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Erschienen in:
09.07.2020 | Less is more in Intensive Care
Less contact isolation is more in the ICU: pro
Erschienen in: Intensive Care Medicine | Ausgabe 9/2020
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Additional contact precautions (ACP) have been endorsed by International Recommendations in patients with colonisation or infection by multidrug-resistant organisms (MDRO) [1, 2]. Contact isolation (CI), considered initially as the holy grail of the interruption of transmission of MDROs, currently remains debated [3, 4]. Suboptimal contact of healthcare personnel with the patients has been associated with service care errors including falls, pressure ulcers, fluid/electrolyte disorders and suboptimal documentation of vital signs or physician notes. Patients’ dissatisfaction and stress as well as increased healthcare costs are the major downsides of CI [3]. In view of the divergent opinions in the literature, infection control practices in ICU vary considerably. In this narrative review, we will focus on the most relevant studies, with messages in line with the principle “less is more” (Table 1). In the present manuscript, we considered “less CI” as surrogate to “not universal" or “targeted” CI (and evidently not “no CI”). However, we also discuss studies in which CI seems less important or less effective compared to other pivotal infection control measures, therefore, less desirable. Search methods are shown in Supplement Table.
Table 1
Contemporary studies delivering the message “less contact isolation in the ICU is more”
|
Author, Year
|
Setting design
|
Study Size
|
Target organisms
|
Intervention
|
Main outcomes
|
|---|---|---|---|---|---|
|
Studies accessing efficacy of IC measures in MDRO colonization/infection
|
|||||
|
Huskins WC et al., 2011
[4]
|
Cluster-randomized trial,
Three periods:
Baseline (April through November 2005), Randomization and implementation (December 2005 through February 2006), and Intervention (March through August 2006)
|
5434 admissions to 10 intervention ICUs
3705 admissions to eight control ICUs
|
MRSA
VRE
|
Surveillance cultures were obtained for MRSA and CRE colonization from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention
In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving
|
The intervention was not effective in reducing the transmission of MRSA or VRE
The use of barrier precautions by providers was less than what was required
The turnaround time for reporting a positive result on a surveillance culture was prolonged
|
|
Cepeda JA, et al.,
2005 [5]
|
Multicenter, 1-year Prospective Study conducted in
3 ICUs (Medical and Surgical)
|
Admitted Patients N = 1676
Included N: 866
|
MRSA
|
Nose or groin swabs obtained within 24 h of admission, once a week and at discharge
In the middle 6 months, MRSA-positive patients were not moved to a single room or cohort nursed unless they were carrying other MDROs
|
Transfer of MRSA-colonised or infected patients into single rooms or cohorting did not reduce cross-infection
|
|
Derde LPD, et al
2014 [8]
|
Multicenter (conducted in 13 ICUs), interrupted time series study (phase 2), followed by a cluster randomized trial (phase 3)
A 6-month baseline period was performed before phase 2 (phase 1)
|
1st phase
Screened N = 3215
Analyzed N: 1962
At Risk for MDR colonization: 1688
2nd phase
Screened N = 3345
Analyzed N: 1926
At Risk for MDR colonization: 1681
3rd phase
(conventional screening)
Screened N = 3710
Analyzed N: 2280
At Risk for MDR colonization: 2029
3rd phase
(rapid screening)
Screened N = 4120
Analyzed N: 2351
At Risk for MDR colonization: 2007
|
HRE
VRE
MRSA
|
Chromogenic screening for HRE, MRSA and VRE (conventional screening)
PCR screening for MRSA, VRE
(rapid screening)
ICUs were randomly assigned to either conventional screening or rapid screening [PCR testing for MRSA and VRE and chromogenic screening for highly resistant Enterobacteriaceae (HRE)]; with contact precautions for identified carriers
|
Mean hand hygiene compliance improved from 52% in phase 1 to 69% in phase 2, and 77% in phase 3
A decrease in trend of acquisition of antimicrobial-resistant bacteria in phase 2 was largely caused by changes in acquisition of MRSA
In the context of a sustained high level of compliance to hand hygiene and chlorhexidine bathings, screening and isolation of carriers did not reduce acquisition rates of multidrug-resistant bacteria, whether or not screening is done with rapid testing or conventional testing
|
|
Ledoux G, et al
2016 [10]
|
Prospective, before-after study, conducted in a mixed ICU, during two 12-month periods
1-month ‘wash-out’ period interval
|
N = 1221
1st period
N = 585
2nd period
N = 636
|
A.baumannii
