Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in ICUs

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Abstract

The intensive control strategy involves: 1) identifying patients who are colonized with MRSA or VRE by reporting the results of surveillance cultures of the anterior nares and stool or perianal area; 2) Universal Gloving (use of gloves during interactions with the patient or the patients environment) until the patients are discharged or their surveillance culture results show they are not colonized with MRSA or VRE (whichever happens first); and 3) Contact Precautions (use of gloves and gowns during interactions with the patient or the patients environment) during care of patients who are colonized with MRSA or VRE. Standard care involves proper hand hygiene (handwashing or use of a waterless hand antiseptic) and use of Standard Precautions (use of gloves and other barriers as needed for interactions involving contact with mucous membranes, wounds, and body fluids) and collection of surveillance cultures, but not reporting of results to these sites. The surveillance cultures will be performed by obtaining swabs of the nose and stool or perianal area from patients upon admission to the ICU, at weekly intervals thereafter, and upon discharge from the ICU. The results of the surveillance cultures will be used to compare the rate of colonization with MRSA and VRE in ICUs using the intensive control strategy with those that use standard care alone. Progress Report: This study is a multi-center trial supported by the National Institute of Allergy and Infectious Diseases (NIAID) and is conducted through the Bacteriology and Mycology Study Group, a clinical trials network funded by NIAID. Male and female patients, ages 18 and above, who are admitted to the MICU, SICU or MICU/SICU at one of the 20 participating sites are eligible for the study. The NIH Clinical Center provides the microbiology support for this protocol and has no direct patient contact. All microbiology specimens from participating sites are sent to the Department of Laboratory Medicine. The specimens are processed and recorded in the BAMBU database. In addition to providing microbiology support for the participating sites, several sub-studies are underway testing novel rapid diagnostic tools for MRSA and VRE against culture results. We have enrolled 20,059 patient specimens and the study is now closed. (Last day for enrollment was August 25, 2006). The study remains open for continued data analysis only. Analysis of the primary endpoint show: 1.Intensive control strategy was not effective in reducing the incidence density of colonization or infection with MRSA or VRE in ICUs in which these organisms were endemic 2. Colonization with VRE was more common than colonization with MRSA, both on admission and as a new colonization event 3. Surveillance cultures initially identified the majority of subjects who became colonized during their ICU stay & a substantial proportion of those colonized on admission 4. Hand hygiene & use of barrier precautions, as practiced in the intensive control strategy ICUs, were not sufficient to reduce the transmission of MRSA and VRE compared with the standard control strategy ICUs