Contact Precautions Debate Teleclass Slides, Sep.27.16 · Weist K ICHE March 2002 FOR MORE INFO... Patient A MRSA+ ... Huang SS CID 2008 3. Huang SS, Platt R, Clin Infect Dis 2003

House believes contact precautions are essential for the management of patients with MDROs

Debate ....

www.webbertraining.com September 27, 2016

Speaking FOR the motion ..... Prof. Eli Perencevich University of Iowa

Speaking AGAINST the motion ..... Dr. Fidelma Fitzpatrick Royal College of Surgeons in Ireland

EliPerencevich,MDMSProfessorofInternalMedicine

UniversityofIowa,CarverCollegeofMedicine

PIandDirector,VAHSR&DCenterforComprehensiveAccessandDeliveryResearch&EvaluaDon

ControversiesBlog:stopinfecDons.org

[email protected]:@eliowa

Housebelievescontactprecau1onsareessen1alforthemanagementofpa1entswithMDROs

FOR:

ConflictsofInterestStatement

! Nofinancialconflicts! SecDonEditorforGuidelines,PosiDonPapers,andInvitedReviews@ICHE

! FederalFunding! VAHSR&D(COINandCREATE)! CDCPrevenDonEpicenter! AHRQ

ContractPrecau,onsPreventTransmission

MyExperiencewithContactPrecau,ons

BasicsofHowContactPrecau,onsWork

Review“SideEffects”

HandHygieneCompletelyDead

! “HandHygieneCompliance:arewekiddingourselves?”1

! Targetssetat>90%,metbymostfaciliDes! 2009-2014SystemaDcReview2

! MeancompliancebeforeintervenDon34%! AaerintervenDon57%

! Ifwecan’tdohandhygiene,weneedSOMETHINGtopreventtransmission

1. Mahida N. JHI 2016 (92) 307-8 2. Kingston L. et al. JHI 2016:309-20

FOR MORE INFO...

SignificantpaDent-to-paDentspreadoccurringinICUs

! ProspecDvecohort,5ICUsin2hospitals1

! GeneDcallylinked10pathogens! 14.5%ofinfecDonscouldbept-to-pt

! ProspecDvecohort,GermanICU2

! PFGEforMRSAandPCR! 37.5%ofnosocomialinfec,onscouldbeduetocross-transmission

1.Grundmann H et al. Crit Care Med 2005 2. Weist K ICHE March 2002

FOR MORE INFO...

Patient A MRSA+

Patient B MRSA-

Nosocomial Transmission

HowCParetypicallyuDlized

! LinkedtoacDvesurveillanceofMDROpaDents

! AppearsweareprotecDngHCW?

Patient A MRSA+

Patient B MRSA-

Nosocomial Transmission

HowmightCPbebeKeruDlized?

! StrategiesthatisolateMDRO-paDentsprotectthem

BenefitsofAcDveSurveillance(VRE)

Perencevich et al. Clin Infect Dis 2003

FOR MORE INFO...

BenefitsofIsolaDonforVRE

Perencevich et al. Clin Infect Dis 2003

FOR MORE INFO...

Youcan’tstudywithMathModels

! ThearDclebyPerencevichetal.haspotenDalformoving…infecDon-controlcommuniDesclosertoaDppingpointonthecontrolofthisimportantpathogen…IthasthispotenDalbecausethemodelseemstobelogicalandmathemaDcallycorrect(and)providesvaluableinsightintotheimportanceofvariablessuchastheprevalenceofcultureposiDvityatICUadmissionandtheduraDonofICUstay.”–BarryFarr,ClinInfectDis2003

Uncolonized Colonized, No infection Infected

Outcomes (Mortality)

LOS, comorbidity, colonization

pressure

Severity of Illness, comorbidity,

antibiotic exposure

Severity of illness, comorbidity,

source control, antibiotics

Bare Below Elbows, White Coats, Contact

Precautions

Key question: How many colonized become infected? 20:1 vs 10:1 vs 1:1

Interven,onsTarge,ngTransmission

Studiesdon’tincludepost-dischargeinfecDons

! Including30-daypostdischargeincidentMRSAinfecDonstripledmedianincidence1

! From12.2to35.7/10,000atriskadmissions,p<0.01! LimitedbyuseofICD-9codeforMRSA

! ProspecDvecohortof281MRSAcarriers2! 40%MRSAinfecDonsoccurredduringlaterhospitalizaDons,higherriskforrecentcarriers

! ProspecDvecohortof209newcarriers3

! 49%ofincidentMRSAinfecDonswerepost-discharge

1. Avery et al. ICHE February 2012 2. Datta R, Huang SS CID 2008 3. Huang SS, Platt R, Clin Infect Dis 2003

FOR MORE INFO...

