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SHEA issues guidance on contact precautions

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January 11, 2018

The Society for Healthcare Epidemiology of America has released expert guidance on when hospital staff should end contact precautions for patients with multidrug-resistant bacterial infections.

The recommended duration of contact precautions (CP), including the use of gowns, gloves and masks, is specific to certain multidrug-resistant pathogens, according to SHEA. The new guidance was published in the organization’s official journal, Infection Control & Hospital Epidemiology.

“Because of the virulent nature of multidrug-resistant infections and Clostridium difficile infections (CDIs), hospitals should consider establishing policies on the duration of contact precautions to safely care for patients and prevent spread of these bacteria,” David Banach, MD, MPH, a hospital epidemiologist at the University of Connecticut Health Center and a co-author of the guidance, said in a news release. “Unfortunately, current guidelines on contact precautions are incomplete in describing how long these protocols should be maintained. We outlined expert advice for hospitals to consider in developing institutional policies to more effectively use contact precautions to safely care for patients.”

The SHEA Guidelines Committee of experts on infection control and prevention developed the guidance. It is based on available evidence, theoretical and practice considerations, a survey of SHEA members and the opinions of the authors. The guidance was endorsed by the Association for Professionals in Infection Control and Epidemiology, the Society of Hospital Medicine and the Association of Medical Microbiology and Infectious Disease Canada.

The guidance says hospital staff should consider how long it has been since the last positive culture was taken from a patient to decide whether contact transmission is likely. It also describes factors that can used to determine duration of care.

For patients with CDI, staff are advised to maintain CP for at least 48 hours after diarrhea is resolved and possibly to extend the precautions “through the duration of hospitalization” if CDI rates are elevated even after prevention and control measures are taken.

For patients with MRSA who are not receiving antimicrobials with activity against it, the guidance says that negative cultures should help determine when to end CP. The best number of negative cultures is unknown, the authors noted, but hospitals often use between one and three.

In cases of vancomycin-resistant enterococci infection, the guidance suggests that negative stool or rectal swab cultures should be used. Again, one to three negative cultures are common.

For multidrug-resistant Enterobacteriaceae (MDR-E), recommendations are broken down by specific pathogens in that group. For extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE), they advise considering several factors, including whether at least 6 months have passed since the last positive culture.

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For extensively resistant Enterobacteriaceae, such as carbapenemase-producing CRE or Enterobacteriaceae that are susceptible to no more than two antibiotic classes that are used to treat them, staff should maintain CP “indefinitely,” the authors said.

The authors said they could not yet recommend molecular testing to guide decisions on maintaining CP.

“While we assume that PCR tests perform with superior sensitivity compared to culture, due to lack of high-quality studies at this time, we cannot definitively ascertain the impact of molecular methods on informing the duration of colonization and guiding decisions about CP,” they wrote.

Any guidance should be overseen and revisited by infection control leaders, especially during outbreaks, the recommendations state.

“The duration of contact precautions can have a significant impact on the health of the patient, the hospital and the community,” guideline co-author Gonzolo Bearman, MD, MPH, chairman of the division of infectious diseases at Virginia Commonwealth University, said in the news release. “This guidance is a starting point. However, stronger research is needed to evaluate and optimize its use.”

The guideline authors cautioned that, before adopting new CP policies, hospital leadership should assess the costs and feasibility of doing so. – by Joe Green

Disclosures: Banach reports no relevant financial disclosures. Please see the guidelines for all other authors’ relevant financial disclosures.

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Perspective

This new guidance on the duration of CPs provides important information that can be used by health care providers and administrators in the fight against multidrug-resistant bacteria.

CPs are a basic infection control tool used to prevent the spread of antimicrobial resistance in hospitals, although the optimal duration for which precautions are needed is often unclear. This guidance provides new clarity and practical guidance that improve upon existing information and can be used to protect patients from acquiring resistant bacteria while also limiting the duration of time that patients remain on CP isolation unnecessarily.

For years, these antimicrobial-resistant infections have challenged health care personnel who work tirelessly to prevent their spread. This guidance will have a significant impact on the prevention of antimicrobial resistance and will also improve the quality and safety of patient care.

Keith S. Kaye, MD, MPH

Infectious Disease News Editorial Board member
President, SHEA Board of Trustees
Professor of internal medicine
Director of clinical research
Division of infectious diseases
University of Michigan Medical School

Disclosure: Kaye reports no relevant financial disclosures.