Chapter 7Barrier Precautions, Patient Isolation, and Routine Surveillance for Prevention of Health Care-Associated Infections: Brief Update Review

Schweizer M.

Publication Details

Introduction

Healthcare-associated infections are linked to high morbidity, mortality, and costs worldwide. In 2002, an estimated 1.7 million healthcare-associated infections were seen in U.S. hospitals, resulting in approximately 99,000 deaths.1 In 2005, 18,650 patients with methicillin-resistant Staphylococcus aureus (MRSA) died, more than the number of Americans who died from HIV/AIDS in that same year.2 In 2007, Clostridium difficile was ranked among the 20 leading causes of mortality among Americans over 65 years of age.3 Despite decades of infection control interventions, health care-associated infections continue to be a major burden on U.S. hospitals.4

Currently, there is a rising wave of new emergent healthcare-associated infections, including multi-drug resistant strains of Acinetobacter baumannii and Klebsiella pneumoniae. Additionally, reports of vancomycin-resistant S. aureus have appeared sporadically across the Nation.5-7 No effective antibiotics are available for some strains of these pathogens, and few new antibiotics are in the developmental pipeline. For example, since 2007, only two new antibiotics have been developed. Thus, prevention, not treatment, is the most sustainable strategy to control health care-associated infections.

Findings of Original Report

When “Making Health Care Safer” was first published in 2001, the main healthcare-associated pathogens of interest were vancomycin-resistant enterococci (VRE) and C. difficile. Three types of barrier precaution interventions were actively being studied, including (1) gowns and gloves for all contact with patients with VRE or C. difficile followed by immediate hand hygiene, (2) use of dedicated or disposable examining equipment for patients with VRE or C. difficile, and (3) patient and/or staff cohorting for patients with VRE or C. difficile.

Nearly all of the studies that assessed the effectiveness of barrier precautions were simple before-after studies with small cohorts of patients. Additionally, these studies usually assessed a large bundle of practices to prevent infections, thus it was difficult to elucidate which components of the bundle were effective.

Although results varied, the majority of the studies demonstrated significant reduction in the incidence of VRE or C. difficile following barrier precaution interventions. A review of the literature published just before the publication of “Making Health Care Safer” noted that there had been little progress in assessing the psychological effects of contact isolation. However, it was noted that attending physicians may examine patient on barrier precautions less often. The barrier precautions chapter of “Making Health Care Safer” concluded that barrier precaution interventions are effective and called for future studies of the long-term efficacy of barrier precaution interventions as well as the cost-effectiveness of barrier precaution interventions.

This update review focuses on what we have learned about infection prevention measures and their effectiveness since the publication of the original report. We conducted a search of the health care and health services literature for the time interval 2001 to 2011 and reviewed all studies relevant to this topic.

What Are Infection Prevention Measures?

The reservoir for many healthcare-associated infections is primarily colonized or infected patients. Transiently colonized health care workers and contaminated items in the environment are often intermediates in the patient-to-patient transmission of these pathogens. Thus, breaking transmission from these reservoirs is the most important strategy to prevent healthcare-associated infections. Multiple interventions can prevent transmission. Vertical interventions, in which specific organisms are targeted, include active surveillance plus contact isolation or nurse cohorting. Horizontal interventions, in which all healthcare-associated infections are targeted, include universal contact precautions in high-risk settings.8

Active Surveillance and Isolation

Active surveillance is the process of testing patients for asymptomatic colonization. Active surveillance is usually only performed for MRSA or VRE, since these organisms have established reservoirs and valid screening tests.9Universal active surveillance entails testing all admitted patients for colonization, while targeted active surveillance only tests patients at high risk for colonization (e.g., patients who recently received antimicrobials).

Patients found to be colonized through active surveillance are then isolated from other patients in order to prevent transmission. Isolation can be performed through nurse cohorting or contact isolation. Nurse cohorting is defined as physical segregation of colonized or infected patients from patients not known to harbor the specific pathogen in a distinct area of the same ward, and nursed by designated staff.10 When a patient is placed on contact precautions, health care workers are required to wear a gown and gloves when they come in contact with the patient then remove the gown and gloves and wash their hands after the contact, to prevent transmission to other patients via their hands or clothing.

Contact isolation includes contact precautions but the patient is also placed in a single room. If a single room is not available, contact isolation can be performed by cohorting patients colonized or infected with the same pathogen in the same room. Currently, most of the studies that assess active surveillance or universal contact precautions have only assessed these interventions in intensive care units (ICUs), since ICU patients are at high risk of healthcare-associated infections.11-13

What Have We Learned About Infection Control Practices Since the Original Report?

