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Delays in accessing radiology in patients under contact precautions because of colonization with vancomycin-resistant enterococci
... However, while contact precautions are in common use, their efficacy in controlling the transmission of multi-drug-resistant organisms is unclear, compliance is poor, and contact precautions may result in un- intended harmful consequences. 2e7 Specifically, reported consequences of contact precautions include: reduced patient contact with healthcare workers; 2,8e12 increased numbers of preventable adverse events; 13e15 decreased psychological well-being; 7 decreased patient satisfaction; 13 delays in access to radiological examinations; 16 and decreased quality of hos- pital care. 17 Stelfox et al. reported that patients placed under contact precautions were eight times more likely to experience supportive care failures (e.g. ...
We read with great interest the article by Martin et al published online in May 2018 in Infection Control and Hospital Epidemiology. We previously reported on the impact of elimination of contact precautions (CP) in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) patients on noninfectious complications, although our analysis was limited to falls and pressure ulcers. Our findings differed from those of Martin et al; we observed no statistically significant difference in the rate of falls or pressure ulcers among MRSA/VRE patients in the years before and after eliminating CP.
... It appears that the increased use of contact precautions also leads to delays in hospital admission for the emergency department [25,26], as well as delays in obtaining radiologic testing while admitted as an inpatient [27]. More concerning are the increasing reports of potential patient harm attributable to contact isolation practices including an increase in patient injuries and medication administration errors [28] and increased incidence of venous thromboembolism [VTE] in surgical patients [29] as well as patients who are the victims of traumatic injuries [30]. ...
Background:
Victims of traumatic injuries represent a population at risk for a wide variety of complications. Contact isolation (CI) is a set of restrictions designed to help prevent the transmission of medically significant organisms in the healthcare setting. A growing body of literature demonstrates that CI can have significant implications for the individual isolated patient. Our goal was to characterize the use of contact isolation at our Level I trauma center and investigate the association of CI with infectious complications.
Patients and methods:
An existing trauma database containing data on patients admitted at our Level I trauma center between January 1, 2011 and December 31, 2012, along with their contact isolation status, was queried. Demographics, injuries, and the presence of infections were collected. Diagnosis of pneumonia or UTI was based on clinical documentation in the patient's medical record. A chart review was performed to ascertain the reason for CI including specific organisms. Because of differences in patient demographics between the CI and non-CI groups, linear regression was performed to adjust for the effects of different variables.
Results:
A total of 4,423 patients were admitted over this period. Of these, 4,318 (97.6%) had complete records and were included in the subsequent analysis. The CI was in place in 249 (5.8%) patients; 4,069 (94.2%) were not isolated. The number who had CI initiated for MRSA nasal colonization was 173 (69.5%). Twenty-two (8.9%) had no reason for CI documented. Pneumonia occurred in 190 (4.4%), 54 (21.7) in the CI group versus 136 (3.3%) in the non-CI group. Urinary tract infection (UTI) was diagnosed in 166 (3.8%), 48 (19.3%) in the CI group versus 118 (2.9%) in the non-CI group. Using logistic regression and excluding patients placed on contact isolation for the development of a new resistant nosocomial infection, CI, Injury Severity Score, gender, length of stay, and mechanical ventilation were identified as common covariates for pneumonia (PNA) and UTI. Chronic obstructive pulmonary disease COPD was specifically identified for PNA. Spinal cord injury, vertebral column injury and pelvic-urogenital injury were also significant for UTI.
Conclusions:
The development of pneumonia and UTI in patients with trauma was significantly associated with the use of CI. Because the majority of these patients had CI precautions in place for asymptomatic colonization, the CI provided them no direct benefit. Because the use of CI is associated with multiple negative outcomes, its use in the trauma population needs to be carefully re-evaluated.
... kod bolesnika sa zatajenjem srca nije učinjena ehokardiografija, ergometrija, koronarografija; druga studija pokazuje da bolesnici koji su u izolaciji značajno dulje čekaju na CT pretragu]. Razlike u konačnom ishodu liječenja nisu statistički značajne u odnosu na uporabu metoda izolacije, a mortalitet je među obje grupe bolesnika podjednak [18,19]. Sama izolacija ima negativan psihološki utjecaj na bolesnike, a uzroci su u osjećaju gubitka kontrole, socijalnoj izolaciji i nedostatku komunikacije [20,21]. ...
