Best article for 2018 – #blogoff

Jon Otter and I have been having a ‘blog off’, with the aim of presenting the best infection control paper for 2018 (to date). Below, I put my case forward. You can read Jon’s post here. After you read both blogs and listen to points made via Twitter, we encourage you to vote (for the article I present!). Follow more on Twitter (@1healthau) and #mitchellvsotter via this link. Results will be presented during my social media talk on Monday 1st October (& via Twitter). You can vote using this link: https://www.surveymonkey.com/r/SL23H6K

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My (Brett Mitchell’s) choice of article

Choosing the best article is always fraught with danger. There are so many great infection control articles in 2018, but for this blog, I have chosen something that impacts everyone working in infection control – contact precautions (CP).  The article – Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis by Bearman et al.

There are three main reasons, why I believe this article is noteworthy:

  1. Advancement of knowledge in a difficult area
  2. Sets foundation for additional studies
  3. The implications for changing practice around contact precautions are profound

What is the article about?

In this single centre quasi experimental study, seven horizontal infection control interventions were evaluated. One of these, was the discontinuation of CP for patients with MRSA and VRE. During the study period, using interrupted time-series analysis, infection rates for MRSA and VRE decreased, in addition to device associated HAIs – following discontinuation of CP. Importantly, compliance with CP was monitored prior to cessation, 94% compliance with CPs hospital wide, from nearly 2700 observations. The authors conclude with the suggestions that the discontinuation of CP for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. MRSA HAI decreased by 1.3 per 100,000 bed days and VRE HAI decreased by 7.5/100,000 bed days. Not statistically significant, but clinically relevant in the context of no increase or difference.

Advancement of knowledge

Evidence supporting the use of CPs is largely based on observational studies, theory and expert opinion. Undertaking RCTs in infection control is challenging and not always possible, not the least on the topic of evaluating the impact of stopping CPs.  We have seen other work which has tested the value of universal glove and gown use, but limited work on ceasing CPs. This study takes a big step forward, using a robust design. It adds to a small but growing body of evidence investigating the universal application of CP for patients with any MRO.

Sets foundation

Another important aspect of this study, is that it sets the foundation for more work. It appears that no harm was caused as a result of ceasing CPs. This evidence is critical when attempting to seek funds for future studies, convincing a hospital to attempt something similar and obtaining ethical approvals. It was ‘gutsy’ to undertake a study that ceased CP, but the pragmatic and clever approach of bundling this with other horizontal infection control initiative made this palatable, as well as being able to unpick the relative effect of ceasing CP, using interrupted time series. In so doing, the authors have taken this controversial topic forward and established platform for multi-site sites (plus or minus randomisation).

For the record, I am not suggesting we should change practice around CPs yet, nor I am suggesting CP do not work in the prevention transmission of certain organisms. Rather, I am saying we should be open to the idea and support work that helps answer this question one way or another.

Implications

Imagine the implications if CPs were not required for patients with certain organisms. As quoted in a recent paper by Prof Nick GravesBecause you exist in a world of scarce resources, the choices you make have economic consequences”. The implications regarding CPs are significant and include the (reduction) in cost of personal protection equipment to the increased availability of single rooms as a starting point. In addition, think about the time invested in

identifying patients with MROs, placing them in CPs, monitoring compliance and the associated education with staff. The freeing up of resources, where there are finite resources, is critically important and present new opportunities.

The authors are to be congratulated for tackling a vexed issue and opening the door to the next stage. We need more research in infection prevention and control, that tackles the ‘known unknowns’, so we can advance the science of the profession, have practice underpinned by strong evidence and provide optimal patient care. Where else to start, than with evidence around CPs?  Regardless of whether you are clinician, an infection control professional, policy maker or researcher, this article should be of interest to you. Let’s hope more studies can build on this in the near future.

If you are in agreement, don’t forget to vote for this article here

 

4 thoughts on “Best article for 2018 – #blogoff

  1. Glenys Harrington

    Many articles have reached the same conclusion and a number of hospitals in Australia have not been isolating patients with MRSA or VRE for some years now.

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  2. Michael Wishart

    I agree this is a topic worth further exploration, but we must be clear on what we are looking to achieve. CP for MRO’s potentially does more than just reduce risks of actual infection with that MRO in other patients; it can help to reduce the burden of MRO across the facility. What the impact of increased MRO burden is in a facility is not well demonstrated yet. We need to be careful not to give ourselves a longer term problem by trying to prevent a short term one.

    To me, this is similar to the arguments about PIVC management, where good studies powered for phlebitis as an end point demonstrate no value in set device changes. Yet there are concerns that risk of phlebitis does not necessarily equate to risk of BSI from these devices, and we need better studies powered to demonstrate the end point of BSI rather than phlebitis before we jump in boots and all.

    We live in interesting times, yes.

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    1. Brett Mitchell @1healthau Post author

      Hi Michael, I agree. For me this article takes an important advancement in the quality of evidence on this topic (methodologically) compared to previous work and demonstrates that such studies are feasible, especially when considering ethical issues. We need good quality evidence to inform practice and policy in many areas of IC.

      The authors also use historical infection data to look for trends. This is important as rates may been going down (or stagnant) anyway. Many infection control articles fail to account for this. If you don’t you could find an association between reducing SAB and things like inflation. Importantly, the authors also applied a range of horizontal IC measures and monitored compliance with these. That meant, they could unpick the effect of each intervention as well as reducing the risk of just stopping CP without considering other influencers. There are other considerations – no randomisation and the role of colonisation pressure. On the latter, where the pressure of an organism is very high e.g. everyone has it, then the use of CP may subject to question. However, it is important as you say, to consider other effects. The study doesn’t give us the definitive answer for wholesale broad changes to CP recommendations, but sets things up nicely for more in this area. All that said, definitive answers are near impossible in IC – another reason why its good to see the authors tackle a difficult topic.

      Brett

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  3. Pingback: Reflections from Infection Prevention 2018 | Reflections on Infection Prevention and Control

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