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

Contact precautions for MRSA and VRE should be used to interrupt transmission during uncontrolled outbreaks, and in patients with open wounds, uncontained secretions, or incontinent diarrhea.

In addition, there are other commonly encountered organisms for which CP should be continued. CP should be used for active Clostridium difficile infection to prevent transmission. Due to the paucity of data regarding prevention of novel and highly resistant organisms and the complexity in treating these MDROs, it is reasonable to initiate CP in these cases.²⁶ Examples include active infection with multidrug resistance, including carbapenem-resistant Enterobacteriaceae, highly drug-resistant Pseudomonas aeruginosa, and other emerging MDROs such as vancomycin-resistant or -indeterminate S. aureus (VRSA or VISA) and Candida auris.²⁷ Limiting CP to instances where there is clear evidence to support will ensure patient safety and limit the harms associated with CP.

Horizontal prevention aims to reduce the burden of all microorganisms. This includes techniques such as hand hygiene, antimicrobial stewardship, CHG bathing, and environmental cleaning methods to decrease colonization of all MDROs in hospital rooms. Compared with vertical prevention strategies that use active surveillance testing for colonization and CP, horizontal interventions are the most effective means to reduce transmission of MDROs.²⁸ The simplest and the most well-studied method for reducing transmission of all organisms in the hospital remains hand hygiene.²⁹ High institutional hand hygiene rates of at least 90% are critical to the success of any initiative that seeks to eliminate CP.

CHG bathing has also been studied across multiple patient settings for reducing MRSA and VRE acquisition, catheter-associated urinary tract infections, and central line-associated bacterial infections.³⁰ In addition, hospital-wide daily CHG bathing has been associated with decreased C. difficile infection, and the baths were well tolerated by patients.³¹

SHEA recently released recommendations for timing of discontinuation of CP for patients with MDROs and emphasized that hospital systems must take an individual approach to discontinuing CP that takes into account local prevalence, risk, and resources.³² The decision to not place a patient on CP is one side of this high-value coin. The other side is knowing when it is appropriate to discontinue CP.

• Discontinue the use of CP for MRSA and VRE in hospitals with low endemic rates and high hand hygiene compliance.
• Improve horizontal preventions by promoting hand hygiene, antimicrobial stewardship, and considering CHG bathing for all patients.
• Create a systematic approach to discontinuing CP and compare transmission of MRSA and VRE rates through microbiology surveillance before and after discontinuation.

Contact precautions for MRSA and VRE are another example of a “Thing We Do for No Reason”. For most patients with MRSA and VRE, CP have not been shown to effectively reduce transmission. In addition, CP are expensive and associated with increased rates of patient adverse events. Hospitalists can lead the effort to ensure optimal hand hygiene and work with local infection control teams to reevaluate the utility of CP for patients with MRSA and VRE.