Increasing Resistance and Changing Epidemiology Among Staphylococcus aureus

Since the publication of the “Making Health Care Safer” report in 2001, Staphylococcus aureus has gained considerable attention due to a number of factors. First, healthcare-associated methicillin-resistant S. aureus infections increased rapidly with a high mortality rate.2,7 However, since 2007 rates of healthcare-associated MRSA have begun to decline.14 Second, community-associated MRSA infections caused by the USA300 clone emerged between 1999 and 2001.15 USA300 MRSA has caused severe infections in previously healthy people with no prior contact with the health care system, thus alarming both health care professionals and the general public.15 Additionally, USA300 MRSA infections have not replaced healthcare-associated MRSA infections (e.g. USA100), rather they have occurred as a separate epidemic leading to an increasing number of MRSA infections.16 Third, isolated cases of vancomycin-resistant S. aureus (VRSA), first recognized in 2002, have led to fears that failure to control VRE and MRSA transmission may lead to a new epidemic of VRSA, which will be very difficult to treat.5-7

Hypervirulent Strains of Clostridium difficile Have Emerged

The epidemiology of C. difficile has also changed since the publication of the “Making Health Care Safer” report. A ‘hypervirulent’ strain known as PCR ribotype 027, restriction endonuclease analysis group BI, and North American PFGE pulsotype 1 (027/BI/NAP1) has emerged worldwide and is associated with increased morbidity and mortality.17,18 In fact, U.S. mortality due to C. difficile increased from 793 deaths in 1999 to 6,372 deaths in 2007.3 Many countries, including the United States, have also reported an increased incidence of community-associated C. difficile infections among previously healthy people.17,19

What Methods of Infection Control Are Currently Being Studied?

There is great debate in the field of infection control over whether vertical or horizontal approaches should be used to prevent healthcare-associated infections.8 Active surveillance, a vertical approach because it focuses only on one organism, has been credited with the low rates of morbidity and mortality from MRSA in northern Europe and in Western Australia.20,21 Proponents of active surveillance argue that active surveillance and isolation, which has prevented spread of other nosocomial pathogens such as smallpox and severe acute respiratory syndrome, can also be used to contain MRSA or VRE.20,22,23 Proponents of active surveillance acknowledge that a single-pathogen approach is not ideal; however, current horizontal approaches have not decreased healthcare-associated infection rates significantly.20 Furthermore, active surveillance and isolation for asymptomatic carriers could prevent transmission of MRSA or VRE through multiple routes such as directly from one patient to another, via health care workers' contaminated hands or clothing, and via the environment.24

In contrast, proponents of a horizontal approach argue that hospitals should implement interventions that will decrease the spread of all healthcare-associated infections, which would decrease the overall rate of healthcare-associated infections.8,25,26 Advocates of a horizontal approach also argue that strategies focusing on active surveillance and contact isolation for MRSA or VRE will not prevent spread of susceptible S. aureus or enterococcus, spread of other resistant organisms, or endogenous infections in patients already colonized with MRSA or VRE. Also, active surveillance programs that only assess one body site will miss colonization of other body sites.25 The increasing burden of antibiotic-resistant infections, including highly transmissible pathogens such as Acinetobacter baumannii, cannot currently be prevented through active surveillance.27,28 Furthermore, the costs for active surveillance may decrease the funds available to implement other important infection prevention interventions.26

Even current guidelines disagree over the use of active surveillance for MRSA or VRE. The Society for Healthcare Epidemiology of America (SHEA) Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of Staphylococcus aureus and Enterococcus, as well as Dutch and British guidelines, recommend routine screening of high-risk patients for MRSA or VRE. However the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (CDC HICPAC) Guideline on Management of Multidrug-Resistant Organisms in Healthcare Settings, as well as an Australian guideline, recommend active surveillance as a targeted measure to be implemented only when the incidence or prevalence of MRSA or VRE is not decreasing despite other infection control strategies.7,29-32

Evidence for Effectiveness of Infection Control Practices

Multiple systematic literature reviews concluded that the evidence for interventions for the prevention and control of multidrug-resistant organisms were of poor quality and that definitive recommendations could not be made.10,33-35 However, a large number of new articles have been published on these topics including multiple studies with large patient populations and have not been included in these systematic reviews.13,24,36,37

