Contact precautions (CPs) are commonly employed in pediatric populations for the control of endemic pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Presumably, CPs limit infections by preventing contamination of healthcare personnel (HCP) and are often utilized to prevent hospital-associated infections (HAIs). Data on the effectiveness of CPs in reduction of HAIs in pediatric patients are scarce. Several adult studies observed that CPs negatively impact some aspects of patient care including reduced visits by HCP,Reference Harris, Pineles and Belton1 increase rates of anxiety/depression,Reference Catalano, Houston and Catalano2, Reference Day, Morgan, Himelhoch, Young and Perencevich3 and increase patient dissatisfaction.Reference Stelfox, Bates and Redelmeier4 We investigated the impact of discontinuing CPs for patients with MRSA and VRE colonization/infection on central-line associated bloodstream infections (CLABSIs) in an academic children’s hospital.
Materials and methods
This quasi-experimental, before-and-after study of discontinuing CPs for MRSA or VRE infected or colonized patients was conducted at the Children’s Hospital of Richmond (CHoR) at Virginia Commonwealth University Health System. CHoR is a 103-bed academic children’s hospital integrated within a larger adult facility with 40 and 21 beds for the neonatal intensive care unit (NICU) and the pediatric intensive care unit (PICU), respectively. PICU and NICU rooms are private, although several NICU rooms are set up to accommodate multiple births. Nearly half of the rooms in acute-care pediatrics (ACP) can accommodate double occupancy. The pediatric progressive care unit (PPCU) housed semi-private rooms and closed in January 2018 (58 months after discontinuation of CPs) to accommodate an expansion of the PICU from 14 to 21 beds. Historically, patients with multidrug-resistant organisms were placed on CPs. On April 1, 2013, we discontinued CPs in patients with MRSA or VRE colonization/infection. Patients with draining wounds or uncontained respiratory secretions remained on CPs regardless of organism. Trained infection preventionists monitored CLABSIs, as defined by the National Healthcare Safety Network (NHSN), in the PPCU, PICU, NICU, and ACP. Since 2008, our institution implemented multiple different infection prevention interventions as part of a bundled horizontal infection control platform. These interventions included (1) hand hygiene (HH) monitoring in 2008, (2) implementation of central-line checklists in 2008, (3) a bare-below the elbows (BBE) approach to HCP attire in 2009, (4) CP monitoring in 2009, and (5) daily chlorohexidine (CHG) bathing in patients ≥2 months of age with central lines and urinary catheters in 2016 (Table 1). We used a 2-proportion Z test to compare CLABSI rates in the 60-month period before and after discontinuation of CPs spanning from April 1, 2008, to March 31, 2018. Surveillance of CLABSI in ACP and PPCU did not start until 2010 (39 months before discontinuation of CPs), and our PPCU unit closed in January 2018 (58 months after discontinuation of CPs). We used the Student t test to assess the difference in antimicrobial consumption before and after discontinuation of CPs. All statistical tests were performed using JMP Pro 13 software (SAS Institute, Inc, Cary, NC). P < .05 was considered statistically significant.
Pediatric Infection Prevention Process of Care Measures
Note. ICU, intensive care unit; BBE, bare below the elbows; CHG, chlorhexidine gluconate; N/A, not available.
a Monitoring for CP and BBE by trained hand hygiene monitors began in 2016.
b Monitoring of central line checklist completion began in the ICUs in 2016.
c Monitoring of hand-hygiene compliance data is for the complete study period from April 1, 2008 to March 31, 2018.
d Total antibiotic consumption data collected from August 2012 through December 2017.
Results
There was no difference in the rates of MRSA and VRE CLABSI before and after discontinuation of CPs in ACP, PPCU, PICU, NICU, or all settings combined (Table 2). We observed no change in CLABSI rates due to all pathogens (including MRSA and VRE) in the PPCU or PICU. There was a statistically significant reduction in the rate of CLABSI due to all pathogens in ACP, in the NICU, and in all settings combined. The process of care measures including CPs, daily CHG bathing, central-line checklist completion, BBE approach, and HH are summarized in Table 1. Notably, HH compliance was >90% hospital-wide for the 60 months before and after discontinuation of CPs. Monitoring for CPs and BBE by trained HH monitors began in 2016. Monitoring of central-line checklist completion began in the intensive care units (ICUs) in 2016. Daily CHG bathing occurs in patients with central lines and urinary catheters, but compliance data on this metric were not available. Record of antimicrobial consumption data across units began August 2012. The mean total antimicrobial consumption measured in days of therapy (DOT) per 1,000 patient days (PD) before and after discontinuation of CPs were 567 DOT per 1,000 PD and 500 DOT per 1,000 PD, respectively (P = .0164).
