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 VCU Infectious Diseases Research Conference February 27, 2006

2. 30%-40% of all Nosocomial Infections are Attributed to Cross Transmission: The Importance of Hand Hygiene

3. Hand Hygiene Single most important method to limit cross transmission of nosocomial pathogens Multiple opportunities exist for HCW hand contamination –Direct patient care –Inanimate environment Alcohol based hand sanitizers are ubiquitous –USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

4. Hand Hygiene HCW’s perceive that their hand hygiene practice is excellent –Observational data does not support this claim New technologies such alcohol based hand sanitizers make the practice of hand hygiene simpler than ever –There is simply no excuse for poor hand hygiene compliance

5. Contact Precautions for drug resistant pathogens. Gowns and gloves must be worn upon entry into the patient’s room

6. Glove Use for Infection Control VariableRationaleComment Gloves Prevent healthcare worker exposure to bloodborne pathogens Prevent contamination of hands with drug resistant pathogens during patient care activities Even with proper glove use, hands may become contaminated during the removal of the glove or with micro- tears that allow for microorganism transmission

7. Gown Use for Infection Control VariableRationaleComment Gowns Several studies have documented colonization of healthcare worker apparel and instruments during patient care activities without the use of gowns The use of gloves and gowns is the convention for limiting the cross transmission of nosocomial pathogens, however, the incremental benefit of gown use, in endemic settings, may be minimal

8. Hard At work thinking of research questions

9. What about the role of Universal Gloving For All Patient Care?

10. 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 for the following reasons: –Compliance with universal gloving will likely be greater than compliance with contact precautions. Bearman et al.

11. CDC/NNIS NI definitions applied; surveillance performed by VCUMC IC Department Hand hygiene observations performed by trained observers Active surveillance nasal and rectal cultures were obtained on all patients within the unit Bearman et al.

12. Methods Microbiologic Data –One rectal swab culture performed for VRE and 1 nasal swab culture for MRSA performed on admission and every 4 days. Once a patient was culture positive; then 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 isolated after study was completed. Bearman et al.

13. Methods Healthcare Questionnaire –Administered at the end of the study protocol Target: MRICU Nurses and Attending Physicians –Focus: »self reported compliance with infection control practice » acceptability of universal gloving vs. standard of care. Bearman et al.

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

15. Results: VariablePhase IPhase IIP value Total patient days 10901377- Total observations for IC compliance 12201102- Total patients screened for VRE 1922570.54 Total patients screened for MRSA 2283010.60 Bearman et al.

16. Results: Hand Hygiene Compliance Phase IPhase II VariableN Obs% %P-value Hand Hygiene before patient contact 22818.712611.4<0.001 Hand Hygiene after patient contact 70457.757852.50.011 A statistically significant reduction in hand-hygiene was observed in phase II Bearman et al.

17. Results:Compliance with Contact Precautions vs. Universal Gloving Variable Phase IPhase II P N%N% Compliance with gloving for patients on contact precaution 38789.4N/A Compliance with gowns for patients on contact precaution 33577.4N/A Gowns and gloves for patients on contact precaution 32875.7N/A Total Compliance: (Contact Precautions vs. Universal Gloving) 32875.795987.0<0.001 Greater adherence during universal gloving was observed Bearman et al.

18. Results: VRE screening VariablePhase IPhase IIP value Total Patients Screened for VRE 192257 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) 890.79 No difference was observed in the rate of VRE acquisition Bearman et al.

19. Results: MRSA Screening VariablePhase IPhase IIP value Total Patients Screened for MRSA 228301- 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) 890.95 No difference was observed in the rate of MRSA acquisition Bearman et al.

