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De-Escalation of Contact Precautions for MRSA and VRE patients
Care Coordinators Meetings
6/16/15Kim Delahanty, Admin DirectorInfection Prevention Clinical Epidemiology
*HAI- Healthcare Associated Healthcare Onset Infection** NHSN=CDC National Healthcare Safety Network
UCSD HAI Rates Reported to CDPH(Infections per 1000 patient-days)
Q1 2011 – Q1 2015
California Confidential Evidence Code 1157
UCSF Experience
2001-2013
4
• Community Onset: Specimen collected < 3 days after admission
• Hospital Onset: Specimen collected ≥ 3 days after admission
• Patient days from all locations
• Clinical cultures only - screening cultures not included
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
2
4
6
8
10
12
14
16
Methicillin-Resistant Staphylococcus aureus (MRSA)MRSA / 10,000 Patient Days at UCSF Medical Center and Benioff Children's Hospi-
talSpecimens Collected from Adult and Pediatric In-patient Locations, 2001 - 2013
Community Onset MRSA/10,000 Pt Days Trend (MRSA/10,000 Pt Days, Community Onset
Hospital Onset MRSA/10,000 Pt Days Trend (MRSA/10,000 Pt Days, Hospital Onset)
Total MRSA/10,000 Pt Days Trend (Total MRSA/10,000 Pt Days)
Year
MR
SA
/10,
000
Pat
ien
t D
ays
5
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
2
4
6
8
10
12
14
16
18
Methicillin-Resistant Staphylococcus aureus (MRSA)MRSA / 10,000 Adult Patient Days at UCSF Medical Center
Specimens Collected from Adult In-patient Locations, 2001 - 2013
Community Onset MRSA/10,000 Pt Days Trend (Community Onset MRSA/10,000 Pt Days)
Hospital Onset MRSA/10,000 Pt Days Trend (Hospital Onset MRSA/10,000 Pt Days)
Total MRSA/10,000 Pt Days Trend (Total MRSA/10,000 Pt Days)
Year
MR
SA
/ 1
0,00
0 P
atie
nt
Day
s
Includes Labor and Delivery
• Community Onset: Specimen collected < 3 days after admission
• Hospital Onset: Specimen collected ≥ 3 days after admission
• Patient days from pediatric locations only
• Clinical cultures only - screening cultures not included
6
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
1
2
3
4
5
6
7
8
9
10
Methicillin-Resistant Staphylococcus aureus (MRSA)MRSA / 10,000 Pediatric Patient Days, Benioff Children's Hospital
Specimens Collected from Pediatric In-patient Locations, 2001 - 2013
Community Onset MRSA/10,000 Pt Days Trend (Community Onset MRSA/10,000 Pt Days)
Hospital Onset MRSA/10,000 Pt Days Trend (Hospital Onset MRSA/10,000 Pt Days)
Total MRSA/10,000 Pt Days Trend (Total MRSA/10,000 Pt Days)
Year
MR
SA
/ 1
0,00
0 P
atie
nt
Day
s
Excludes Labor and Delivery
• Community Onset: Specimen collected < 3 days after admission
• Hospital Onset: Specimen collected ≥ 3 days after admission
• Patient days from pediatric locations only
• Clinical cultures only - screening cultures not included
7
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
50
100
150
200
250
0
2
4
6
8
10
12
14
Vancomycin-Resistant Enterococcus (VRE)VRE Infections/Colonizations in Adult and Pediatric Patients
UCSF Medical Center and Benioff Children's HospitalSpecimens Collected from In-Patient Locations 1995 - 2013
New VRE Patients Total VRE/10,000 Pt Days
Year
To
tal
Nu
mb
er N
ew V
RE
Cas
es
New
Cas
es p
er 1
0,00
0 P
t D
ays
Contact isolation discon-tinued
YEAR 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
New VRE Patients 114 105 126 127 178 195 214 169 200 212 215 210 174
# Patient with Linezolid I or R Strain * unk unk unk unk unk 1 8 1 2 2 6 9 9
% Patients with Linezolid I or R VRE n/a n/a n/a n/a n/a 0.5% 3.7% 0.6% 1.0% 0.9% 2.8% 4.3% 5.2%
*Data Source only goes back to 2006
8
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