Rate of MRSA, VRE and All Pathogens Central-Line Bloodstream Infections
Note. CLABSI, central-line associated bloodstream infections, MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus; CP, contact precautions; ACP, acute-care pediatrics; PPCU, pediatric progressive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit.
a No. of infections/1,000 central-line days.
b Bold indicates significance.
Discussion
We discontinued CPs for MRSA and VRE colonized or infected patients in 2013, and we observed no negative impact on CLABSI rates in pediatric patients at an academic children’s hospital. We previously reported that discontinuation of CPs did not negatively impact device-associated HAI rates hospital-wide in combined adult and pediatric patients.Reference Edmond, Masroor, Stevens, Ober and Bearman5 This practice change was associated with an estimated annual cost savings of $500,000 across all inpatient populations.Reference Edmond, Masroor, Stevens, Ober and Bearman5 Importantly, patients with draining wounds or uncontained respiratory secretions and potentially at increased risk of transmitting MRSA or VRE remained on CPs.
At CHoR, our pediatric services are integrated within a larger adult facility. Reviewing our inpatient pediatric specific data, we observed an overall significant reduction in the rate of CLABSIs due to all pathogens during the study period, likely due to a horizontal infection prevention platform. Although individual infection prevention strategies have an unknown impact on HAIs, bundled interventions yield improved clinical outcomes. Our finding is consistent with previously published reports of hospital-wide, sustained HAI decreases.Reference Bearman, Abbas and Masroor6, 7
We add to the growing body of literature that discontinuation of CPs for MRSA or VRE infected or colonized patients does not adversely affect HAIs, specifically the rates of CLABSIs in pediatric patients. To our knowledge, this is the first study focused on the impact of discontinuation of CPs exclusively in pediatric patients.
A study strength included standardized data collection by the infection prevention team employing NHSN CLABSI definitions. The study has several limitations. We used a quasi-experimental design and single-center data. Data on compliance for BBE, CHG bathing, and central-line checklists throughout the study period were incomplete. Generalizability to larger children’s hospitals may be limited due to CHoR’s small size and integration into an adult facility. The total antibiotic consumption was significantly higher before the discontinuation of CPs. Antibiotic consumption data were only available for 8 months before the change in CP strategy, thereby limiting the comparison between the 2 periods. The potential impact of greater antibiotic use is unknown and may have presumably decreased the overall rate of infection or increased multidrug-resistant organism selective pressure during standard CP practice. Furthermore, longitudinal data were not available on MRSA or VRE colonization burden, although active surveillance for MRSA in the NICU was previously performed from 2007 to 2015. Discontinuation of MRSA surveillance occurred in February 2015 due to a sustained MRSA colonization rate of <1%. In an adult cluster-randomized trial, active MRSA and VRE detection and isolation did not control endemic infection.Reference Huskins, Huckabee and O’Grady8 Additionally, an adult study discontinued CPs and found no increase in MRSA or VRE colonization/infection with active surveillance methods in place.Reference Gandra, Barysauskas, Mack, Barton, Finberg and Ellison9
In conclusion, we discontinued CPs for infected or colonized pediatric patients with MRSA or VRE and did not observe an increase in CLABSI rates at our institution. Discontinuation of MRSA and VRE CPs in the setting of a bundled horizontal infection prevention platform may be an alternative for the control of endemic pathogens. Further studies are needed to define optimal infection prevention strategies to control MRSA and VRE in pediatric populations.
Author ORCIDs
Emily J. Godbout, 0000-0001-6732-7751
Financial support
No financial support was provided relevant to this article.
Conflicts of interest
All authors report no conflicts of interest relevant to this article. MD and GB have received grant support from Molnlycke Health Care.
