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A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug- Resistant Pathogens G. Bearman, MD, MPH A.

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Presentation on theme: "A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug- Resistant Pathogens G. Bearman, MD, MPH A."— Presentation transcript:

1 A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug- Resistant Pathogens G. Bearman, MD, MPH A. Marra, MD C. Sessler, MD W.R. Smith, MD R.P. Wenzel MD, MSc M.B. Edmond, MD, MPH, MPA Disclosure: nothing to disclose

2 Hypothesis The effectiveness of universal gloving (use of gloves for all patient care activity) in preventing the transmission of multidrug- resistant pathogens will be greater than the effectiveness of contact precautions since compliance with universal gloving will be greater than compliance with contact precautions (gown and glove use).

3 Methods: Setting 12-bed medical ICU in an 820-bed, tertiary care, academic medical center Closed-ICU staffing model with 5 attending intensivists

4 Concurrent surveillance for nosocomial infections VRE, MRSA surveillance cultures on admission & every 4 days Measure hand hygiene compliance, antimicrobial usage Contact precautions for VRE, MRSA colonized/infected pts Universal gloving; no contact precautions Methods: Study Design Phase IPhase II

5 Methods: Surveillance CDC/NNIS NI definitions used; surveillance performed by experienced ICPs Hand hygiene observations performed by trained observers Active microbiologic surveillance: nasal and rectal cultures obtained on all patients in the unit

6 Methods: Microbiologic Studies One rectal swab culture for VRE and one nasal swab culture for MRSA performed on admission and every 4 days –Once a patient was culture positive, no further cultures were obtained for that organism Pulse field gel electrophoresis (PFGE) for genetic typing and antibiotic susceptibility testing were performed on all MRSA and VRE isolates

7 Methods: Healthcare Worker Questionnaire 15 item survey was administered at the end of the study protocol Target: MICU nurses and attending physicians Focus: –self reported compliance with infection control practice –acceptability of universal gloving vs. standard of care

8 Methods: Additional Data Elements Phase I vs. Phase II Length of stay MICU occupancy rate per month MICU invasive devices utilization ratios Nurse to patient ratio Antibiotic usage: defined daily dose (DDD)

9 Results VariablePhase IPhase IIP value Total patient days1,0901,377- Total observations for IC compliance 1,2201,102- Total patients screened for VRE Total patients screened for MRSA

10 Results: Hand Hygiene Compliance Phase I Contact Precautions Phase II Universal Gloving Hand hygieneN Obs% %P-value Before patient contact <0.001 After patient contact A statistically significant reduction in hand-hygiene was observed in phase II

11 Results: Compliance with Contact Precautions vs. Universal Gloving Variable Phase IPhase II P N%N% Compliance with gloving for patients on contact precautions N/A Compliance with gowns for patients on contact precautions N/A Compliance with gowns and gloves for patients on contact precautions N/A Total compliance: contact precautions vs. universal gloving <0.001 Greater adherence during universal gloving was observed

12 Results: VRE screening Variable Phase I Contact Precautions Phase II Universal GlovingP value Patients screened for VRE Patients VRE positive upon admission to ICU 3 (1.5%)3 (1.1%)0.70 Patients with VRE conversion during ICU stay 39 (20%)35 (14%)0.31 Days to acquire VRE (median) No difference was observed in the rate of VRE acquisition

13 Results: MRSA Screening VariablePhase IPhase IIP value Patients screened for MRSA Patients MRSA positive upon admission to ICU 11 (4.8%)6 (2.0 %)0.11 MRSA conversion during ICU stay 13 (5.7%)15 (5.0%)0.92 Days to acquire MRSA (median) No difference was observed in the rate of MRSA acquisition

14 Results: MRSA PFGE MRSAPhase IPhase II Number of strains2125 Conversion: negative to positive 13 13/13 clonal or related (100%) Type A1, A2, A3, A /15 clonal or related(100%) Type A1, A5 PFGE typesA1: 13 (62%) A2: 5 (23%) A3: 1 (5%) A4: 1 (5%) B: 1 (5%) A1: 18 (72%) A5: 2 (8%) C: 3 (12%) D: 2 (8%) All MRSA conversions were with clonal or related isolates

