BACKGROUND
Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) are endemic in hospital settings. The Centers for Disease Control and Prevention (CDC) recommend placement of patients with a history of MRSA-and/or VRE-colonization on Contact Precautions (CP).1,2 While placement in private rooms is preferred, cohorting is an acceptable, common scenario in semi-private room facilities. Although MRSA and VRE colonization clear spontaneously, no national guidelines exist to inform when or how CP may be discontinued.1,2 We conducted a nationwide survey to gain insight into institutional CP practice.
METHODS
We electronically surveyed members of the Association for Professionals in Infection Control and Epidemiology (APIC, Partners Human Research Committee [P2010-001336]. Participants received a link to the web-based survey on July 5, 2011, which remained active for one month. Study data were collected and managed using Research Electronic Data Capture (REDCap).3
Survey questions covered facility and respondent characteristics, infection control policies, and CP discontinuation policies. Details of discontinuation policies included time since last positive culture prior to eligibility for CP discontinuation, use of microbiological assays to confirm clearance, and permissiveness of concurrent antimicrobial use. For policies requiring microbiological confirmation, respondents were queried regarding the screening site(s), and the timing and number of specimens collected. We analyzed variation in protocols by examining the frequency of respondents with shared protocol elements as a proportion of all reported policies.
RESULTS
Selected institutional characteristics and reported infection control policies are provided (Table 1). Of 11,368 APIC members emailed, 3,057 responded (26.9%), among whom 2,580 (84.4%) self-identified as working primarily in inpatient settings. Most reported a mix of private and semi-private, or all semi-private, accommodations (1,830/2,580, 70.9%); 1,544/1,830 (84.4%) reported cohorting MRSA or VRE patients (data not shown).
Table 1.
Respondent Institutional Characteristics and Infection Control Policiesa
| Institution Characteristics (N=2,580) | |
| Location | |
| Rural/small town (population <20,000) | 679 ( 26.3% ) |
| Town (population 20,000–49,999) | 376 ( 14.6% ) |
| Urban (population 50,000) | 1506 ( 58.4% ) |
| Licensed Beds | |
| <400 bed | 1991 ( 77.2% ) |
| ≥ 400 beds | 584 ( 22.6% ) |
| Bed Organization | |
| All single occupancy | 734 ( 28.4% ) |
| All double occupancy | 59 ( 2.3% ) |
| Mix of single and double occupancy | 1771 ( 68.6% ) |
| MRSA Infection Control Policies | |
| Is there a policy that allows for discontinuation of CP for MRSA? (N=2,580) | |
| Yes | 1873 ( 72.6% ) |
| No | 640 ( 24.8% ) |
| Do you actively screen for the purposes of discontinuation of MRSA CP? (N=2,580) | |
| Never | 809 ( 31.4% ) |
| Sometimes | 1094 ( 42.4% ) |
| Always | 629 ( 24.4% ) |
| Does your MRSA CP policy incorporate any of the following components? (N=1,873)* | |
| Time since last positive culture before screening eligibility | 460 ( 24.6% ) |
| Use of microbiological assays to confirm clearance | 1465 ( 78.2% ) |
| Permissiveness of concurrent or recent antibiotic use | 616 ( 32.9% ) |
| Other/none of the above | 377 ( 20.1% ) |
| Details of MRSA CP policies incorporating use of microbiological assays(N=1,465) | |
| Time since last positive culture before screening eligibility (N=460) | |
| <6 months | 118 ( 25.7% ) |
| ≥6 months | 335 ( 72.8% ) |
| Body site(s) of screening (N=1,465) | |
| Nares | 420 ( 28.7% ) |
| Nares plus original site of infection | 668 ( 45.6% ) |
| Other | 367 ( 25.1% ) |
| Number of negative specimens required to confirm clearance (N=1,465) | |
| 1 | 466 ( 31.8% ) |
| 2 | 444 ( 30.3% ) |
| 3 | 503 ( 34.3% ) |
| >3 | 27 ( 1.8% ) |
| Time interval between specimen collection (N=974) | |
| 24 hours | 333 ( 34.2% ) |
| 48 hours | 215 ( 22.1% ) |
| 1 week | 348 ( 35.7% ) |
| >1 week | 55 ( 5.7% ) |
| VRE Infection Control Policies | |
| Is there a policy that allows for discontinuation of CP for VRE? (N=2,580) | |
| Yes | 1457 ( 56.5% ) |
| No | 973 ( 37.7% ) |
| Do you actively screen for the purposes of discontinuation of VRE CP? (N=2,580) | |
| Never | 1284 ( 49.8% ) |
| Sometimes | 861 ( 33.4% ) |
| Always | 327 ( 12.7% ) |
| Does your VRE CP policy incorporate any of the following components? (N=1,457)* | |
| Time since last positive culture before screening eligibility | 320 ( 22.0% ) |
| Use of microbiological assays to confirm clearance | 1122 ( 77.0% ) |
| Permissiveness of concurrent or recent antibiotic use | 412 ( 28.3% ) |
| Other/none of the above | 253 ( 17.4% ) |
| Details of VRE CP policies incorporating use of microbiological assays(N=1,122) | |
| Time since last positive culture before screening eligibility (N=320) | |
| <6 months | 100 ( 31.3% ) |
| ≥6 months | 213 ( 66.6% ) |
| Body site(s) of screening (N=1,122) | |
| Rectum | 281 ( 25.0% ) |
| Original site of infection | 201 ( 17.9% ) |
| Rectum plus original site of infection | 628 ( 56.0% ) |
| Number of negative specimens required to confirm clearance (N=1,122) | |
| 1 | 212 ( 18.9% ) |
| 2 | 180 ( 16.0% ) |
| 3 | 691 ( 61.6% ) |
| >3 | 24 ( 2.1% ) |
| Time interval between specimen collection (N=895) | |
| 24 hours | 132 ( 14.8% ) |
| 48 hours | 110 ( 12.3% ) |
| 1 week | 597 ( 66.7% ) |
| >1 week | 41 ( 4.6% ) |
Respondents reporting “I don’t know” or not responding to a particular question are not provided, and thus the summed percentages may not equal 100%.
