1. Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis
AJIC April Volume 46, Issue 4, p
APIC Greater NYC Meeting – May 16, 2018
Steve Bock RN CIC FAPIC

3. Study Intent / Design – Literature review, meta-analysis of numerous articles on Discontinuing Contact Precautions for MDROs
Systematic review of 74 articles over the past 30 years, 14 used for this report.
Focus on MDROs, specifically MRSA, VRE, ESBL-E. coli, and C. difficile.
Numerous exclusion criteria to eliminate articles w/o primary data, and if article was focused on stopping precautions only after negative surveillance cultures.
Contact Precautions (CP) has been in use since at least 1970, when the CDC issued its first isolation guidelines, predates many “modern” IPC activities and practices (CHG bathing, alcohol-based hand rubs, etc.)
CP not systematically or rigorously validated as effective at preventing the spread of MDRO infections in endemic settings.
Study seeks to test hypothesis that not using CP for MDROs will not lead to infection risk increases.

4. Study Design
Searched in: PubMed, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Scopus (which includes Embase abstracts), and PsycINFO via PsycNET
After eliminating a number of articles, 14 were reviewed extensively, and data from each was evaluated based on study design, population and setting, interventions tested, and measurement of discontinuation for CPs.
Articles were scored 1-4 (4 = highest quality of evidence) for sample representativeness, bias and confounding, description of the intervention, outcomes and follow-up, and statistical analysis.
All these studies were considered quasi-experimental studies. 12 were nonrandomized quasi-experimental studies comparing infection rates pre- and post discontinuation of CPs.

5. Study Design, continued
10 were from US hospitals, 3 western Europe (Swiss, French), and one from Canada. 10 were academic medical centers, 3 were community medical centers, and 1 was a cancer institute.
12/14 studies discontinued CPs in the entire hospital, 1 study discontinued CPs in a leukemia, bone marrow transplant, and lymphoma service of a cancer institute, and 1 was limited to trauma patients (academic medical center).
Study duration varied from 1-10 years. Overall, half included MRSA or VRE screening to determine colonization rates (thus the rest relied only on MDRO infections to assess impact of not using CP).
7 of 9 MRSA studies and 5 of 8 VRE studies did use surveillance cultures, however.

6. Study Design, continued
What does it mean to stop CP? For which MDROs?
9 studies discontinued CPs for MRSA, 6 of these also stopped CP for VRE
8 studies discontinued CPs for VRE, and 6 of these also discontinued CP for MRSA
2 studies discontinued CPs for ESBL–E. coli
1 study stopped CPs for C. difficile infection (except for hypervirulent (NAP-1) strains or patients with stool incontinence)
The studies that discontinued CPs for C. difficile (1 study) and ESBL–E. coli (2 studies) stopped CPs only for the mentioned microorganisms, respectively.

7. Study Outcomes
9 of 14 studies were considered completely adequate for reporting compliance rates of infection prevention process metrics (hand hygiene, environmental cleaning, and chlorhexidine bathing), and 1 study reported compliance with “bare-below-the-elbows,” practices to be used in place of CP.
2 studies used molecular typing to attempt to link cases (post discontinuation of CP with index cases.
So, what did the authors find?

8. Study Outcomes
For MRSA, there was a non-statistically significant reduction in the risk of acquiring MRSA if CP was not used!
A = MRSA

9. Study Outcomes
For VRE, there was a statistically significant reduction in the risk of acquiring VRE if CP was not used!
B = VRE

10. Study Outcomes
For ESBL-E. Coli, the two studies were discordant. One showed no change in rates of MDRO E. coli, and one showed an increased risk of patients getting MDRO E. coli (colonization or infection) after CP was no longer used.
For C. difficile, the one study showed an increased risk of patients getting C. difficile in an environment without CP for this infection, although the rates were very low (2.8 to 4.3 per 10,000 pt days, p = 0.13).

11. Study Discussion
The authors suggest facilities that discontinue CP as a main practice may be able to spend resources more on other infection prevention activities, such as hand hygiene, bare-below-the-elbows, chlorhexidine bathing, care bundles, and environmental cleaning.
Facilities in these studies did not show an increased risk overall to their patients following the cessation of using CP.
Why did these studies seem to be successful?
CP simply doesn’t work to prevent endemic MRSA and VRE infections. Why not?
Maybe HCWs don’t follow them well
Maybe the practices used instead of mandatory gown/glove use work just as well (though most of the studies didn’t say what they did instead…)

12. Study Outcomes
While most of the hospitals that ceased using CP for MRSA & VRE, they kept doing surveillance cultures to make sure there was not an increase in colonization.
Most hospitals that stopped CP for MRSA & VRE continued to use CP for MDRO gram negative rods (GNRs) and C. difficile. Why? (authors don’t offer any ideas)
The authors cite several other studies not included in their analysis that showed similar results – not using CP did not lead to increases in MRSA or VRE.
They also discuss the “Benefits of Universal Gown and Glove” (BUGG) study (JAMA, 2013). It used universal CP in an ICU setting; a significant decrease in MDRO transmission resulted. However, about 500,000 patient-caregiver encounters would be needed to prevent 1 MRSA case, based on the BUGG study.

13. Study Outcomes, Limitations
Other studies they mention point out harm from CP: decreased time spent with patients, delays in transferring patients between inpatient units, excess attributable length of stay, increased readmission rates, and patients’ perception of poor quality of care.
Limitations are well discussed; this analysis depends on the quality of the original studies, all of which are quasi-experimental and often pre/post-test design (making them fairly weak).
Not enough well-designed studies exist to evaluate CP for C. difficile or MDRO GNRs.
Uncontrolled bias, confounding variables, and other study design weaknesses exist in these 14 studies; however, none showed an increased benefit of CP.

14. Study – Final Claim
“We think discontinuation of CPs (as currently practiced) for MRSA and VRE can be safely accomplished, particularly in hospitals with a strong horizontal infection prevention strategy, including high levels of compliance with hand hygiene.”
Do you agree?