2
4
6
8
10
12
14
Vancomycin-Resistant Enterococcus (VRE)New VRE Infections and Colonizations per 10,000 Patient Days
Unique Adult and Pediatric Patients, UCSF Medical Center and Benioff Children's Hospital
Specimens Collected from In-patient Locations, 2001 - 2013
Total VRE/10,000 Pt Days Trend (Total VRE / 10,000 Pt. Days)
Community Acquired VRE / 10,000 Pt Days Trend (Community Acquired VRE / 10,000 Pt Days)
Hospital Onset VRE / 10,000 Pt Days Trend (Hospital Onset VRE / 10,000 Pt Days)
Year
Nu
mb
er o
f N
ew P
atie
nts
w/
Cu
ltu
reP
osi
tive
fo
r V
RE
/ 1
0,00
0 P
atie
nt
Day
s
• Community Onset: Specimen collected < 3 days after admission
• Hospital Onset: Specimen collected ≥ 3 days after admission
Contact isolation discontinued
9
2006 2007 2008 2009 2010 2011 2012 20130
2
4
6
8
10
12
14
Vancomycin-Resistant Enterococcus (VRE)New VRE Infections and Colonizations per 10,000 Patient Days
Unique Adult and Pediatric Patients, UCSF Medical Center and Benioff Children's Hospital
Specimens Collected from In-patient Locations, 2006 - 2013
Total VRE/10,000 Pt Days Trend (Total VRE / 10,000 Pt. Days)
Community Acquired VRE / 10,000 Pt Days Trend (Community Acquired VRE / 10,000 Pt Days)
Hospital Onset VRE / 10,000 Pt Days Trend (Hospital Onset VRE / 10,000 Pt Days)
Nu
mb
er o
f N
ew P
atie
nts
w/
Cu
ltu
reP
osi
tive
fo
r V
RE
/ 1
0,00
0 P
atie
nt
Day
s
UC’s that have this policy
• UCSF• UCLA• UCD considering it• UCSD-implementing it• UCI-not considering it
Effective June 30th
• No contact precautions for MRSA or VRE colonized or infected patients
• Working with IS to remove the banners in EPIC for these precautions– May or may not happen
Why now?
• Down side of contact precautions– Increased Medication errors– Fewer care visits– Less patient satisfaction– Costs (~500K)
• Experience at UCSF, UCLA and in the literature– No change in transmission rate
• Contact precaution fatigue– Once precaution rate hits 40% fatigue occurs and precautions are
no more effective than no precautions
What about
• A patient with uncontrolled MRSA drainage?!?!?– Standard precautions– Remember MSSA and MRSA are transmitted the same way
• Explosive diarrhea with VRE– Standard Precautions– Remember stool should never be handled without gloves
• Reinforce it is all about hand hygiene!
MRSA AST(Active Surveillance testing)
• According to CDPH mandated law we still have to screen for MRSA but will not place in precautions if positive.
• MD still needs notification to prescribe the correct antibiotic for prophylaxis and or treatment.
Documents Being Updated
• Contact precautions P&P• EPIC organisms to choose for contact precautions• MRSA AST FAQ documents • Discontinue of Contact Precautions for MRSA and VRE• MDRO Definitions
Evidence and Science• The Impact of Discontinuing Contact Precautions for VRE and MRSA on Device-
Associated Infections• Michael B. Edmond, Nadia Masroor, Michael P. Stevens, Janis Ober and Gonzalo Bearman• Infection Control & Hospital Epidemiology / FirstView Article / April 2015, pp 1 – 3• DOI: 10.1017/ice.2015.99, Published online: 27 April 2015•
Isolation Precautions for Visitors• L. Silvia Munoz-Price, David B. Banach, Gonzalo Bearman, Jane M. Gould, Surbhi Leekha,
Daniel J. Morgan, Tara N.Palmore, Mark E. Rupp, David J. Weber and Timothy L. WiemkenInfection Control & Hospital Epidemiology / FirstView Article / April 2015, pp 1 – 12
• DOI: 10.1017/ice.2015.67, Published online: 10 April 2015•
Contact precautions: more is not necessarily betterDhar S, Marchaim D, Tansek R, et al.. Infect Control Hosp Epidemiol. 2014;35(3):213-221.
Thank you
