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Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis

  • Alexandre R. Marra
    Correspondence
    Address correspondence to Alexandre R. Marra, MD, MS, Office of Clinical Quality, Safety and Performance Improvement, University of Iowa Hospitals and Clinics, C51 GH, 200 Hawkins Dr, Iowa City, IA 52242. (A.R. Marra).
    Affiliations
    Office of Clinical Quality, Safety and Performance Improvement, University of Iowa Hospitals and Clinics, Iowa City, IA

    Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
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  • Michael B. Edmond
    Affiliations
    Office of Clinical Quality, Safety and Performance Improvement, University of Iowa Hospitals and Clinics, Iowa City, IA

    Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
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  • Marin L. Schweizer
    Affiliations
    The Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA

    Division of General Internal Medicine, Department of Internal Medicine, Carver College of Medicine, Iowa City, IA
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  • Grace W. Ryan
    Affiliations
    Department of Community and Behavioral Health, University of Iowa, College of Public Health, Iowa City, IA
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  • Daniel J. Diekema
    Affiliations
    Office of Clinical Quality, Safety and Performance Improvement, University of Iowa Hospitals and Clinics, Iowa City, IA

    Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA

    Division of Medical Microbiology, Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA
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Published:October 12, 2017DOI:https://doi.org/10.1016/j.ajic.2017.08.031

      Highlights

      • Increasingly, hospitals are discontinuing contact precautions for patients colonized and infected with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).
      • This systematic review and meta-analysis showed that discontinuing contact precautions for endemic MRSA and VRE was not associated with an increase in infection rates.
      • The utility of contact precautions for controlling MRSA and VRE is probably low.

      Background

      Several single-center studies have suggested that eliminating contact precautions (CPs) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) control in nonoutbreak settings has no impact on infection rates. We performed a systematic literature review and meta-analysis on the impact of discontinuing contact precautions in the acute care setting.

      Methods

      We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Embase through December 2016 for studies evaluating discontinuation of contact precautions for multidrug-resistant organisms. We used random-effect models to obtain pooled risk ratio estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled risk ratios for MRSA and VRE were assessed separately.

      Results

      Fourteen studies met inclusion criteria and were included in the final review. Six studies discontinued CPs for both MRSA and VRE, 3 for MRSA only, 2 for VRE only, 2 for extended-spectrum β-lactamase–producing Escherichia coli, and 1 for Clostridium difficile infection. When study results were pooled, there was a trend toward reduction of MRSA infection after discontinuing CPs (pooled risk ratio, 0.84; 95% confidence interval, 0.70-1.02; P = .07) and a statistically significant reduction in VRE infection (pooled risk ratio, 0.82; 95% confidence interval, 0.72-0.94; P = .005).

      Conclusions

      Discontinuation of CPs for MRSA and VRE has not been associated with increased infection rates.

