Things We Do For No Reason: Contact Precautions for MRSA and VRE

Inspired by the ABIM Foundation’s Choosing Wisely® campaign, the “Things We Do for No Reason” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A 67-year-old man is admitted to a telemetry ward for an acute myocardial infarction and treated with percutaneous coronary intervention. He is currently on day three of antibiotics for a methicillin-resistant Staphylococcus aureus (MRSA) lower extremity soft tissue infection that is healing without a draining wound. He is placed on contact precautions based on institutional infection control guidelines. The hospitalist overhears members of the team commenting on having to don gowns to see this patient each day and wonders aloud whether care is impacted by the use of contact precautions.

Contact precautions (CP) for patients with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) infections are common in several hospitals. CP pose a significant burden to health systems, with an estimated 20%-25% of hospitalized patients on CP for MRSA or VRE alone.¹ CP are becoming increasingly more prevalent with state laws and the Veterans Affairs (VA) hospital system requiring active surveillance cultures (ASC) and subsequent CP when ASC are positive.²

Supporters highlight the utility of CP in preventing the spread of infection, controlling outbreaks, and protecting healthcare workers from certain transmissible diseases. The Centers for Disease Control and Prevention (CDC) recommended CP after prior studies demonstrated their effectiveness during outbreaks of transmissible infections.³ CP were included in bundles alongside interventions such as improving hand hygiene, chlorhexidine gluconate (CHG) bathing, and ASC with targeted or universal decolonization.² The VA MRSA bundle, for example, demonstrated a reduction of healthcare-associated MRSA in the ICU by 62% after implementation. The Society for Healthcare Epidemiology of America Research Network (SHEA) and the Infectious Diseases Society of America (IDSA) recommend CP for MRSA-infected and colonized patients in acute care settings to control outbreaks.^4,5 The CDC also has broad recommendations supporting CP for all patients infected and previously identified as being colonized with target multidrug-resistant organisms (MDROs) without identifying which are considered to be “targets.”⁶

Despite current guidelines, cluster-randomized trials have not shown a benefit of initiating CP over usual care for the prevention of acquiring MRSA or VRE in the hospital. One study demonstrated no change in MRSA and VRE acquisition with broad screening and subsequent CP.⁷ Another study evaluated a universal gown and glove policy in an ICU setting and found a reduction in MRSA acquisition, but no reduction in VRE acquisition.⁸ A third study investigated hand hygiene and daily CHG bathing and noted a reduction in MRSA transmission rates, where CP for screened colonized patients had no effect on transmission of MRSA or VRE.⁹