Current Infectious Disease Reports

, Volume 14, Issue 6, pp 620–626 | Cite as

Control of Drug-Resistant Pathogens in Endemic Settings: Contact Precautions, Controversies, and a Proposal for a Less Restrictive Alternative

Healthcare-Associated Infections (G Bearman and M Stevens, Section Editors)


Contact precautions are routinely employed for the control of multidrug-resistant organisms. Robust measures, however, for the incremental benefit of contact precautions, gowns, gloves, and active detection and isolation strategies for the prevention of cross-transmission in endemic settings are lacking. Unintended consequences and adverse effects from contact precautions, including patient dissatisfaction with care, depression, medication errors, and fewer provider visits, have been reported. Universal gloving strategies in lieu of contact precautions have produced mixed results and raise concerns about a decrease in hand hygiene by glove wearers. We suggest that the use of a sound, horizontal infection prevention strategy that widely and consistently implements infection prevention best practices may be a sufficient and least restrictive alternative strategy for the control of endemic multidrug-resistant pathogens.


Drug-resistant pathogens Endemic settings Contact precautions Multidrug-resistant pathogens 



The authors would like to recognize Ms. Samantha McClure for her invaluable assistance with preparation of the final manuscript.


No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Morgan DJ, Diekema DJ, Sepkowitz K, Perencivich EN. Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control. 2009;37:85–93. This study demonstrated that significant adverse effects are associated with the use of contact precautions and include non-infectious adverse events, depression, anxiety and dissatisfaction with care.PubMedCrossRefGoogle Scholar
  2. 2.
    •• Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalized patients: a systematic review. J Hosp Infect. 2010;76:97–102. This systematic review demonstrated a negative impact on patient mental well-being and behavior, including higher scores for depression, anxiety and anger among isolated patients. Healthcare workers spent less time with patients in isolation. Patient satisfaction was adversely affected by isolation.PubMedCrossRefGoogle Scholar
  3. 3.
    Siegel JD, Rhinehart E, Jackson M, Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control. 2007;35(10 Suppl 2):S165–93.PubMedCrossRefGoogle Scholar
  4. 4.
    Calfee DP, Salgado C, Classen D, et al. Strategies to prevent transmission of methicillin-resistant Staphylococcus aureus in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29 Suppl 1:62–80.CrossRefGoogle Scholar
  5. 5.
    • Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee. Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65–S164. Comprehensive document by HICPAC for the prevention of transmissible agents within health care settings.PubMedCrossRefGoogle Scholar
  6. 6.
    2012 CRE toolkit - guidance for control of carbapenem-resistant Enterobacteriaceae. Centers for Disease Control and Prevention Web site. Accessed July 3, 2012.
  7. 7.
    Farr BM, Jarvis WR. Why we disagree with the analysis of Wenzel et al. Infect Control Hosp Epidemiol. 2009;30:497–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Wenzel RP, Bearman G, Edmond MB. Screening for MRSA: a flawed hospital infection control intervention. Infect Control Hosp Epidemiol. 2008;29:1012–8.PubMedCrossRefGoogle Scholar
  9. 9.
    • Wenzel RP, Edmond MB. Infection control: the case for horizontal rather than vertical interventional programs. Int J Infect Dis. 2010;14 Suppl 4:S3–5. The authors advocate the broad application of common sense, evidence based infection prevention practices for the control of all hospital acquired infections. Active detection and isolation strategies for the control of MRSA and other pathogens are useful only if an incremental value can be demonstrated.PubMedCrossRefGoogle Scholar
  10. 10.
