRE acquisition, health care worker (HCW) patient visits, HH compliance, health care-associated infections (HAIs), and adverse events.

The findings? Although UGG did not prove to reduce primary MRSA or VRE acquisition, it did impact secondary MRSA acquisition with a 40% relative risk reduction. He noted that HCW patient visits decreased with UGG; however, HH compliance increased upon room exit. No significant differences were noted pertaining to adverse events.

He went on to cite another study published in 2014 in Infection Control and Hospital Epidemiology by Dhar et al which looked at the use of contact precautions and the impact they had on practice. The investigators found that when contact isolation burden was at 20% or less, HH compliance was 44% and contact precautions compliance was about 32%. However, when the contact isolation burden increases to 60% or higher, both HH and contact precautions compliance plummet to 5% and 7%, respectively.

“The real goal is to provide that sweet spot for the use of contact precautions,” he noted.

Furthermore, adverse events have been associated with the use of contact precautions. Findings from a study published by Morgan et al in the American Journal of Infection Control in 2009 noted that some associated adverse events included falls, pressure ulcers, fluid/electrolyte disorders, inappropriate documentation of vital signs, and days without a provider note. In addition, the authors noted that patients reported decreased satisfaction with care, which is, according to Dr. Bearman, “certainly something that we don’t want to easily overlook.”

Another study published in 2015 by Croft et al echoed this sentiment when they found that 35% of 296 non-ICU medical and surgical patients experienced at least 1 adverse event. However, Dr. Bearman pointed out that “Contact precautions in this study was associated with fewer non-infectious adverse events, once again, adding to the controversy over how to best employ contact precautions.”

Going back to the idea of the concept of “satisfice,” Dr. Bearman asked attendees if they considered the use of UGG feasible and cost-effective. He pulled data from 2 publications, one a cost-benefit analysis of UGG and the other which performed mathematical modeling to find out the same thing. The first found that the range of benefit was 1.7 times higher cost to 13.5 cost savings, while the second concluded that UGG was not cost-effective.

“I think that with any intervention that we do in infection prevention, particularly when there are costs associated, we must always consider potential opportunity cost when making a key decision to do or not to do something,” he stressed.

He added that when it comes to donning and doffing personal protective equipment (PPE), oftentimes the process is performed incorrectly, resulting in skin and clothing contamination. One study published in JAMA Internal Medicine by Tomas et al in 2015 found that in 80% of glove simulations, skin and clothing contamination was noted due to incorrect technique. When incorrect technique is used while gowning, there was up to 60% skin and clothing contamination.

Dr. Bearman’s own research conducted at VCU also found issues regarding self-contamination via PPE. One study which looked at the donning and doffing of PPE at the institution found that in 24% of doffs, contact was observed between presumably contaminated PPE and the provider’s skin and clothing. Arguably the most troubling aspect of this study was that survey data of providers showed that most of them did not feel that self-contamination occurred. As such, Dr. Bearman stressed, “PPE must be used selectively, correctly, and judiciously.”

He then proposed another question to the audience: Could other strategies be as effective and perhaps easier to both implement and sustain than routine contact precautions or contact precautions as we currently use them?

One strategy, according to Dr. Bearman, may be the use of universal gloving rather than UGG. “Just let me underscore that universal gloving is not the same as universal gloving and gowning; we’re not isolating patients, we’re essentially washing our hands and donning gloves,” he clarified. Dr. Bearman published research in 2010 in Infection Control and Hospital Epidemiology which compared the use of contact precautions for MRSA/VRE colonized/infected patients (standard of care) with universal gloving, using “no contact precautions for any pathogen of any sort.” The quasi-experimental study was broken down into 2 phases over the duration of a year: 6 months for the standard of care approach and 6 months for the universal gloving approach.

The facility also performed VRE/MRSA surveillance cultures on admission and every 4 days for the duration of the study. They also looked at HH compliance, HCW hand cultures, and skin assessment in addition to conducting concurrent surveillance for other hospital-acquired infections.

Some of their main findings included:

• A decreasing trend from phase 1 to phase 2 in bloodstream infections and UTIs; there was no change in pneumonia. These weren’t statistically significant.
• A decrease in the number of VRE/MRSA infections from phase 1 to phase 2 (4 to 2)
• An increase in HH compliance from phase 1 to phase 2 before patient contact (going from 35% to 40%, not statistically significant) and after patient contact (going from 51% to 64%, which is statistically significant)

As such, Dr. Bearman suggests that there may be a paradigm shift in the making when it comes to contact precautions. He and his colleagues surveyed members from the SHEA Research Network to glean insight into how epidemiologists feel about the use of contact precautions. Surprisingly, they found that 60% of those surveyed reported being interested in alternate options to contact precautions.

“Our conclusions were that there was no high-quality data to support or reject the use of contact precautions for endemic MRSA or VRE,” he said. “At the time of that publication, there were over 30 US hospitals that did not employ contact precautions to control endemic MRSA or VRE. And we suggest that until definitive data are available, the use of contact precautions for these endemic pathogens in acute care settings should be guided by local needs and resources, not necessarily by a mandate.”

According to Dr. Bearmean, contact precautions have limited impact on endemic multidrug-resistant organisms. Furthermore, the use of contact precautions could lead to poorer adherence and could be associated with adverse events.

“Alternative approaches for the control of endemic pathogens include starting first with a horizontal infection control program, considering universal gloving as an infection prevention adjunct,” he concluded, “and last but not least, contact precautions for endemic pathogens should be driven by local need and, in my opinion, used selectively.”