      Key Words

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      References

        • Siegel J.D.
        • Rhinehart E.
        • Jackson M.
        • Chiarello L.
        • The Healthcare Infection Control Practices Advisory Committee
        Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings.
        (Available from:)
        http://www.cdc.gov/hicpac/pdf/Isolation/Isolation2007.pdf
        Date: 2007
        Date accessed: December 5, 2016
        • Wenzel R.P.
        • Edmond M.B.
        Infection control: the case for horizontal rather than vertical interventional programs.
        Int J Infect Dis. 2010; 14: S3-S5
        • Edmond M.B.
        • Wenzel R.P.
        Targeted decolonization to prevent ICU infections.
        N Engl J Med. 2013; 368: 2614-2615
        • Harris A.D.
        • Pineles L.
        • Belton B.
        • Johnson J.K.
        • Shardell M.
        • Loeb M.
        • et al.
        Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.
        JAMA. 2013; 310: 1571-1580
        • Huskins W.C.
        • Huckabee C.M.
        • O'Grady N.P.
        • Murray P.
        • Kopetskie H.
        • Zimmer L.
        • et al.
        Intervention to reduce transmission of resistant bacteria in intensive care.
        New Engl J Med. 2011; 364: 1407-1418
        • Morgan D.J.
        • Kaye K.S.
        • Diekema D.J.
        Reconsidering isolation precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus.
        JAMA. 2014; 312: 1395-1396
        • Morgan D.J.
        • Diekema D.J.
        • Sepkowitz K.
        • Perencevich E.N.
        Adverse outcomes associated with contact precautions: a review of the literature.
        Am J Infect Control. 2009; 37: 85-93
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • The PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6 (e1000097)
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • Olkin I.
        • Williamson G.D.
        • Rennie D.
        • et al.
        Meta-analysis of observational studies in epidemiology: a proposal for reporting.
        JAMA. 2000; 283: 2008-2012
        • Aboelela S.W.
        • Saiman L.
        • Stone P.
        • Lowy F.D.
        • Quiros D.
        • Larson E.
        Effectiveness of barrier precautions and surveillance cultures to control transmission of multidrug-resistant organisms: a systematic review of the literature.
        Am J Infect Control. 2006; 34: 484-494
        • Cohen C.C.
        • Cohen B.
        • Shang J.
        Effectiveness of contact precautions against multi-drug-resistant organism transmission in acute care: a systematic review of the literature.
        J Hosp Infect. 2015; 90: 275-284
      1. Alderson P.G.S. Higgins J.P.T. Assessment of study quality. Cochrane reviewer's handbook 4.2.3. John Wiley & Sons, Ltd, Chichester, UK2004
        • Harris A.D.
        • Lautenbach E.
        • Perencevich E.
        A systematic review of quasi-experimental study designs in the fields of infection control and antibiotic resistance.
        Clin Infect Dis. 2005; 41: 77-82
        • Gandra S.
        • Barysauskas C.M.
        • Mack D.A.
        • Barton B.
        • Finberg R.
        • Ellison 3rd., R.T.
        Impact of contact precautions on falls, pressure ulcers and transmission of MRSA and VRE in hospitalized patients.
        J Hosp Infect. 2014; 88: 170-176
        • Martin E.M.
        • Russell D.
        • Rubin Z.
        • Humphries R.
        • Grogan T.R.
        • Elashoff D.
        • et al.
        Elimination of routine contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: a retrospective quasi-experimental study.
        Infect Control Hosp Epidemiol. 2016; 37: 1323-1330
        • Graman P.
        • Shelly M.
        • Pettis A.M.
        • Bronstein M.
        • Greene L.
        Incidence of nosocomial Staphylococcus aureus infections after suspension of contact precautions (CP) for methicillin-resistant S. aureus.
        Open Forum Infectious Diseases. 2015; 2: 1-66
        • Edmond M.B.
        • Masroor N.
        • Stevens M.P.
        • Ober J.
        • Bearman G.
        The impact of discontinuing contact precautions for VRE and MRSA on device-associated infections.
        Infect Control Hosp Epidemiol. 2015; 36: 978-980
        • Rupp M.E.
        • Fitzgerald T.
        • Hayes K.
        • Van Schooneveld T.
        • Hewlett A.
        • Clevenger R.
        • et al.
        Effect of cessation of contact isolation for endemic methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococci.
        Infect Control Hosp Epidemiol. 2017; 38: 1005-1007
        • Deatherage N.
        Impact of reduced isolation and contact precaution procedures on infection rates and facility costs at a non-profit acute care hospital.
        Am J Infect Control. 2016; 44 (9-255) (APIC 43rd Annual education conference & international meeting charlotte, NC June 11-13 2016): S101-S102
        • Almyroudis N.G.
        • Osawa R.
        • Samonis G.
        • Wetzler M.
        • Wang S.
