SHEA Releases Contact Precaution Guidelines for Multidrug-Resistant Infections
The guidance describes the use of molecular testing to help guide clinical decision-making.
A new expert guidance concerning contact precautions (CP) for multidrug-resistant bacteria has been released and published in Infection Control and Hospital Epidemiology.
The document was authored by members of the SHEA Guidelines Committee and was based on current literature, theoretical rationale, author opinions, and other practical considerations. The guidance, intended for acute care hospitals that already use CP, also describes the use of molecular testing to help guide clinical decision-making.
For methicillin-resistant Staphylococcus aureus (MRSA), negative screening cultures should guide CP discontinuation. Although the number of cultures needed is unclear, the authors write, "1-3 negative cultures are often used." High-risk patients (eg, chronic wounds, long-term care facilities) should receive extended CP from their last MRSA-positive culture before assessing for CP discontinuation. Moreover, if a facility's MRSA infection rates are low, it may alternatively consider CP for patients with active MRSA infection "for the duration of the index admission and discontinuing CP on hospital discharge."
For vancomycin-resistant Enterococci (VRE), negative stool or rectal swab cultures should guide the decision on CP discontinuation. If the patient is highly immunosuppressed, receiving broad spectrum systemic antimicrobial therapy without VRE activity, receiving care in protected environments, or receiving care at institutions with high rates of VRE infection, the hospital should then consider extending CP before assessing for CP discontinuation.
For multidrug-resistant Enterobacteriaceae (MDR-E), the authors suggest taking a case-by-case approach to CP discontinuation accounting for the time elapsed since the last positive culture, the presence of infection and ongoing antibiotic use, and the procurement of ≥2 consecutive negative rectal swab samples obtained ≥1 week apart. Hospitals should maintain CP indefinitely for extensively drug-resistant Enterobacteriaceae.
For Clostridium difficile infection (CDI), CP care should be continued for ≥48 hours after diarrhea resolution. If rates of CDI are elevated despite prevention and control measures, the hospital should consider extending CP for the duration of the hospitalization.
The authors indicate that further research is needed to improve "understanding of the role of molecular testing in evaluating the transmissibility of organisms in healthcare settings, and how these tests perform in comparison to culture-based methodologies in guiding decisions regarding the duration of CP."
They conclude by suggesting large multicenter trials in real-world settings using evidence of CP use in the spread of multidrug-resistant organisms would be valuable in developing evidence-based guidelines for CP implementation.
Banach DB, Bearman G, Barnden M, et al. Duration of contact precautions for acute-care settings [published online January 11, 2018]. Infect Control Hosp Epidemiol. doi: 10.1017/ice.2017.245