Wednesday, July 5, 2017

Reflections on Gowns, Gloves and the Endemic Threshold

I apologize for a longer than usual blog post today.

I have been giving some thought to comments relevant to my work posted on the HAI Controversies Blog. First, I would like to say that the comments are welcomed and drive discussion and debate. I love it.

With respect to the BUGG study and universal gloving, I am not dismissive of personal protective equipment (PPE). As posted in the comment section by one reader, the way that PPE is used probably is important. In this vein, we feel that healthcare workers should be trained for competency in the use of gowns and gloves, as published here. However, we struggle to take make the training effective to scale- across 7000+ healthcare workers in our institution. This would have to be done in a sustained fashion, particularly as employment status changes across personnel. No easy task.

I am frequently asked about a threshold for instituting or discontinuing contact precautions for endemic pathogens such as VRE and MRSA. This is explored in a recent blog post by Dr. Perencevich. I have no endemic threshold (infection or colonization pressure) in mind. Before making a change in infection prevention strategy it is important to understand your institutional trend in all device associated infections, surgical site infections and MRSA and VRE infections.  One must also have confidence in the reliability, as judged by aggressive, standardized audit and feedback, of a horizontal infection prevention platform. With consistently decreasing device associated infections/surgical site infections (CDC definition), decreasing MRSA and VRE infections and a reliable, horizontal infection prevention platform, we discontinued contact precautions for MRSA and VRE in our institution in 2013. The infection rates continue to decline and we have observed no increase in patient harm. We are not alone in this approach, as summarized here.

I realize that the above may not satisfy the calls for high level methodology, however, cluster randomized trials to answer the above 'endemic threshold' question for contact precautions may never materialize. 

Should new data contradict our experience or should infection rates increase, regardless of pathogen, it would be time to critically reassess all elements of our infection prevention program. Everything would then be back on the table.

If I am labelled as biased then that bias is pragmatism.

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