Four large studies have assessed the effectiveness of active surveillance plus contact isolation for preventing spread of MRSA or VRE. Robicsek et al. performed a three-phase quasi-experimental study in three hospitals. Phase one was a baseline assessment in which no intervention was performed. Phase two included surveillance for MRSA in ICUs and contact isolation for MRSA carriers. Phase three expanded to whole-hospital universal surveillance for MRSA, contact isolation for MRSA carriers, and decolonization of MRSA carriers with topical mupirocin. These investigators demonstrated that the aggregate hospital-associated MRSA disease prevalence density decreased by 36.2% (P=0.17) from baseline to ICU surveillance and by 69.6% (P =0.03) from baseline to universal surveillance.36

Similarly, investigators in the Veterans Health Administration performed a quasi-experimental study to assess their nationwide MRSA Prevention Initiative. This initiative was composed of an MRSA prevention bundle which included (1) hand hygiene promotion, (2) an infection prevention culture change, and (3) whole-hospital universal surveillance for MRSA and contact isolation for MRSA carriers. In their analysis of all 153 Veterans affairs hospitals, they found that the rates of healthcare-associated MRSA infections declined by 45% in non-ICUs and by 62% in ICUs after the Initiative was implemented.24

In contrast, Harbarth et al. implemented active surveillance for MRSA carriers in six surgical wards while six other surgical wards served as a control. After a washout period, the intervention and control wards were switched. MRSA carriers identified by active surveillance received a bundled intervention which included contact isolation, adjustment of perioperative antibiotic prophylaxis, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing). This study did not find a significant change in MRSA infections (adjusted incidence rate ratio, 1.20; 95% confidence interval, 0.85-1.69; P=0.29).37

Finally, the STAR*ICU Trial was a cluster-randomized trial of 18 ICUs. This study randomized eight ICUs to standard of care and ten ICUs to a bundle that included universal surveillance for MRSA and VRE, contact isolation for MRSA or VRE positive patients, and universal gloving until surveillance culture results were negative for all other ICU patients. That study found no difference between the intervention and control groups in terms of mean ICU-level incidence of colonization or infection with MRSA or VRE per 1,000 patient-days (40.4±3.3 and 35.6±3.7 in the two groups, respectively; P = 0.35).13

These four studies differed in multiple ways. First, the two studies with positive results assessed their interventions both in the ICUs and universally throughout the health care institutions, while the two studies with negative results only assessed their interventions in ICUs or surgical wards. Each study implemented a unique bundle in which the only common factor in all four bundles was active surveillance plus contact precautions. For example, both the Harbarth and Robicsek included nasal decolonization while the other two studies did not. The studies also varied in how their laboratory testing was performed. For example, in the Veterans Health Administration study, surveillance samples were tested at the local clinical microbiology laboratory. In contrast, in the Star*ICU study, all surveillance samples were mailed to the Clinical Microbiology Laboratory of the National Institutes of Health Clinical Center. Interestingly, when comparing all four of these studies, the studies with negative results had stronger study designs.

The studies above assessed active surveillance among ICU patients. Admission to the ICU is a large risk factor for healthcare-associated infections, therefore, it may be cost-effective to target only ICU patients for active surveillance rather than the entire hospital.38 The high cost of active surveillance has led to multiple cohort studies with the goal of establishing a rule to predict which patients are at high risk for MRSA or VRE colonization.39 A prediction rule would help infection prevention staff determine which patients are likely to carry MRSA or VRE and, thus, could transmit MRSA or VRE to other patients or could acquire an MRSA or VRE infection. Ideally, screening the patients identified as high risk of colonization would be more cost-effective and take less time than testing all patients for MRSA or VRE using traditional active surveillance. Many prediction rules include recent admission to the hospital, which is a strong predictor of MRSA and VRE colonization, with sensitivities ranging from 44% to 77% and specificities ranging from 46% to 98%.38,40-45 Prediction rules have also included risk factors for colonization such as prior operation, hemodialysis, prior history of MRSA or VRE, transfer from long-term care facility, age, antimicrobial use during the past year, and a current wound. If these prediction rules were applied, the proportion of MRSA or VRE colonized patients who would be missed ranged from 15% to 43%.38,40-45 Thus, current prediction rules have had varying success.