Patient safety is becoming an increasingly important part of health policy. Prevention and control of infections associated with the implementation of methods/ procedures of medical treatment and healthcare is one of the most important components of patient safety concerns. Methods of contact isolation of patients colonized or infected with multiresistant microorganisms are today the basis for prevention and control of nosocomial infections which are considered adverse events. Today the question is how isolation affects patients. The research results show that isolation multiplies the frequency of adverse events, especially those that can be prevented. Isolation has a negative impact on the patients’ psychological wellbeing and psychological changes are more common when patients are not sufficiently informed about the measures taken. Isolation methods lead to more efficient use of methods for prevention of nosocomial infections in healthcare workers. Results of up to date published studies do not describe negative impact of the isolation on the final outcome of treatment of patients in isolation. It is necessary to assess when to apply the methods of isolation, to ensure that patients in isolation receive appropriate medical methods and procedures during the treatment and appropriate healthcare methods.
... However, while contact precautions are in common use, their efficacy in controlling the transmission of multi-drug-resistant organisms is unclear, compliance is poor, and contact precautions may result in unintended harmful consequences. 2e7 Specifically, reported consequences of contact precautions include: reduced patient contact with healthcare workers; 2,8e12 increased numbers of preventable adverse events; 13e15 decreased psychological well-being; 7 decreased patient satisfaction; 13 delays in access to radiological examinations; 16 and decreased quality of hospital care. 17 Stelfox et al. reported that patients placed under contact precautions were eight times more likely to experience supportive care failures (e.g. ...
Hospitals use contact precautions to prevent the spread of meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). There is concern that contact precautions may have adverse effects on the safety of isolated patients. In November 2010, the infection control policy at an academic medical centre was modified, and contact precautions were discontinued for patients colonized or infected with MRSA or VRE (MRSA/VRE patients).
AIM: To assess the rates of falls and pressure ulcers among MRSA/VRE patients and other adult medical-surgical patients, as well as changes in MRSA and VRE transmission before and after the policy change.
METHODS: A single-centre retrospective hospital-wide cohort study was performed from 1st November 2009 to 31st October 2011.
FINDINGS: Rates of falls and pressure ulcers were significantly higher among MRSA/VRE patients compared with other adult medical-surgical patients before the policy change (falls: 4.57 vs 2.04 per 1000 patient-days, P < 0.0001; pressure ulcers: 4.87 vs 1.22 per 1000 patient-days, P < 0.0001) and after the policy change (falls: 4.82 vs 2.10 per 1000 patient-days, P < 0.0001; pressure ulcers: 4.17 vs 1.19 per 1000 patient-days, P < 0.0001). No significant differences in the rates of falls and pressure ulcers among MRSA/VRE patients were found after the policy change compared with before the policy change. There was no overall change in MRSA or VRE hospital-acquired transmission.
CONCLUSION: MRSA/VRE patients had higher rates of falls and pressure ulcers compared with other adult medical-surgical patients. Rates were not affected by removal of contact precautions, suggesting that other factors contribute to these complications. Further research is required among this population to prevent complications.
... They found that the overall rate of adverse events was not significantly different, but that there was an increase in medication administration errors and nonpressure-related injuries. The same group also observed that the waiting time for patients to obtain a CT scan, whereas under contact precautions for VRE colonization, was 46% longer than those who were not isolated [98]. ...
Purpose of review
Hand hygiene and isolation are basic, but very effective, means of preventing the spread of pathogens in healthcare. Although the principle may be straightforward, this review highlights some of the controversies regarding the implementation and efficacy of these interventions.
Recent findings
Hand hygiene compliance is an accepted measure of quality and safety in many countries. The evidence for the efficacy of hand hygiene in directly reducing rates of hospital-acquired infections has strengthened in recent years, particularly in terms of reduced rates of staphylococcal sepsis. Defining the key components of effective implementation strategies and the ideal method(s) of assessing hand hygiene compliance are dependent on a range of factors associated with the healthcare system. Although patient isolation continues to be an important strategy, particularly in outbreaks, it also has some limitations and can be associated with negative effects. Recent detailed molecular epidemiology studies of key healthcare-acquired pathogens have questioned the true efficacy of isolation, alone as an effective method for the routine prevention of disease transmission.
Summary
Hand hygiene and isolation are key components of basic infection control. Recent insights into the benefits, limitations and even adverse effects of these interventions are important for their optimal implementation.
This audit reviewed the impact on access to routine medical care and adverse outcomes in patients with suspected SARS‐CoV‐2 infection managed on a ‘COVID’ ward (CV), compared to a General Medicine ward (GM) at Box Hill Hospital, Victoria. Data was collected at two time points to capture changes associated with onsite testing. We found no healthcare delays from admission to CV wards and observed faster exits from CV wards with improved testing efficiency. This critical finding is relevant as Victoria manages a third wave of infections. This article is protected by copyright. All rights reserved.