Ceftazidime or Imipenem-resistant P. aeruginosa
ESBL-GNB
MRSA
S.maltophilia
VRE
|
Nasal and Rectal swabs, Tracheal Aspirate in intubated or tracheostomized patients obtained on admission and once a week
During 1st period: systematic isolation performed in all patients at ICU admission
During 2nd period: patient isolation performed when at least one risk factor for MDRO was met
|
Targeted isolation of patients at ICU admission was not inferior to systematic isolation, regarding the percentage of patients with ICU-acquired infections related to MDR bacteria [85 of 585 (14.5%) vs. 84 of 636 (13.2%) patients, risk difference,− 1.3%, 95% confidence interval (− 5.2 to 2.6%)]
|
|
Djibré M, et al
2017 [11]
|
Single-Center, Observational Study performed in patients admitted to MICU and SICU during 2 consecutive 6-month periods
|
1st period
Screened N = 413
Included N = 327
2nd period
Screened N: 368
Included N = 297
|
CRE
ESBL
(very low infection rate of MRSA and VRE in this Unit)
|
Rectal swabs were obtained on admission and once a week
Universal screening for MDRO carriage and ACPs during the first 6-month period
During the second 6-month period screening was maintained, but ACP were enforced in the presence of at least 1 defined risk factor for MDRO
|
The rate of acquired MDRO (positive screening or clinical specimen) was similar during both periods (10% [n = 15] and 11.8% [n = 15], respectively; p = .66)
A targeted isolation screening policy on ICU admission was safe compared with universal screening and isolation regarding the rate of ICU acquired MDRO colonization or infection
|
|
Studies assessing safety and adverse events with the application of contact isolation
|
|||||
|
Zahar JR, et al
2013 [12]
|
Based on the database of Iatroref III (a multicenter cluster-randomized clinical trial, testing the effects of MFSP, NCT00461461)
Two centers included
|
Screened N = 1221
Included N = 1150
Isolated patients: 170
Non- isolated patients: 980
|
GNB
MRSA
VRE
|
A subdistribution hazard regression model with careful adjustment on confounding factors was used to assess the effect of patient isolation on the occurrence of medical errors and adverse events
|
After adjustment of confounders, errors in anticoagulant prescription [subdistribution hazard ratio (sHR) = 1.7, p = 0.04], hypoglycaemia (sHR = 1.5, p = 0.01), hyperglycaemia (sHR = 1.5, p = 0.004), and ventilator-associated pneumonia caused by MDRO (sHR = 2.1, p = 0.001) remain more frequent in isolated patients
|
|
Searcy R.J., et al
2018 [13]
|
Single-Center, Retrospective Chart Review of patient on MV receiving MRSA nasal screening and sedated within 24–48 h of ICU admission
|
Screened N = 389
Included N = 226
MRSA-positive: 114 (contact isolated)
MRSA negative:112
|
MRSA
|
Nasal PCR assay
Calculation of rate of inappropriate sedation, length of ICU stay, length of time on MV, and incidence of ventilator-associated complications
|
Patients placed on CI spent longer in the ICU (10.4 vs. 6.8 days, p = 0.0006), longer on MV (8.98 vs. 4.81 days, p < 0.001), and required a tracheostomy more frequently (37 (32%) vs. 14 (13%), p = 0.0003)
|
|
Other studies (mathematic models etc.)
|
|||||
|
Sypsa V et al., 2012
[7]
|
Prospective observational study conducted in a surgical unit of a tertiary-care hospital Surveillance culture for CPKP were obtained from all patients upon admission and weekly thereafter
|
Screened N = 850; 18 patients were colonized with CPKP on admission and 51 acquired CPKP during hospitalization
|
Carbapenemase-producing Klebsiella pneumoniae
|
The Ross-Macdonald model for vector-borne diseases was applied to obtain estimates for the basic reproduction number R0 (average number of secondary cases per primary case in the absence of infection control) and assess the impact of infection control measures on CPKP containment in endemic and hyperendemic settings
|
The use of surveillance culture on admission and subsequent separation (mostly cohorted, less often in single room CI) of carriers from non-carriers coupled with improved hand hygiene compliance and contact precautions may attain maximum containment of CPKP in endemic and hyperendemic settings; it was estimated that in periods where R0 is 2, hand hygiene compliance should exceed 50% in order to attain an effective reproduction number below unity
|
|
Dhar S et al., 2014 [14]
|
Prospective cohort study
Eleven teaching hospitals
|
1013 observations conducted on HCP
|
Not applicable
|
Compliance with individual components of contact isolation precautions and overall compliance (all five measures together) during varying burdens of isolation
|
Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6–4.9%) and with all five components (31.5–6.5%) was observed
|