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How Should We Prevent Transmission of MDROs?

Reviewed by Emily S. Spivak, MD, MHS; University of Utah School of Medicine and John A. Sellick, DO, MS; University at Buffalo Jacobs School of Medicine and Biomedical Sciences

Whether a strategy using single-bed as opposed to multi-bed rooms on top of existing contact precautions (CP) confers additional protection against transmission of drug-resistant organisms is debated. Kluytmans-van den Bergh and colleagues performed a cluster-randomized, crossover, non-inferiority study on medical and surgical wards in 16 Dutch hospitals between 2011 and 2014 to compare the role of single-bed rooms versus multi-bed rooms in addition to CP for patients with ESBL-producing Enterobacteriaceae from clinical cultures. The primary outcome was transmission of ESBL-producing Enterobacteriaceae to other patients on the ward, defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate clonally related to the index patient’s isolate. 463 index patients and 7093 ward mates were evaluated in the per-protocol population. Screening of ward mates for ESBL-producing Enterobacteriaceae was performed on day 7 (range 5–9) after enrollment of the index patient with perianal or per-stomal swabs cultured on ESBL selective media. ESBL-producing Enterobacteriaceae transmission to at least one wardmate was identified for 11 (4%) of 275 index patients during the single-bed room strategy period and 14 (7%) of 188 index patients during the multi-bed room strategy period (crude risk difference 3·4%, 90% CI –0·3 to 7·1). The authors note non-inferiority of a multi-bed strategy and emphasize the availability of multi-bed isolation rooms for patients with ESBLs may minimize resource utilization and increases flexibility for infection prevention without adversely affecting transmission risk.

The use of CP likewise has engendered brisk debate. The Department of Veterans Affairs (VA) mandated Universal MRSA screening with CP for all acute-care patients colonized/infected with MRSA in 2007 and expanded the use of CP to long-term care (LTC) in 2013. The impact of the latter recommendation is not clear so Morgan et al from the VA Maryland network used a “big data” approach to evaluate the potential benefit. Using the VA’s Corporate Data Warehouse and Inpatient Evaluation Center (IPEC) they extracted data on patients in 74 of the total 136 long-term care facilities in the VA system. This group of LTCs provided their written policies regarding the use of MRSA CP for review. The authors analyzed patients who had negative MRSA screening on admission and then sought evidence of new MRSA colonization or infection following admission. In the pre-expanded policy era, the number of new colonization was 2.55/1000 patient days and in the CP policy era it was 2.54/1000 patient days. MRSA infections declined overall during the study and were not different pre/post policy. Sensitivity analyses were done to identify confounders related to severity of illness and colonization pressure but there were no obvious interactions identified. This led the authors to conclude that in VA LTCs, the use of CP did not decrease the transmission of, or infection with, MRSA. The caveats include whether or not this would apply to non-VA facilities that may have different policies or levels of staffing, and the fact that this was a retrospective quasi experimental study. Nonetheless, the potential lack of impact of CP must be balanced against the negatives of placing LTC patients in CP.

References:

Kluytmans-van den Bergh MFQ, et al. Contact precautions in single-bed or multiple-bed rooms for patients with extended-spectrum β-lactamase-producing Enterobacteriaceae in Dutch hospitals: a cluster-randomized, crossover, non-inferiority study. Lancet Infect Dis. 2019 Oct; 19(10): 1069-1079. https://www.ncbi.nlm.nih.gov/pubmed/31451419 

Morgan DJ, Zhan M, Goto M, et al. The effectiveness of Contact Precautions on methicillin-resistant Staphylococcus aureus (MRSA) in long-term care across the United States. Clin Infect Dis. 2019 Oct 22. pii: ciz1045. doi: 10.1093/cid/ciz1045 https://www.ncbi.nlm.nih.gov/pubmed/31637429 

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