Background:
Several single-center studies have suggested that eliminating contact precautions (CPs) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) control in nonoutbreak settings has no impact on infection rates. We performed a systematic literature review and meta-analysis on the impact of discontinuing contact precautions in the acute care setting.
Methods:
We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Embase through December 2016 for studies evaluating discontinuation of contact precautions for multidrug-resistant organisms. We used random-effect models to obtain pooled risk ratio estimates. Heterogeneity was evaluated with I(2) estimation and the Cochran Q statistic. Pooled risk ratios for MRSA and VRE were assessed separately.
Results:
Fourteen studies met inclusion criteria and were included in the final review. Six studies discontinued CPs for both MRSA and VRE, 3 for MRSA only, 2 for VRE only, 2 for extended-spectrum β-lactamase-producing Escherichia coli, and 1 for Clostridium difficile infection. When study results were pooled, there was a trend toward reduction of MRSA infection after discontinuing CPs (pooled risk ratio, 0.84; 95% confidence interval, 0.70-1.02; P = .07) and a statistically significant reduction in VRE infection (pooled risk ratio, 0.82; 95% confidence interval, 0.72-0.94; P = .005).
Conclusions:
Discontinuation of CPs for MRSA and VRE has not been associated with increased infection rates.
There is evidence that contamination of patient rooms from previous occupants is associated with hospital-associated Clostridium difficile infection (HA-CDI). During January 2011, the use of 2 portable pulsed xenon ultraviolet light devices (PPX-UV) to disinfect patient rooms was added to routine hospital discharge cleaning in a community hospital. In 2010, the HA-CDI rate was 9.46 per 10,000 patient-days; in 2011, the HA-CDI rates was 4.45 per 10,000 patient-days (53% reduction, P = .01). The number of deaths and colectomies attributable to hospital-associated C difficile infection also declined dramatically.
Current guidelines for control of Clostridium difficile infection (CDI) suggest that contact precautions be discontinued after diarrhea resolves. However, limited information is available regarding the frequency of skin contamination and environmental shedding of C. difficile during and after treatment.
We conducted a 9-month prospective, observational study involving 52 patients receiving therapy for CDI. Stool samples, skin (chest and abdomen) samples, and samples from environmental sites were cultured for C. difficile before, during, and after treatment. Polymerase chain reaction ribotyping was performed to determine the relatedness of stool, skin, and environmental isolates.
Fifty-two patients with CDI were studied. C. difficile was suppressed to undetectable levels in stool samples from most patients during treatment; however, 1-4 weeks after treatment, 56% of patients who had samples tested were asymptomatic carriers of C. difficile. The frequencies of skin contamination and environmental shedding remained high at the time of resolution of diarrhea (60% and 37%, respectively), were lower at the end of treatment (32% and 14%, respectively), and again increased 1-4 weeks after treatment (58% and 50%, respectively). Skin and environmental contamination after treatment was associated with use of antibiotics for non-CDI indications. Ninety-four percent of skin isolates and 82% of environmental isolates were genetically identical to concurrent stool isolates.
Skin contamination and environmental shedding of C. difficile often persist at the time of resolution of diarrhea, and recurrent shedding is common 1-4 weeks after therapy. These results provide support for the recommendation that contact precautions be continued until hospital discharge if rates of CDI remain high despite implementation of standard infection-control measures.
Hospital infection control policies that use patient isolation prevent nosocomial transmission of infectious diseases, but may inadvertently lead to patient neglect and errors.
To examine the quality of medical care received by patients isolated for infection control.
We identified consecutive adults who were isolated for methicillin-resistant Staphylococcus aureus colonization or infection at 2 large North American teaching hospitals: a general cohort (patients admitted with all diagnoses between January 1, 1999, and January 1, 2000; n = 78); and a disease-specific cohort (patients admitted with a diagnosis of congestive heart failure between January 1, 1999, and July 1, 2002; n = 72). Two matched controls were selected for each isolated patient (n = 156 general cohort controls and n = 144 disease-specific cohort controls).
Quality-of-care measures encompassing processes, outcomes, and satisfaction. Adjustments for study cohort and patient demographic, hospital, and clinical characteristics were conducted using multivariable regression.