This question was asked in a “check all that apply” format, so summed percentages may exceed 100%.
MRSA: methicillin-resistant Staphylococcus aureus; VRE: Vancomycin-resistant enterococcus; CP: Contact Precautions
The majority of respondents reported institutional policies allowing for CP discontinuation in patients with a history of MRSA (1,873/2,580; 72.6%) or VRE (1,457/2,580; 56.5%). A minority of respondents reported a policy for actively screening patients for these purposes.
Characteristics of MRSA CP discontinuation policies
Of the 1,873 respondents reporting the existence of a MRSA CP discontinuation policy, 460 (24.6%) indicated that eligibility for screening depended on time since last positive MRSA culture. For policies where time was a consideration, 25.7% reported waiting times of <6 months, and 72.8% reported waiting ≥6 months prior to screening.
The majority of respondents (1,465/1,873; 78.2%) reported a policy that required microbiological confirmation of clearance of MRSA colonization. Analysis of MRSA CP discontinuation policies revealed that clearance was based on: the timing and number of specimens collected, the specimen collection site, and the time elapsed since last positive culture. The combination of reported requirements yielded 64 distinct MRSA CP discontinuation strategies, only two of which accounted for ≥5% of respondents. These two policies both required ≥6 months to elapse prior to screening and used a single sample from either the nares or nares in addition to the original infection site.
Characteristics of VRE CP discontinuation policies
Of the 1,457 respondents reporting the existence of a VRE CP discontinuation policy, 320 (22.0%) indicated that the policy considered time since last positive VRE culture when determining CP discontinuation eligibility. For policies where time was a consideration, 31.3% reported waiting <6 months, while 66.6% reported waiting 6 months since most recent positive culture prior to screening.
The majority of respondents reported the existence of an institutional policy requiring microbiological confirmation of VRE clearance (1,122/1,457; 77.0%). Analysis of VRE CP discontinuation policies revealed that clearance was based on: the timing and number of specimens collected, the collection site, and the time elapsed since last positive culture. The combination of reported requirements yielded 48 unique strategies, with four strategies accounting for >5% of respondents each. A single strategy requiring 6 months since prior positive culture and three specimens obtained from both the rectum and original infection site at one-week intervals was reported by 17.2% of respondents.
DISCUSSION
This survey highlights the substantial variation in CP discontinuation policies that occurs in the absence of national guidance. Though most respondents indicated the existence of MRSA/VRE CP discontinuation policies at their institutions, the majority did not actively screen patients for CP discontinuation. In the absence of an active screening program, formerly colonized patients may inappropriately remain on CP indefinitely, even in institutions with discontinuation policies.
CP results in fewer patient-provider interactions, possibly leading to delays in care or reductions in the quality of care.4 In settings that allow cohorting, patients who have cleared colonization (but have not been tested and confirmed as such) may be falsely cohorted with others who have active infection or colonization, thus risking re-acquisition.5,6 From the hospital perspective, misclassification of CP patients wastes resources in the form of gowns and gloves, personnel time spent cleaning rooms and donning and doffing protective equipment, and in reductions in bed availability and delays in bed assignment due to cohorting requirements.7–9
Due to the anonymous nature of the survey, we were unable to assess whether respondents to our survey differed from non-responders. It is also possible that more than one response per institution was included. Although our response rate of 26.9% was less than optimal, this survey provides insights into the diverse set of institutional policies in the absence of national guidelines.
Given the paucity of data to inform evidence-based guidelines, further research on the most effective strategies for discontinuation of CP in MRSA/VRE patients is needed. Such research could inform national guidelines to address the growing pool of colonized and resource-intensive patients.
Acknowledgments
We thank the leadership and membership of APIC for participation in the survey. We also thank Elena Losina, Ph.D., for helpful comments on the design of the survey instrument. We thank Lynn Simpson for assistance with REDCap. This work was conducted with support a 2010 MGH Clinical Innovation Award (ESS), NIH Training grant (ESS, NIH T32 A107061), MGH Institutional Funds, the Harvard Catalyst | The Harvard Clinical and Translational Science Center (NIH Award #UL1 RR 025758 and financial contributions from Harvard University and its affiliated academic health care centers), and the Harvard University Center for AIDS Research (CFAR), an NIH funded program (P30 AI060354) which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, NCCAM, FIC, and OAR. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, the National Center for Research Resources, or the National Institutes of Health. None of those acknowledged received financial compensation for their contributions. A copy of the Survey Instrument is available upon request.
Footnotes
CONFLICT OF INTEREST
ESS: No potential conflicts of interest.
HH: No potential conflicts of interest.
FN: No potential conflicts of interest.
DCH: No potential conflicts of interest.
RPW: No potential conflicts of interest.
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