Similarly, three studies have created prediction rules to predict patients at high risk for C. difficile infection.46,47 The first prediction rule included age, C. difficile infection pressure, recent admission to the hospital, severity of illness score, days of high-risk antibiotic use, low albumin level, ICU admission, and receipt of laxatives, gastric acid suppressors or antimotility drugs.46 The second rule only included the Waterlow score, a nursing tool routinely used to assess a patient's risk of developing a pressure ulcer.47 The third rule included age, hemodialysis and length of ICU stay.48 The sensitivity of the C. difficile infection prediction rules ranged from 60% to 70% and the specificity ranged from 89% to 95%.46,47

Horizontal approaches to infection control could utilize contact precautions without the use of expensive laboratory surveillance tests. A single ICU, quasi-experimental study of a bundle which included universal contact precautions found that not only did this bundle stop an outbreak of multidrug-resistant Acinetobacter baumannii, it also led to a decrease in MRSA acquisition from 14% to 10%, and VRE acquisition from 21% to 9%.11 Two quasi-experimental studies compared universal gloving (wearing a new pair of gloves for each patient) to active surveillance and contact precautions in a single ICU.49,50 Active surveillance and contact precautions included VRE and MRSA surveillance cultures on admission and every 4 days with contact precautions for patients colonized or infected with VRE or MRSA. Both studies found no difference in MRSA or VRE colonization no matter which intervention was implemented. However, one study found an increase in nosocomial infection rates during the universal glove period, potentially due to decreased compliance with hand hygiene after removal of gloves.49

Another horizontal approach would be to place patients at high risk for acquiring a healthcare-associated infection under pre-emptive contact precautions.51,52 One ICU found that their intubated patients were eight times more likely to acquire healthcare-associated MRSA compared with non-ventilated patients, thus they performed a quasi-experimental study to assess an intervention where all intubated patients were placed under pre-emptive contact precautions. In the first phase of the study, active surveillance for MRSA was performed at ICU admission and weekly with contact precautions for MRSA positive patients. In the second phase of the study, active surveillance and contact precautions for MRSA remained, however all intubated patients were also placed on contact precautions. This study found a decrease in healthcare-associated MRSA infections for both intubated patients (p=0.02) and in all ICU patients (p<0.05).52

Less is known about optimal methods to prevent C. difficile transmission compared with VRE and MRSA.53 Most studies of C. difficile prevention are simple quasi-experimental studies that test a bundled intervention. Multiple recommendations and guidelines suggest contact isolation for symptomatic C. difficile infected patients only.17,53,54 Contact isolation for C. difficile infected patients should include single rooms with private toilets if possible.17 According to the SHEA/IDSA Expert Panel, the only two approaches to preventing C. difficile with good evidence to support them are wearing gloves when caring for an infected patient and antimicrobial stewardship.17,54 No data currently support isolating asymptomatic C. difficile carriers.53,54 An unresolved issue is whether to place symptomatic patients with a history of C. difficile infection under contact precautions.17

Some Potential for Harm Is Associated With Contact Precautions

At the time that “Making Health Care Safer” was published, very few studies assessed the potential harm associated with contact isolation. Recent studies, including a systematic literature review, found that contact precautions have been associated with less patient-to-health care worker contact, changes in systems of care that produce delays and more noninfectious adverse events (e.g., falls, pressure ulcers), increased symptoms of depression and anxiety, and decreased patient satisfaction with care.55-59

Costs and Implementation of Infection Prevention Interventions Have Been Examined

Both vertical and horizontal interventions to prevent healthcare-associated infections require upfront investments to pay for components of the intervention such as supplies (e.g., gowns and gloves) and laboratory resources (e.g., tests, personnel).9 However, a business case can be made for these interventions since the estimated median cost of a healthcare-associated infection ranges from $26,424 to $34,657 for MRSA and from $17,1438 to $36,380 for VRE.60-64 Two studies found that clinical active surveillance of ICU patients for VRE or MRSA colonization was cost effective compared with the cost savings of preventing these infections.63,65 Similarly, another study found that active surveillance and isolation for VRE colonization among high-risk patients cost effective.66 A mathematical model compared whole hospital universal active surveillance for MRSA to targeted active surveillance for MRSA and found that targeted surveillance was more cost effective.67

The cost-effectiveness studies estimated that the cost of active surveillance and contact isolation strategies for MRSA or VRE to range from $1,913 to $10,545 per month.63,65,66 The mathematical model found that the average cost of targeted active surveillance of high risk patients ranged from $4,100 to $12,508 per infection adverted depending on MRSA prevalence and screening test used, while the average cost of universal active surveillance ranged from $5,799 to $21,195 per infection adverted.67 When these costs were itemized, 13% to 99% of the total cost was spent on specimen collection and laboratory testing while the remaining proportion was spent on isolation (e.g., gowns, gloves, nurse time to don gowns and gloves).63,65-67 The vast differences in these proportions were due to how labor costs were accounted for. Studies varied as to how they assessed the cost of laboratory technologists, cost of nursing time to collect swabs, and cost of nursing time to don and remove gowns and gloves.