    Huang SS, Yokoe DS, Hinrichsen VL, et al. Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis. 2006;43:971–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148:409–18.PubMedGoogle Scholar
  12. 12.
    Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299:1149–57.PubMedCrossRefGoogle Scholar
  13. 13.
    Huskins WC, Huckabee CM, O’Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364:1407–18.PubMedCrossRefGoogle Scholar
  14. 14.
    Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med. 2011;364:1419–30.PubMedCrossRefGoogle Scholar
  15. 15.
    Gurieva T, Bootsma MCJ, Bonten MJM. The successful Veterans Affairs Initiative to prevent methicillin-resistant Staphylococcus aureus infections revisited. Clin Infect Dis. 2012;54:1618–20.PubMedCrossRefGoogle Scholar
  16. 16.
    Perencevich EN. Deconstructing the Veterans Affairs MRSA prevention bundle. Clin Infect Dis. 2012;54(11):1621–3.PubMedCrossRefGoogle Scholar
  17. 17.
    Eveillard M, Grandin S, Zihoune N, et al. Evaluation of compliance with preventive barrier precautions to control methicillin-resistant Staphylococcus aureus cross-transmission in four non-intensive acute-care wards of a French teaching hospital. J Hosp Infect. 2007;65:81–3.PubMedCrossRefGoogle Scholar
  18. 18.
    Vayalumkal JV, Streitenberger L, Wray R, et al. Survey of isolation practices at a tertiary care pediatric hospital. Am J Infect Control. 2007;35:207–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Manian FA, Ponzillo JJ. Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions. Infect Control Hosp Epidemiol. 2007;28(3):337–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Clock SA, Cohen B, Behta M, et al. Contact Precautions for Multidrug Resistant Organisms: Current Recommendations and Actual Practice. Am J Infect Control. 2010;38:105–11.PubMedCrossRefGoogle Scholar
  21. 21.
    Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect. 2007;66:6–14.PubMedCrossRefGoogle Scholar
  22. 22.
    Ross B, Marine M, Chou M, et al. Measuring compliance with transmission-based isolation precautions: comparison of paper-based and electronic data collection. Am J Infect Control. 2011;39:839–43.PubMedCrossRefGoogle Scholar
  23. 23.
    Pittet D. The Lowbury lecture: behaviour in infection control. J Hosp Infect. 2004;58(1):1–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Bearman G, Rosato AE, Duane TM, et al. Trial of universal gloving with emollient-impregnated gloves to promote skin health and prevent the transmission of multidrug-resistant organisms in a surgical intensive care unit. Infect Control Hosp Epidemiol. 2010;31(5):491–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Bearman GM, Marra AR, Sessler CN, et al. A controlled trial of universal gloving versus contact precautions for preventing the transmission of multidrug-resistant organisms. Am J Infect Control. 2007;35:650–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Eveillard M, Guilloteau V, Kempf M, et al. Impact of improving glove usage on the hand hygiene compliance. Am J Infect Control. 2011;39(7):608–10.PubMedCrossRefGoogle Scholar
  27. 27.
    Eveillard M, Joly-Guillou ML, Brunel P. Correlation between glove use practices and compliance with hand hygiene in a multicenter study with elderly patients. Am J Infect Control. 2012;40(4):387–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Fuller C, Savage J, Besser S, et al. "The dirty hand in the latex glove": a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011;32(12):1194–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Eveillard M. Wearing gloves: the worse enemy of hand hygiene. Future Microbiol. 2011;6:835–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Gammon J. Analysis of the stressful effects of hospitalization and source isolation on coping and psychological constructs. Int J Nurse Pract. 1998;4:84–96.CrossRefGoogle Scholar
  31. 31.
