Transcript A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the

A Controlled Trial of
Universal Gloving vs.
Contact Precautions for
Preventing the
Transmission of MultidrugResistant Pathogens
VCU Infectious Diseases
Research Conference
February 27, 2006
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
30%-40% of all Nosocomial
Infections are Attributed to
Cross Transmission:
The Importance of Hand Hygiene
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
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
Contact
Precautions
for drug
resistant
pathogens.
Gowns and gloves
must be worn upon
entry into the
patient’s room
Glove Use for Infection Control
Variable
Rationale
Comment
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 microtears that allow for
microorganism
transmission
Gown Use for Infection Control
Variable
Rationale
Comment
Gowns
The use of gloves
Several studies have and gowns is the
convention for
documented
limiting the cross
colonization of
transmission of
healthcare worker
nosocomial
apparel and
pathogens, however,
instruments during
patient care activities the incremental
benefit of gown use,
without the use of
in endemic settings,
gowns
may be minimal
Hard At
work
thinking of
research
questions
What about the role of Universal
Gloving For All Patient Care?
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.
Methods: Study Design
Concurrent surveillance for nosocomial infections
VRE, MRSA surveillance cultures on admission & every 4 days
Measure hand hygiene frequency
Contact precautions for VRE,
MRSA colonized/infected
patients
0
1
2
Universal gloving: No Contact
Precautions
3
4
5
6
Month
•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.
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.
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.
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.
Results:
Variable
Phase I
Phase II
P value
Total patient
days
1090
1377
-
Total
observations for
IC compliance
1220
1102
-
Total patients
screened for
VRE
192
257
0.54
Total patients
screened for
MRSA
228
301
0.60
Bearman et al.
Results: Hand Hygiene Compliance
Phase I
Variable
Phase II
N Obs
%
N Obs
%
P-value
Hand Hygiene
before patient
contact
228
18.7
126
11.4
<0.001
Hand Hygiene
after patient
contact
704
57.7
578
52.5
0.011
A statistically significant reduction in hand-hygiene
was observed in phase II
Bearman et al.
Results:Compliance with Contact Precautions
vs. Universal Gloving
Phase I
Variable
Phase II
N
%
N
%
P
Compliance with gloving for
patients on contact precaution
387
89.4
N/A
N/A
N/A
Compliance with gowns for
patients on contact precaution
335
77.4
N/A
N/A
N/A
Gowns and gloves for patients
on contact precaution
328
75.7
N/A
N/A
N/A
Total Compliance: (Contact
Precautions vs. Universal
Gloving)
328
75.7
959
87.0
<0.001
Greater adherence during universal gloving was observed
Bearman et al.
Results: VRE screening
Variable
Total Patients
Screened for VRE
Phase I
Phase II
P value
192
257
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
8
9
0.79
Days to acquire VRE
(median)
No difference was observed in the rate of VRE acquisition
Bearman et al.
Results: MRSA Screening
Variable
Phase II
P value
228
301
-
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
8
9
0.95
Total Patients
Screened for MRSA
Days to acquire MRSA
(median)
Phase I
No difference was observed in the rate of MRSA acquisition
Bearman et al.
Results: MRSA PFGE
MRSA
Phase I
Phase II
Number of
Strains
21
25
Conversion:
negative to
positive
13
13/13 clonal (100%)
Type A1, A2, A3, A4
15
15/15 clonal (100%)
Type A1, A5
PFGE Types
A1:13/21 (62%)
A2: 5/21 (23%)
A3: 1/21 (5%)
A4:1/21 (5%)
B: 1/21 (5%)
A1:18/25
A5: 2/25
C: 3/25
D:2/25
( 72%)
(8%)
(12%)
(8%)
ALL MRSA conversions were with clonal isolates
Bearman et al.
Results: VRE PFGE
VRE
Phase I
Phase II
Number of
Strains
40
35
Conversion:
negative to
positive
39
20/40 clonal: (50%)
Type A, B
35
28/35 clonal (80%)
Type A, AA, AB
PFGE Types
Type 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
Results:
Nosocomial Infections Rates
Outcome
Phase I
Phase II
P
BSI/1000
catheter days
6.2
14.1
P<0.001
UTI/1000
catheter days
4.3
7.4
P<0.001
0
2.3
P<0.001
Pneumonia
A statistically significant increase in NIs was observed
Bearman et al.
Results: Nosocomial Infections
Phase I
Phase II
Infection #
Organisms
#
Organisms
BSI
5
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)
UTI
6
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)
VAP
0
NA
2
MRSA(1)
P.aeruginosa (1)
Results: Nosocomial Infections with
VRE or MRSA
Phase I
Infection
Phase II
VRE
MRSA
VRE
MRSA
BSI
0
0
1
2
UTI
0
0
0
0
VAP
0
0
0
1
4 VRE and MRSA infections were identified in
Phase II
MRICU Demographics
Phase I
Phase II
P value
5.3
6.8
0.07
Average length of stay
87%
92%
0.36
MRICU occupancy rate
per month
1:1.9
1:1.9
NS
Nurse to patient ratio
Device utilization ratio
Variable
Phase I
Phase II
P
Urinary Catheter
0.85
0.87
0.83
Central line
0.74
0.72
0.87
Ventilator
0.56
0.62
0.47
Utilization ratio=device days/patient days
Results: Antibiotic Usage
Defined daily dose (DDD/1000 patients-day)
Antibiotic
DDD
Phase I
DDD
Phase II
P value
B-lactams
391.6
352.9
0.075
B-lactam/inhibitor
210.1
211.5
1.0
Aminoglycosides
68.2
118.2
<0.001
Glycopeptides
190.1
226
0.079
Metronidazole
127.0
118.6
0.582
Quinolones
385.7
359.0
0.206
Total
1372.7
1386.2
0.806
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
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%
Results:
Questionnaire about IC compliance
Questionnaire Item:
Proportion of respondents indicating that
universal glove use was impractical
Proportion of respondents reporting good
compliance with infection control
measures
Proportion of respondents reporting good
compliance with Hand hygiene
Proportion
12%
97%
97%
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%
Results:
Questionnaire about IC compliance
During Universal Gloving Study
Overall better care is delivered when:
Contact Precautions
Universal Gloving
No difference
Majority of respondents felt that better care was delivered
during the Universal Gloving Phase of the study
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
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
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
After a long, hard day at the
SHEA Conference, 2004