Isolated and control patients generally had similar baseline characteristics; however, isolated patients were twice as likely as control patients to experience adverse events during their hospitalization (31 vs 15 adverse events per 1000 days; P<.001). This difference in adverse events reflected preventable events (20 vs 3 adverse events per 1000 days; P<.001) as opposed to nonpreventable events (11 vs 12 adverse events per 1000 days; P =.98). Isolated patients were also more likely to formally complain to the hospital about their care than control patients (8% vs 1%; P<.001), to have their vital signs not recorded as ordered (51% vs 31%; P<.001), and more likely to have days with no physician progress note (26% vs 13%; P<.001). No differences in hospital mortality were observed for the 2 groups (17% vs 10%; P =.16).
Compared with controls, patients isolated for infection control precautions experience more preventable adverse events, express greater dissatisfaction with their treatment, and have less documented care.
We surveyed patient access managers on the impact of contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) on time to bed assignment, and we investigated the factors influencing infection control policies allowing for discontinuation of CP. The majority of respondents reported an increase in time to bed assignment for patients with a history of MRSA and/or VRE infection or colonization. Infect Control Hosp Epidemiol 2012;33(8):849-852
We aimed to estimate the risk of secondary cases of Clostridium difficile infection (CDI) among household contacts of index cases.
We reviewed all 2222 patients with confirmed CDI in a region of Quebec, Canada, during 1998-2009. Our laboratory serves a well-defined population for which it is the sole centre providing CDI testing, enabling us to calculate accurate population annual incidence rates of CDI. Cases with the same phone number were verified individually to determine whether they were indeed related. We considered as related two cases occurring in the same household within one year of each other.
We estimated that 1061 spouses and 501 children (<25 years-old) lived in the same household as the index cases, of which respectively 5 and 3 developed CDI. Among spouses and children, the attack rate was 4.71/1000 and 5.99/1000 respectively, and the relative risk was 7.61 (95%CI: 5.77-9.78) and 90.6 (95%CI: 33.89-487.64) for the three months after the diagnosis in the index case.
Although the relative risk of CDI among household contacts is somewhat increased for a few months, the absolute risk is too low to justify interventions, apart from avoiding unnecessary courses of antimicrobials.
Toilet facilities in healthcare settings vary widely, but patient toilets are commonly shared and do not have lids. When a toilet is flushed without the lid closed, aerosol production may lead to surface contamination within the toilet environment.
To substantiate the risks of airborne dissemination of C. difficile following flushing a toilet, in particular when lids are not fitted.
We performed in-situ testing, using faecal suspensions of C. difficile to simulate the bacterial burden found during disease, to measure C. difficile aerosolization. We also measured the extent of splashing occurring during flushing of two different toilet types commonly used in hospitals.
C. difficile was recoverable from air sampled at heights up to 25 cm above the toilet seat. The highest numbers of C. difficile were recovered from air sampled immediately following flushing, and then declined 8-fold after 60 min and a further 3-fold after 90 min. Surface contamination with C. difficile occurred within 90 min after flushing, demonstrating that relatively large droplets are released which then contaminate the immediate environment. The mean numbers of droplets emitted upon flushing by the lidless toilets in clinical areas were 15-47, depending on design. C. difficile aerosolization and surrounding environmental contamination occur when a lidless toilet is flushed.
Lidless conventional toilets increase the risk of C. difficile environmental contamination, and we suggest that their use is discouraged, particularly in settings where CDI is common.
BACKGROUND. The high transmissibility and widespread environmental contamination by Clostridium difficile suggests the possibility of airborne dissemination of spores. We measured airborne and environmental C. difficile adjacent to patients with symptomatic C. difficile infection (CDI). METHODS. We conducted air sampling adjacent to 63 patients with CDI for 180 h in total and for 101 h in control settings. Environmental samples were obtained from surfaces adjacent to the patient and from communal areas of the ward. C. difficile isolates were characterized by ribotyping and multilocus variable-number tandem-repeat analysis to determine relatedness. RESULTS. Of the first 50 patients examined (each for 1 h), only 12% had positive air samples, most frequently those with active symptoms of CDI (10%, vs 2% for those with no symptoms). We intensively sampled the air around 10 patients with CDI symptoms, each for 10 h over 2 days, as well as a total of 346 surface sites. C. difficile was isolated from the air in the majority of these cases (7 of 10 patients tested) and from the surfaces around 9 of the patients; 60% of patients had both air and surface environments that were positive for C. difficile. Molecular characterization confirmed an epidemiological link between airborne dispersal, environmental contamination, and CDI cases. CONCLUSIONS. Aerosolization of C. difficile occurs commonly but sporadically in patients with symptomatic CDI. This may explain the widespread dissemination of epidemic strains. Our results emphasize the importance of single-room isolation as soon as possible after the onset of diarrhea to limit the dissemination of C. difficile.