DifficulttostudycontactprecauDons

! Needsurveillanceswabsonadmission/dischargetomeasurebenefits! SensiDvity/specificity/costsofsurveillancetests! Typicallylookatonly1-2organisms! Veryhardtopower/designgoodefficacytrials

" Morelikelytobeunderpowered/negaDvestudies

! RCTscan’tanswerforallcondiDons" Organismprevalence,ICUlengthofstay" Needcohortstudiesandmathmodels

Don’twaitforRCT

! MustconsiderotherformsofepidemiologicaldatawhenassessingbenefitsofcontactprecauDons

! WewillbewaiDngforyearsforwell-poweredRCTs! Airlinesafety:

! Traytablesupbeforetake-off–RCT?! Nosleepinginaislesofplane–RCT?

! Parachutes

MyContactPrecauDonsDecade

! July2002,MICU

! EveryoneonvacaDon,except…

! 5paDentswithMDR-ABbacteremiainJuly! 4inAugust

! Controlplan

! ShutMICU

! Press

! BanarDficialnails

0

1

2

3

4

5

Whathappened?

! Lawsuits

! ClosedMICU2002

! ClosedSICU2007and2009! ClosedseveralShockTraumaICUs

! Universalgown/gloveinMICUandSICU1

! AcDvesurveillanceonalltransfersfromOSH;isolatedunDlculturesreturn

! StatewideABsurveillance(2010)

1. Wright MO et al, Infect Control Hosp Epi

Red >48 hours

ResearchQuesDons

! 1.Howimportantarecontactprecau,onsforMRSA,VRE,MDRA.baumanniiorMDRP.aeruginosa?

! 2.Howimportantishand-hygieneaaerusingcontactprecauDonsforMDRA.baumannii?

1. Morgan D, et al, Infect Control Hosp Epidemiol July 2010 2. Snyder G, et al, Infect Control Hosp Epidemiol July 2008; 29(7):584-589

FOR MORE INFO...

Methods

! Culturedhands! beforeentry! gowns/glovesaaerexit! handsaaergown/gloveremovalbeforehandhygiene

TransmissibilityandProtecDon

Organism

HCW Room

Entries

Hand + Before

(%)

Gown and/or

Glove + After %

Hands + After

Removal Effectiveness

of PPE

A. baumannii1 202 1.5% 38.7% 4.5% 88%

P. aeruginosa1 133 0% 8.2% 0.7% 90%

VRE2 94 0% 9% 0% 100%

MRSA2 81 2% 19% 2.6% 85%

1. Morgan D, et al, Infect Control Hosp Epidemiol July 2010 (in press) 2. Snyder G, et al, Infect Control Hosp Epidemiol July 2008; 29(7):584-589

FOR MORE INFO...

Tenorio et al. Clin Infect Dis, March 1, 2001:826-9

EffecDvenessofGloves

! 50HCWcontactswithVRE+paDents

! 44withHandsnegaDveforVREpriortocontact! 6wereVRE+beforeenrollmentandexcluded

! 17of44HCW(39%)acquiredVREontheirgloves

! 12ofthese17(71%)HCWhandswereVREnegaDve

! Thus,glovesreduceVREtransmissionby~70%

FOR MORE INFO...

Hayden M et al. ICHE 2008 Feb;29(2):149-54

Moreevidenceforgloves

! CulturedpaDent,environmentand103HCWhands/glovesbeforeandaaer131observaDons

! 52%contaminatedongowns/glovesaaertouchingenvironment

! 70%contaminatedaaertouchingpaDent/environment

! Handscontaminated37%ofDmeifnogloves

! Only5%handcontaminaDonifglovesworn! 86%benefitofgloves

FOR MORE INFO...

TransmissionMatrix

HowlikelyisaHCWtobecontaminatedaaerleavingroom?