        • McCarthy P.L.
        • et al.
        Discontinuation of systematic surveillance and contact precautions for vancomycin-resistant Enterococcus (VRE) and its impact on the incidence of VRE faecium bacteremia in patients with hematologic malignancies.
        Infect Control Hosp Epidemiol. 2016; 37: 398-403
        • Fazal B.A.
        • Telzak E.E.
        • Blum S.
        • Turett G.S.
        • Petersen-Fitzpatrick F.E.
        • Lorian V.
        Trends in the prevalence of methicillin-resistant Staphylococcus aureus associated with discontinuation of an isolation policy.
        Infect Control Hosp Epidemiol. 1996; 17: 372-374
        • Watkins L.
        • Ali S.
        • Clark A.
        • Brown C.V.
        Transmission-based contact precautions for multidrug-resistant organisms in trauma patients: fewer days in isolation with no increase in hospital-associated infections.
        J Trauma Acute Care Surg. 2014; 77: 960-963
        • Spence M.R.
        • Dammel T.
        • Courser S.
        Contact precautions for methicillin-resistant Staphylococcus aureus colonization: costly and unnecessary?.
        Am J Infect Control. 2012; 40: 535-538
        • Tschudin-Sutter S.
        • Frei R.
        • Schwahn F.
        • Tomic M.
        • Conzelmann M.
        • Stranden A.
        • et al.
        Prospective validation of cessation of contact precautions for extended-spectrum β-lactamase-producing Escherichia coli.
        Emerg Infect Dis. 2016; 22: 1094-1097
        • Lemieux C.
        • Gardam M.
        • Evans G.
        • John M.
        • Suh K.N.
        • vanWalraven C.
        • et al.
        Longitudinal multicenter analysis of outcomes after cessation of control measures for vancomycin-resistant enterococci.
        Infect Control Hosp Epidemiol. 2017; 38: 24-30
        • Zahar J.R.
        • Poirel L.
        • Dupont C.
        • Fortineau N.
        • Nassif X.
        • Nordmann P.
        About the usefulness of contact precautions for carriers of extended-spectrum beta-lactamase-producing Escherichia coli.
        BMC Infect Dis. 2015; 15: 512
        • Widmer A.F.
        • Frei R.
        • Erb S.
        • Stranden A.
        • Kuijper E.J.
        • Knestch C.W.
        • et al.
        Transmissibility of Clostridium difficile without contact isolation: results from a prospective observational study with 451 patients.
        Clin Infect Dis. 2017; 64: 393-400
        • Welsh J.
        Reconsidering contact precautions for MRSA and VRE.
        Am J Nurs. 2015; 115: 14-15
        • Morgan D.J.
        • Murthy R.
        • Munoz-Price L.S.
        • Barnden M.
        • Camins B.C.
        • Johnston B.L.
        • et al.
        Reconsidering contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus.
        Infect Control Hosp Epidemiol. 2015; 36: 1163-1172
        • Huang S.S.
        • Septimus E.
        • Kleinman K.
        • Moody J.
        • Hickok J.
        • Avery T.R.
        • et al.
        Targeted versus universal decolonization to prevent ICU infection.
        N Engl J Med. 2013; 368: 2255-2265
        • Derde L.P.
        • Cooper B.S.
        • Goossens H.
        • Malhotra-Kumar S.
        • Wllems R.J.
        • Gniadkowski M.
        • et al.
        Interventions to reduce colonization and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomized trial.
        Lancet Infect Dis. 2014; 14: 31-39
        • Morgan D.
        • Wenzel R.
        • Bearman G
        Contact precautions for endemic MRSA and VRE.
        (Time to retire legal mandates; Available from:)
        • Kullar R.
        • Vassalo A.
        • Turkel S.
        • Chopra T.
        • Kayne K.S.
        • Dhar S.
        Degowning the controversies of contact precautions for methicillin-resistant Staphylococcus aureus: a review.
        Am J Infect Control. 2016; 44: 97-103
        • Shenoy E.S.
        • Lee H.
        • Hou T.
        • Ware W.
        • Ryan E.E.
        • Hooper D.C.
        • et al.
        The impact of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) flags on hospital operations.
        Infect Control Hosp Epidemiol. 2016; 37: 782-790
        • Johnson D.W.
        • Schmidt U.H.
        • Bittner E.A.
        • Christensen B.
        • Levi R.
        • Pino R.M.
        Delay of transfer from the intensive care unit: a prospective observational study of incidence, causes, and financial impact.
        Crit Care. 2013; 17: R128
        • Karki S.
        • Leder K.
        • Cheng A.C.
        Delays in accessing radiology in patients under contact precautions because of colonization with vancomycin-resistant enterococci.
        Am J Infect Control. 2013; 41: 1141-1142
        • Tran K.
        • Bell C.
        • Stall N.
        • Tomlinson G.
        • McGeer A.
        • Morris A.
        • et al.
        The effect of hospital isolation precautions on patient outcomes and cost of care: a multi-site, retrospective, propensity score-matched cohort study.
        J Gen Intern Med. 2017; 32: 262-268