Contact Precautions (CP) are a standard method for preventing patient-to-patient transmission of multiple drug-resistant organisms (MDROs) in hospital settings. With the ongoing worldwide concern for MDROs including methicillin-resistant Staphylococcus aureus (MRSA) and broadened use of active surveillance programs, an increasing number of patients are being placed on CP. Whereas few would argue that CP are an important tool in infection control, many reports and small studies have observed worse noninfectious outcomes in patients on CP. However, no review of this literature exists.
We systematically reviewed the literature describing adverse outcomes associated with CP. We identified 15 studies published between 1989 and 2008 relating to adverse outcomes from CP. Nine were higher quality based on standardized collection of data and/or inclusion of control groups.
Four main adverse outcomes related to CP were identified in this review. These included less patient-health care worker contact, changes in systems of care that produce delays and more noninfectious adverse events, increased symptoms of depression and anxiety, and decreased patient satisfaction with care.
Although CP are recommended by the Centers for Disease Control and Prevention as an intervention to control spread of MDROs, our review of the literature demonstrates that this approach has unintended consequences that are potentially deleterious to the patient. Measures to ameliorate these deleterious consequences of CP are urgently needed.
Clostridium difficile is the most important cause of antibiotic-associated colitis. Using selective media, it was found that contamination with this organism was common in the environment of patients in the hospital with the disease. It was often found on floors, hoppers, toilets, bedding, mops, scales and furniture. This organism was also present on these items, but less often, in areas in which patients known to carry this hardy spore-forming organism had not been detected. Air, food and walls were negative. The organism was isolated from the hands and stools of asymptomatic hospital personnel. It was also found on surfaces in a patient's home. The importance of the various sources of the organism in its spread in the hospital is not known, and further studies are needed. It is suggested that enteric isolation precautions, and careful handwashing and cleansing of potentially contaminated surfaces and objects may be worthwhile when cases of antibiotic-associated colitis are identified.
Clostridium difficile is the most important cause of antibiotic-associated colitis, but its epidemiology remains unknown. Using a selective medium
for the isolation of C. difficile, cultures were obtained from the environment and contacts of hospitalized patients carrying C. difficile in their stools. In areas where carriers had diarrhea, 85 (9.3%) of 910 cultures of floors and other surfaces, especially
those subject to fecal contamination, were positive. In areas where there were no known carriers, only 13 (2.6%) of 497 cultures
of similar sites were positive (P <0.005). C. difficile was isolated from hands and stools of asymptomatic hospital personnel, from sewage and soil, and from the home of a patient.
Environmental isolates were toxigenic. C. difficile inoculated onto a floor persisted there for five months. Further studies are needed to document how often C. difficile shed by patients with antibiotic-associated colitis is acquired by other persons and whether isolation precautions are capable
of limiting the organism's spread.
Success of self-administered home fecal trans-plantation for chronic Clostridium difficile infection010 Conflicts of interest: None to report Mohit Girotra, MD * Division of Gastroenterology and Hepatology University of Arkansas for Medical Sciences, Little Rock
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Silverman MS, Davis I, Pillai DR. Success of self-administered home fecal trans-plantation for chronic Clostridium difficile infection. Clin Gastroenterol Hepatol 2010;8:471-3. DOI of original article: http://dx.doi.org/10.1016/j.ajic.2013.02.010 Conflicts of interest: None to report. Mohit Girotra, MD * Division of Gastroenterology and Hepatology University of Arkansas for Medical Sciences, Little Rock, AR Rtika R. Abraham, MD Reynolds Institute of Ageing Department of Geriatrics University of Arkansas for Medical Sciences, Little Rock, AR Mrinal Pahwa, MBBS, MS Department of Surgery, Sir Ganga Ram Hospital, New Delhi, India * Address correspondence to Mohit Girotra, MD, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, 4301 W Markham St, Shorey Building S8/68, Mail slot #567, Little Rock, AR 72205. E-mail address: MGirotra@uams.edu (M. Girotra) http://dx.doi.org/10.1016/j.ajic.2013.06.011 References
Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C difficile infection
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Sethi AK, Al-Nassir WN, Nerandzic MM, Bobulsky GS, Donskey CJ. Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C difficile infection. Infect Control Hosp Epidemiol 2010; 31:21.