! TransmissiondataforMDRA.baumannii! InrelaDonshiptocompliancerates! AssumpDonofindependenceofratesand100%eradicaDonwithhand-hygiene

A.baumannii:TransmissionfromPttoHCWwithVariableCompliance

0 36% 20% 17% 14% 11% 8% 5%

50% 18% 10% 9% 7% 5% 4% 2%

60% 15% 8% 7% 6% 4% 3% 2%

70% 11% 6% 5% 4% 3% 2% 1%

80% 7% 4% 3% 3% 2% 2% 1%

90% 4% 2.% 2% 1% 1% 1% 1%

100% 0 0 0 0 0 0 0

0 50% 60% 70% 80% 90% 100%

Compliance with Gloves (patients on contact precautions)

Com

plia

nce

with

Han

d-H

ygie

ne

TransmissionfromPaDenttoHCWwith50%handhygienecompliance

0 36% 20% 17% 14% 11% 8% 5%

50% 18% 10% 9% 7% 5% 4% 2%

60% 15% 8% 7% 6% 4% 3% 2%

70% 11% 6% 5% 4% 3% 2% 1%

80% 7% 4% 3% 3% 2% 2% 1%

90% 4% 2.% 2% 1% 1% 1% 1%

100% 0 0 0 0 0 0 0

0 50% 60% 70% 80% 90% 100%


Com

plia

nce

with

Han

d-H

ygie

ne

Whatabout90%handhygienecompliance?

0 36% 20% 17% 14% 11% 8% 5%

50% 18% 10% 9% 7% 5% 4% 2%

60% 15% 8% 7% 6% 4% 3% 2%

70% 11% 6% 5% 4% 3% 2% 1%

80% 7% 4% 3% 3% 2% 2% 1%

90% 4% 2.% 2% 1% 1% 1% 1%

100% 0 0 0 0 0 0 0

0 50% 60% 70% 80% 90% 100%


Com

plia

nce

with

Han

d-H

ygie

ne

Whatabout90%handhygieneand70%CPcompliance?

0 36% 20% 17% 14% 11% 8% 5%

50% 18% 10% 9% 7% 5% 4% 2%

60% 15% 8% 7% 6% 4% 3% 2%

70% 11% 6% 5% 4% 3% 2% 1%

80% 7% 4% 3% 3% 2% 2% 1%

90% 4% 2.% 2% 1% 1% 1% 1%

100% 0 0 0 0 0 0 0

0 50% 60% 70% 80% 90% 100%


Com

plia

nce

with

Han

d-H

ygie

ne

ContactPrecauDonsImproveHandHygieneCompliance

! Inlong-termcare,contactprecauDonsassociatedwithhigherhandhygienecompliance1

! BeforeinteracDonRR1.76(0.71-4.33)! AZerinterac,onRR2.68(1.67-4.30)

! 4acutecarehospitalswith7,743HCWvisits2

! Entrycompliance:42.5%onCPvs30.3%,p=0.14! Exitcompliance63.2%onCPvs47.4%,p<0.001

! 38%handhygieneaZerglovesvs9.8%inICUs3

1. Thompson BL et al. ICHE 1997 2. Morgan DM et al ICHE 2013

3. Kim PW et al. AJIC 2003

FOR MORE INFO...

Butwhataboutthisfamousstudy?

! 56wardsin15hospitals! EnglandandWales! InternaDonalPress

MinimalchangeAFTERcontact

Fulmer C. et al. ICHE 2011 FOR MORE INFO...

MinimalchangeAFTERcontact

Fulmer C. et al. ICHE 2011 FOR MORE INFO...

ANDnoneedtoperformhandhygienebeforedonninggloves

! ProspecDverandomizedtrialof230HCWenteringICUrooms! Directlydonnonsterilegloves! Performhandhygieneandthendonnonsterilegloves

! Nosignificantdifferenceincolonycountsofglovedhandsbetweengroups,p=0.52! RaDoofmeancolonycounts0.86(0.53-1.37)

Rock C. et al. AJIC, November 2013 FOR MORE INFO...

Butdotheywork?

! MedicalICUimplementeduniversalcontactprecauDonsduringMaryland’sAcinetobacteroutbreak

! Quasi-experimentalstudy,6monthsbefore/aaer

! Outcome:AcquisiDonofVREandMRSAassessedwithadmission,weeklyanddischargecultures

! VREacquisi,ondeclined,21%to9%,p=0.05

! MRSAacquisiDondeclined14%to10%,p=0.5

Wright MO, et al. ICHE Feb 2004 FOR MORE INFO...