Although cost-effectiveness analyses have not been performed for universal contact precautions to prevent healthcare-associated infections, an analysis by Wenzel et al., compared the cost-effectiveness of active surveillance and contact precautions for MRSA to a population-based infection control approach. This analysis assumed that active surveillance for MRSA would cost approximately $600,000 while the population-based approach would cost approximately $300,000. If the active surveillance program reduced MRSA infections by 50% and the population-based approach reduced healthcare-associated infections by 50%, then the active surveillance program would save $245 million to $980 million nationally while the population-based intervention would save $1.75 billion to $7 billion nationally.26

As with all health care interventions, health care worker support and implementation of the intervention is necessary for the intervention to be successful. The STAR*ICU trial noted suboptimal implementation of their interventions. That study demonstrated that when contact precautions were specified, gloves were used for 82% of contacts, gowns for 77% of contacts, and hand hygiene was performed after gloves were removed for 69% of contacts. Additionally, when universal gloving was specified, gloves were used for 72% of contacts and hand hygiene was performed after gloves were removed for 62% of contacts.13 The Veterans Health Administration's MRSA initiative includes a dedicated MRSA coordinator at each acute care hospital responsible for implementation of the initiative. From the beginning of the initiative in 2007 to the end of the study period in 2010, compliance with surveillance nasal screening for MRSA increased, with the percentage of patients who were screened at admission rising from 82% to 96%, and the percentage who were screened at transfer or discharge rising from 72% to 93%. However adherence to contact precautions was not reported.24 Two studies by Bearman and colleagues found that observed compliance was higher during a universal glove intervention compared with observed compliance with contact precautions (gowns and gloves) during an active surveillance plus contact precaution intervention. However, the studies found conflicting results as to when hand hygiene compliance was greater. The first study found that the active surveillance and contact precautions intervention was associated with greater compliance with hand hygiene compared with hand hygiene compliance during the universal gloving intervention.49 The second study, which included hand hygiene in-service trainings, found that compliance with hand hygiene was higher during the universal gloving phase compared with the active surveillance and contact precautions phase.50

Upcoming Studies

Of late, two multicenter cluster-randomized trials of contact precautions have been implemented. The Cluster Randomized Trial of Hospitals to Assess Impact of Targeted versus Universal Strategies to Reduce MRSA in ICUs (REDUCE – MRSA trial) recently finished collecting data on the effectiveness of the following strategies: (1) MRSA active surveillance of ICU admissions, followed by contact isolation if positive, (2) MRSA active surveillance of ICU admissions followed by nasal decolonization if positive, and (3) universal nasal decolonization of ICU admissions without screening.68 The Benefits of Universal Glove and Gowning Study (BUGG Study) is currently comparing the effectiveness of universal contact precautions to standard of care in multiple ICUs in order to determine whether universal gowns and gloves decrease the overall burden of healthcare-associated pathogens in the ICU setting. The results of these studies should be available soon and will add to the growing body of evidence on interventions to control healthcare-associated infections.12

Conclusions and Comment

Although many studies have been performed since the “Making Health Care Safer” report, there is still much debate as to which interventions should be implemented to prevent healthcare-associated infections. Vertical interventions, such as active surveillance for MRSA or VRE, have been studied the most; however, these studies have had conflicting results. Horizontal approaches, such as universal gloving, have the potential to reduce the burden of all health care-associate pathogens; however these approaches have been understudied. Current evidence should be considered by individual institutions to determine which interventions are right for their institution based on their patient population, problem pathogens, and ability to implement interventions.69 For example, universal active surveillance for MRSA may be optimal for hospitals with endemic MRSA throughout their hospital, whereas ICU-level universal contact precautions may be recommended for hospitals with multidrug-resistant Acinetobacter baumannii transmission in their ICU. Interventions such active surveillance, contact precautions, and contact isolation should not be performed alone. Rather, these interventions must be performed in conjunction with other infection control interventions such as hand hygiene and antimicrobial stewardship. In conclusion, high quality studies are still needed to determine the optimal interventions to reduce healthcare-associated infections. A summary table is located at Table 1, Chapter 7.

Table 1, Chapter 7. Summary table.

Table 1, Chapter 7

Summary table.

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