15 Results: VRE PFGE VREPhase IPhase II Number of Strains4035 Conversion: negative to positive 39 20/40 clonal: (50%) Type A, B 35 28/35 clonal (80%) Type A, AA, AB PFGE TypesType A: 16 (34%) Type B: 4 (11%) Type D: 2 Type G: 3 Type H: 2 Type J: 2 Type K: 2 Types C,E,I, L,M,Q,R S,T: 1 each Type A: 18 (51%) Type AA: 4 (11%) Type AB: 4 (11%) Type H: 2 (6%) Types F,G,I,J,U,V,M: 1 each Most VRE conversions were with clonal or related isolates

16 Results: Nosocomial Infections Rates OutcomePhase IPhase IIP BSI/ 1,000 catheter days P<0.001 UTI/ 1,000 catheter days P<0.001 Pneumonia/ 1,000 ventilator days 02.3P<0.001 A statistically significant increase in NIs was observed

17 Results: Nosocomial Infections Phase IPhase II Infection#Organisms# BSI5 P. aeruginosa (1) E. cloacae (1) K. pneumoniae (1) Prevotella spp (1) C. glabrata (1) 16 Coag. negative staph (6) Enterococcal spp (3) VRE (1) MRSA(2) P. aeruginosa (1) K. pneumoniae (1) C. parapsilosis (1) C. albicans (1) UTI6 E. coli (2) E. cloacae (1) C. albicans (3) 9 Coag. negative staph (1) Enterococcal spp (1) P. aeruginosa (2) E. coli (1) C. albicans (2) C. non-albicans (2) VAP0 NA 2 MRSA(1) P. aeruginosa (1)

18 Results: Nosocomial Infections with VRE or MRSA Phase IPhase II InfectionVREMRSAVREMRSA BSI0012 UTI0000 VAP infections with either VRE or MRSA were identified in Phase II

19 Results: MICU Additional Data Phase IPhase IIP valueVariable Average length of stay (days) 87%92%0.36MRICU occupancy rate/month 1:1.9 NSNurse to patient ratio Device utilization ratioPhase IPhase IIP Urinary Catheter Central line Ventilator Utilization ratio=device days/patient days

20 Results: Antibiotic Usage Defined daily dose (DDD/1000 patients-days) Antibiotic DDD Phase I DDD Phase IIP value  -lactams  -lactam/inhibitor Aminoglycosides <0.001 Glycopeptides Metronidazole Quinolones Total The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults Example: DDD of levofloxacin is 0.5 grams, if 200 grams were dispensed in a period with 4,500 patient days: (200g/0.5g)/4,500 pt days X 1000= 89 DDD/1000 PD

21 Conclusions Observed compliance with universal gloving was significantly greater than compliance with contact precautions (gowns and gloves). However, greater compliance with hand hygiene was observed in the contact precautions phase. No differences were detected between the two study phases for: –LOS, nurse/patient ratio, MICU occupancy rate, invasive device utilization, antibiotic usage

22 Conclusions No differences in VRE and MRSA colonization were observed between the two study phases In both phases, the majority of VRE and MRSA conversions were of a clonal or related isolate However, an increase in nosocomial infection rates was observed during the universal gloving phase of the study 4 VRE/MRSA nosocomial infections were observed during the universal gloving phase

23 Conclusions Although universal gloving was highly accepted by the staff, its implementation should proceed with caution given the observed increase in nosocomial infection rates –The use of universal gloving may have led to a misperception of decreased cross transmission risk –This may have lead to decreased hand hygiene compliance and a consequent increase in the rates of nosocomial infections

24 Conclusions Due to short study period (6 months): –The observed increase in nosocomial infections may have been a result of normal variation and may not have been attributed to the universal gloving intervention.

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26 Criteria for PFGE interpretation Category # of Fragment Differences Inferred relationship Indistinguishable0Isolate represents the outbreak strain Closely related2-3Isolate probably represents the outbreak strain Possibly related4-6Isolate possibly represents the outbreak strain Different>7Isolate is different from outbreak strain Tenover et al.J.Clin Microbiol :


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