BUGG

! Match-pairedcluster-RCT,9months

! 20medicalandsurgicalICUs,20USHospitals

! Poweredtodetect25%reducDoninVREorMRSA! $5.7milliondollars

Harris AD, et al. JAMA 2013 FOR MORE INFO...

BUGGIntervenDon

! 26,180paDentadmissions

! 92,241swabscollected,over84%compliance

! IntervenDonICUs! Glovecompliance86%,gown85%

! ControlICUs(10.5%oncontactprecauDons)! Glovecompliance84%,gown81%

! Comparing85%paDentsunderCPvs8.5%


MRSAand/orVRE

! MRSAandVRE-1.71acquisiDonsper1000paDentdays(-6.15to2.73,p=0.57)

! VRE0.89acquisiDons/1000paDentdays,p=0.70! MRSAreduced-2.98acquisi,ons/1000pa,entdays,(-5.58to-0.38,p=0.046)

! 40.2%reduc,oninMRSAintheinterven,ongroupvs15%reduc,oninthecontrolgroup


Otheroutcomes

! HCWvisitedonefewerDmeperhour! 4.28vs5.24,p=0.02

! Handhygienecomplianceonentrydidn’tdiffer

! HandhygieneonexitimprovedwithCP! 78.3%vs62.9%,p=0.02

! NochangeinCLABSI,CAUTI,VAPormortalityrates


OtherinfecDonrelatedoutcomes?

! HCWvisitedonefewerDmeperhour! 4.28vs5.24,p=0.02

! Handhygienecomplianceonentrydidn’tdiffer

! HandhygieneonexitimprovedwithCP! 78.3%vs62.9%,p=0.02

! NochangeinCLABSI,CAUTI,VAPormortalityrates


Nodifferenceinadverseevents


! RandomselecDon(N=90/ICU),chartreview

! IHIGlobaltriggertool

ButwhatabouttheotherbadsideeffectsofcontactprecauDonsstudies?

Stelfox et al. JAMA October 2003 FOR MORE INFO...

General Cohort

Congestive Heart Failure Cohort

Precautions n=78 Controls n=156 Precautions n=72 Controls n=144

Outcomes: Length of Stay* 31 vs. 12 days 8 vs. 6 days any Adverse Event* 17% vs. 7% 47% vs. 25% Preventable AE* 12% vs. 3% 29% vs. 4% Death 27% vs. 18% 21% vs. 15%


General Cohort




DifferenceinAdverseEventsdueto:—falls

—pressureulcers—fluid&electrolytedisorders



General Cohort







General Cohort




Study never adequately controlled for severity of illness

ContactPrecauDonsassociatedwithreducedhealthcareworkervisits

Design Effect

Kirkland&Weinstein1999

Cohort 2.1vs.4.2hourlycontactswithHCWs

Saintetal2003 Cohort 35%vs.73%paDentsexaminedbyaKendingphysicians

Evansetal2003 Matchedcohort 5.3vs.10.9contactsHCWs22%lesscontactDmeoverall

Morganetal2013

Cohort 2.78vs.4.37visits/hour17.7%lesscontactDme23.6%fewervisitors

Harrisetal2013

Randomizedcontrolledtrial

4.28vs.5.24visits/hour

Arereducedvisits“independently”bad?

! Independently=badforpaDentswithoutcausingotherproblems

! IfnoadverseeventsinRCTthenreducedvisitscouldbegoodforpaDents(oratleastnotbad)

! Fewervisits=feweropportuni,estotransmitinfec,ons

! Fewervisits=fewerdisrup,ons! DetskyandKrumholz,reducingtraumaofhospitalizaDon(post-hospitalsyndrome)

Detsky AS and Krumholz HM, JAMA June 2014 FOR MORE INFO...