    Tarzi S, Kennedy P, Stone S, Evans M. Methicillin-resistant Staphylococcus aureus: psychological impact of hospitalization and isolation in an older adult population. J Hosp Infect. 2001;49:250–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Catalano G, Houston SH, Catalano MC, et al. Anxiety and depression in hospitalized patients in resistant organism isolation. South Med J. 2003;96:141–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Kirkland KB, Weinstein JM. Adverse effects of contact isolation. Lancet. 1999;354:1177–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Evans HL, Shaffer MM, Hughes MG, et al. Contact isolation in surgical patients: a barrier to care? Surgery. 2003;134:180–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Saint S, Higgins LA, Nallamothu BK, Chenoweth C. Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control. 2003;31:354–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Cohen E, Austin J, Weinstein M, Matlow A, Redelmeier DA. Care of children isolated for infection control: a prospective observational cohort study. Pediatrics. 2008;122:e411–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Morgan DJ, Kirkland KB. Uncertainty in the application of contact precautions. Clin Infect Dis. 2012;55(3):474–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Kang J, Mandsager P, Biddle AK, Weber DJ. Cost-effectiveness analysis of active surveillance screening for methicillin-resistant Staphylococcus aureus in an academic hospital setting. Infect Control Hosp Epidemiol. 2012;33(5):477–86.PubMedCrossRefGoogle Scholar
  39. 39.
    Leonhardt KK, Yakusheva O, Phelan D, et al. Clinical effectiveness and cost benefit of universal versus targeted methicillin-resistant Staphylococcus aureus screening upon admission in hospitals. Infect Control HospEpidemiol. 2011;32(8):797–803.CrossRefGoogle Scholar
  40. 40.
    Diekema DJ, Edmond MB. Look before you leap: active surveillance for multidrug-resistant organisms. Clin Infect Dis. 2007;44(8):1101–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Yokoe DS, Mermel LA, Anderson DJ, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control HospEpidemiol. 2008;29 Suppl 1:S12–21.CrossRefGoogle Scholar
  42. 42.
    Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA. 2009;301(12):1231–41.PubMedCrossRefGoogle Scholar
  43. 43.
    Sasichay-Akkadechanunt T, Scalzi CC, Jawad AF. The relationship between nurse staffing and patient outcomes. J Nurs Adm. 2003;33(9):478–85.PubMedCrossRefGoogle Scholar
  44. 44.
    Kane RL, Shamliyan T, Mueller C, et al. Nurse staffing and quality of patient care. Evid Rep Technol Assess (Full Rep). 2007;151:1–115.Google Scholar
  45. 45.
    Frith KH, Anderson EF, Caspers B, et al. Effects of nurse staffing on hospital-acquired conditions and length of stay in community hospitals. Qual Manag Health Care. 2010;19(2):147–55.PubMedGoogle Scholar
  46. 46.
    Moore G, Smyth D, Singleton J, et al. The use of adenosine triphosphate bioluminescence to assess the efficacy of a modified cleaning program implemented within an intensive care setting. Am J Infect Control. 2010;38:617–22.PubMedCrossRefGoogle Scholar
  47. 47.
    Sherlock O, O’Connell N, Creamer E, et al. Is it really clean? an evaluation of the efficacy of four methods for determining hospital cleanliness. J HospInfect. 2009;72:140–6.CrossRefGoogle Scholar
  48. 48.
    Dellit TH, Owens RC, McGowan Jr JE, et al. Infectious diseases society of America and the society for healthcare epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159–77.PubMedCrossRefGoogle Scholar
  49. 49.
    Uniforms and workwear: an evidence base for developing local policy. Department of Health Web site. Accessed July 20, 2009.
  50. 50.
    Treakle AM, Thom KA, Furuno JP, et al. Bacterial contamination of health care workers' white coats. Am J Infect Control. 2009;37(2):101–5.PubMedCrossRefGoogle Scholar
  51. 51.
    Bearman GM, Rosato A, Elam K, et al. A crossover trial of antimicrobial scrubs to reduce methicillin-resistant Staphylococcus aureus burden on healthcare worker apparel. Infect Control HospEpidemiol. 2012;33(3):268–75.CrossRefGoogle Scholar
  52. 52.
    Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay. BMJ. 2011;342:d219. doi: 10.1136/bmj.d219.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Virginia Commonwealth UniversityRichmondUSA

Personalised recommendations