New expert guidance released today by the Society for Healthcare Epidemiology of America advises hospitals on determining when they can safely discontinue contact precautions for patients with multi-drug resistant bacteria. The framework, published in Infection Control and Hospital Epidemiology, addresses how long hospital staff should use these safety protocols to reduce the spread of potentially deadly organisms within the hospital, in most cases ranging from one to three negative cultures prior to discontinuation. The guidance also outlines the use of molecular testing that is guiding these care decisions.
"Because of the virulent nature of multi-drug resistant infections and C. difficile infections, hospitals should consider establishing policies on the duration of contact precautions to safely care for patients and prevent spread of these bacteria," said David Banach, MD, MPH, an author of the study, and hospital epidemiologist at University of Connecticut Health Center. "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, comprised of experts in infection control and prevention, developed the recommendations based on available evidence, theoretical rationale, practical considerations, a survey of SHEA members, author opinion, and consideration of potential harm, where applicable. The recommendations for duration of contact precautions, such as gowns, gloves, and masks, are specific to key multi-drug resistant organisms, such as MRSA, Vancomycin-resistant enterococci (VRE), and Carbapenem-resistant Enterobacteriaceae (CRE), as well as Clostridium difficile. The guidance was endorsed by the Association for Professionals in Infection Control and Epidemiology (APIC), the Society of Hospital Medicine (SHM), and the Association of Medical Microbiology and Infectious Disease Canada (AMMI Canada).
According to the guidance document, hospital personnel should weigh how much time has elapsed since the last positive culture to determine if contact transmission is likely. The guidance also advises on patient characteristics that could determine the duration of care. For Clostridium difficile infections (CDIs) specifically, the recommendation is to continue contact precautions for at least 48 hours after the resolution of diarrhea and consider extending if CDI rates are elevated despite infection prevention and control measures. At this time, insufficient evidence exists to make a formal recommendation on whether patients with CDI be placed on contact precautions if readmitted to the hospital. The recommendations state that any guidance should be overseen and revisited by infection prevention and control leadership, especially in outbreak situations.
"The duration of contact precautions can have a significant impact on the health of the patient, the hospital, and the community," said Gonzolo Bearman, MD, MPH, an author of the study, and chairman of the Division of Infectious Diseases at Virginia Commonwealth University. "This guidance is a starting point, however stronger research is needed to evaluate and optimize the use."
The authors note that hospitals should carefully assess their institutional risks, priorities, and resources prior to adopting a new policy on the duration of contact precautions, as well as weigh the cost and feasibility of implementation.
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David B. Banach et al, Duration of Contact Precautions for Acute-Care Settings, Infection Control & Hospital Epidemiology (2018). DOI: 10.1017/ice.2017.245