PsychologyofIsolaDon

Sejng Design Effect

Kennedy&Hamilton1997

SpinalCordrehabunit

16cases/16controls

85%believedCPlimitedrehab,MoreAnger12.3vs.16.5depressionscores(NS)

Gammon1998 Wards,3hospitals

20cases/20controls

30%higherdepressionandanxietyscores

Tarzietal2001 Rehabunit 20cases/20controls

33%vs.77%depression8.6vs.15anxietyscores

Wassenbergetal.2010

TerDaryHospital

42cases/84controls

Small,nonsignificantdifferenceindepression/anxietyatadmission

Dayetal.2011 VeteransHospital

20cases/83controls


Dayetal.2011 TerDaryHospital

Cohortof28,564

40%morediagnosesofdepressionNodifferenceindiagnosisofanxiety

PsychologyofIsolaDon

Sejng Design Effect

Kennedy&Hamilton1997

SpinalCordrehabunit

16cases/16controls

85%believedCPlimitedrehab,MoreAnger12.3vs.16.5depressionscores(NS)

Gammon1998 Wards,3hospitals

20cases/20controls

30%higherdepressionandanxietyscores

Tarzietal2001 Rehabunit 20cases/20controls

33%vs.77%depression8.6vs.15anxietyscores

Wassenbergetal.2010

TerDaryHospital

42cases/84controls


Dayetal.2011 VeteransHospital

20cases/83controls


Dayetal.2011 TerDaryHospital

Cohortof28,564

40%morediagnosesofdepressionNodifferenceindiagnosisofanxiety

Cross-sec,onalstudies.Studieshavenotcontrolledforbaselinecharacteris,csandunderlyingdiseaseseverity

Isolatedpa,entsaresickerindependentofcontactprecau,onsexposure

PaDentsoncontactprecauDonsarenotmorelikelytodevelopdepressionoranxiety

! ProspecDvecohortofmedical/surgicalpaDents! Matchedonhospitalwardandmonth

! 148exposed(contactprecauDons)vs148controls

! Enrolledonadmission! 36-itemquesDonnaire! Medical/Psychiatrichistory! HospitalAnxietyandDepressionScale(HADS)! Visualanalogmoodscales(VAMS)

Day HR et al. ICHE March 2013 FOR MORE INFO...

StableDepressionSymptomswithCP

6.0

4.0

6.1

4.9

5.0

6.3

HA

DS

-D

StableAnxietySymptomswithCPH

ADS-

A

ContactPrecauDonsAssociatedwithFewerAdverseEvents

Croft LD etc., ICHE November 2015 FOR MORE INFO...

USECONTACTPRECAUTIONS–NOFEAR

! Handhygienecomplianceremainspoor! ContactPrecauDons80-100%effecDveinreducinghandcontaminaDon

! ContactPrecauDonsoaenbundledwithacDvesurveillance,butareeffecDvealone! DatastrongestforMRSA(alsoVRE,Acinetobacter)

! Side-effectsgreatlyoverblown! Longer,lessfrequentHCWvisitscouldbebeneficial

Acknowledgements

! AnthonyHarris

! DanielMorgan

! HannahDay! JKrisDeJohnson

! JonFuruno

! MarinSchweizer

! DanielDiekema

! KentSepkowitz

! GraemeForrest

! HeatherReisinger

! MargaretGraham! MichelleShardell

! LisaPineles

! KerriThom

! PeterKim

! MaryClaireRoghmann

Thankyou

Thankyou–QuesDons?

! Handhygienecomplianceremainspoor! ContactPrecauDons80-100%effecDveinreducinghandcontaminaDon

! ContactPrecauDonsoaenbundledwithacDvesurveillance,butareeffecDvealone! DatastrongestforMRSA(alsoVRE,Acinetobacter)

! Side-effectsgreatlyoverblown! Longer,lessfrequentHCWvisitscouldbebeneficial

QUESTIONS?@[email protected]

September 28 (Free Teleclass – Broadcast live from the annual conference of the Infection Prevention Society – www.ips.uk.net) USING SCIENCE TO GUIDE HAND HYGIENE SURVEILLANCE AND IMPROVEMENT Prof. Eli Perencevich, University of Iowa

September 29 ADHERENCE ENGINEERING TO REDUCE CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS Prof. Frank Drews, University of Utah

October 13 UPDATE ON STRATEGIES FOR CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE Prof. John Boyce, J.M. Boyce Consulting Sponsored by Sealed Air Diversey Care (www.sealedair.com)

October 19 (South Pacific Teleclass) TECHNOLOGY FOR MONITORING HAND HYGIENE IN THE 21ST CENTURY – WHY ARE WE USING IT?

Documents

Contact Precautions Debate Teleclass Slides, Sep.27.16 · Weist K ICHE March 2002 FOR MORE INFO... Patient A MRSA+ ... Huang SS CID 2008 3. Huang SS, Platt R, Clin Infect Dis 2003