20. Results: MRSA PFGE MRSAPhase IPhase II Number of Strains 2125 Conversion: negative to positive 13 13/13 clonal (100%) Type A1, A2, A3, A4 15 15/15 clonal (100%) Type A1, A5 PFGE TypesA1:13/21 (62%) A2: 5/21 (23%) A3: 1/21 (5%) A4:1/21 (5%) B: 1/21 (5%) A1:18/25 ( 72%) A5: 2/25 (8%) C: 3/25 (12%) D:2/25 (8%) ALL MRSA conversions were with clonal isolates Bearman et al.

21. Results: VRE PFGE VREPhase IPhase II Number of Strains 4035 Conversion: negative to positive 39 20/40 clonal: (50%) Type A, B 35 28/35 clonal (80%) Type A, AA, AB PFGE TypesType A: 16/40 (34%) Type B: 4/40 (11%) Type D:2/40 Type G: 3/40 Type H:2/40 Type J:2/40 Type K: 2/36 Type C,E,I, L,M,Q,R S,T: 1 each 9/40 Type A: 18/35 (51%) Type AA: 4/35 (11%) Type AB:4/35 (11%) Type H: 2/35 (6%) Types F,G,I,J,U,V,M:1 each 7/35 (20%) Most VRE conversions were with clonal isolates

22. Results: Nosocomial Infections Rates OutcomePhase IPhase IIP BSI/1000 catheter days 6.214.1P<0.001 UTI/1000 catheter days 4.37.4P<0.001 Pneumonia02.3P<0.001 A statistically significant increase in NIs was observed Bearman et al.

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

24. Results: Nosocomial Infections with VRE or MRSA Phase IPhase II InfectionVREMRSAVREMRSA BSI0012 UTI0000 VAP0001 4 VRE and MRSA infections were identified in Phase II

25. MRICU Demographics Phase IPhase IIP valueVariable 5.36.80.07Average length of stay 87%92%0.36 MRICU occupancy rate per month 1:1.9 NSNurse to patient ratio Device utilization ratioPhase IPhase IIP Urinary Catheter0.850.870.83 Central line0.740.720.87 Ventilator0.560.620.47 Utilization ratio=device days/patient days

26. Results: Antibiotic Usage Defined daily dose (DDD/1000 patients-day) Antibiotic DDD Phase I DDD Phase IIP value B-lactams391.6352.90.075 B-lactam/inhibitor210.1211.51.0 Aminoglycosides68.2118.2<0.001 Glycopeptides190.12260.079 Metronidazole127.0118.60.582 Quinolones385.7359.00.206 Total1372.71386.20.806 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 0.5grams, 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

27. Results: Questionnaire about IC compliance During Universal Gloving Study 34 respondents –30 MRICU Nurses (45 eligible) –4 Attending Physicians (7 eligible) Overall survey compliance 65%

28. Results: Questionnaire about IC compliance Questionnaire Item:Proportion Proportion of respondents indicating that universal glove use was impractical 12% Proportion of respondents reporting good compliance with infection control measures 97% Proportion of respondents reporting good compliance with Hand hygiene 97%

29. Results: Questionnaire about IC compliance Questionnaire Item:Proportion HCWs reporting less frequent entry into a patient room because of contact precautions 48% Belief that proper glove use is more important than hand hygiene to limit the spread of nosocomial organisms 6% Belief that the use of gloves is associated with decreased risk of cross-transmission of nosocomial organisms 94% HCWs reporting no difference in skin problems (e.g., chapping, dryness, cracking) 93%

30. Results: Questionnaire about IC compliance During Universal Gloving Study Overall better care is delivered when: Majority of respondents felt that better care was delivered during the Universal Gloving Phase of the study

31. Universal Gloving 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 standard of care phase. No differences were detected between the two study phases for: –LOS, nurse:patient ratio,MRICU occupancy rate, invasive device utilization, and antibiotic usage

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

33. Universal Gloving Conclusions HCWs found gloving acceptable and believed that the use of universal gloving is associated with decreased risk of cross-transmission of nosocomial organisms HCWs believed that better care was delivered under the universal gloving phase 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 lead 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

34. After a long, hard day at the SHEA Conference, 2004