January 15, 2020
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Discontinuing contact precautions may lead to rise in VRE infections

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Hospitals that discontinued contact precautions saw an associated increase in vancomycin-resistant Enterococcus, or VRE, bloodstream infections in comparison with hospitals where these precautions were maintained, according to findings published in Clinical Infectious Diseases.

“Combating antimicrobial resistance is a global priority [that] includes the prevention of spread of vancomycin-resistant Enterococcus (VRE), an important health care-associated pathogen,” Jennie Johnstone, MD, PhD, FRCPC, infection prevention and control physician scientist at Public Health Ontario, Canada, and colleagues wrote. “However, the optimal approach to VRE control in hospitals is unknown, as there is a paucity of strong evidence supporting the use of contact precautions for patients colonized and infected with VRE.”

Starting in 2012, a number of hospitals in Ontario started suspending the use of contact precautions for VRE and active VRE screening programs, causing a “natural experiment” that allowed for the study of associations between discontinuation of contact precautions and VRE infection rates. Johnstone and colleagues first looked at this association in 2015, finding “an increased rate of rise of VRE bloodstream infection” in hospitals where the VRE infection control strategy was changed. The researchers aimed to reassess this association by analyzing all VRE bloodstream infections reported between January 2009 and December 2018.

Hospitals that reported one or more VRE infections during that time period were stratified into two cohorts — a ceased screening cohort (defined as hospitals that ceased contact precautions for VRE during the study period; 23 hospitals) and a screening cohort (consisting of hospitals that did not alter their VRE control strategy; 77 hospitals).

Overall, there were 1,007 VRE bloodstream infections reported; 551 (55%) occurred in the

ceased screening cohort and 456 (45%) occurred in the screening cohort. Rates of VRE bloodstream infections increased by 22.6% per year, starting at 0.73 per 100,000 patient-days in the first reporting quarter in 2009 to 2.9 per 100,000 patient-days in the last reporting quarter in 2018.

A change in slope after contact precautions were eliminated occurred in the ceased screening cohort (annual incidence rate ratio, 1.31; 95% CI, 1.06-1.63). This change in slope was not seen in screening hospitals.

“We have demonstrated a marked association between rising rates of VRE bloodstream infection and discontinuation of contact precautions and active screening programs for VRE,” the authors concluded. “It is unclear whether this finding is explained by the discontinuation of contact precautions, the discontinuation of an active VRE screening program, both, or other factors; however, the association is impressive and persistent.”

The results of the study, taken together with the global goal of reducing the spread of antimicrobial resistance, suggest that hospitals looking to minimize VRE bloodstream infections use contact precautions and screen at-risk patients for VRE colonization as part of their VRE control strategy. – by Caitlyn Stulpin

Disclosures: The authors report no relevant financial disclosures.