A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens

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A Controlled Trial of Universal Gloving vs.
Contact Precautions for Preventing the
Transmission of Multidrug-Resistant Pathogens
VCU Infectious Diseases Research
Conference February 27, 2006
G. Bearman MD,MPH A. Marra, MD C. Sessler,
MD W.R. Smith, MD R.P. Wenzel MD, MSc M.B. Edmond
MD,MPH,MPA
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30-40 of all Nosocomial Infections are
Attributed to Cross Transmission The
Importance of Hand Hygiene
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Hand Hygiene

• Single most important method to limit cross
  transmission of nosocomial pathogens
• Multiple opportunities exist for HCW hand
  contamination
• Direct patient care
• Inanimate environment
• Alcohol based hand sanitizers are ubiquitous
• USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

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Hand Hygiene

• HCWs perceive that their hand hygiene practice
  is excellent
• Observational data does not support this claim
• New technologies such alcohol based hand
  sanitizers make the practice of hand hygiene
  simpler than ever
• There is simply no excuse for poor hand hygiene
  compliance

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Contact Precautions for drug resistant pathogens.
Gowns and gloves must be worn upon entry into the
patients room
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Glove Use for Infection Control
Variable Rationale Comment
Gloves Prevent healthcare worker exposure to bloodborne pathogens Prevent contamination of hands with drug resistant pathogens during patient care activities Even with proper glove use, hands may become contaminated during the removal of the glove or with micro-tears that allow for microorganism transmission
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Gown Use for Infection Control
Variable Rationale Comment
Gowns Several studies have documented colonization of healthcare worker apparel and instruments during patient care activities without the use of gowns The use of gloves and gowns is the convention for limiting the cross transmission of nosocomial pathogens, however, the incremental benefit of gown use, in endemic settings, may be minimal
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Hard At work thinking of research questions
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What about the role of Universal Gloving For All
Patient Care?
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Hypothesis

• The effectiveness of universal gloving (use of
  gloves for all patient care activity) in
  preventing the transmission of multidrug-resistant
  pathogens will be greater than the effectiveness
  of contact precautions for the following reasons
  
• Compliance with universal gloving will likely be
  greater than compliance with contact precautions.
  

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• CDC/NNIS NI definitions applied surveillance
  performed by VCUMC IC Department
• Hand hygiene observations performed by trained
  observers
• Active surveillance nasal and rectal cultures
  were obtained on all patients within the unit

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Methods

• Microbiologic Data
• One rectal swab culture performed for VRE and 1
  nasal swab culture for MRSA performed on
  admission and every 4 days.
• Once a patient was culture positive then no
  further cultures were obtained for that organism.
  
• Pulse field gel electrophoresis (PFGE) for
  genetic typing and antibiotic susceptibility
  testing were performed on all MRSA and VRE
  isolated after study was completed.

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Methods

• Healthcare Questionnaire
• Administered at the end of the study protocol
• Target MRICU Nurses and Attending Physicians
• Focus
• self reported compliance with infection control
  practice
• acceptability of universal gloving vs. standard
  of care.

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MethodsAdditional Data Elements
Phase I vs. Phase II
Length of stay
MRICU occupancy rate per month
MRICU invasive devices utilization ratios
Nurse to patient ratio
Antibiotic usage defined daily dose (DDD)
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Results
Variable Phase I Phase II P value
Total patient days 1090 1377 -
Total observations for IC compliance 1220 1102 -
Total patients screened for VRE 192 257 0.54
Total patients screened for MRSA 228 301 0.60
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Results Hand Hygiene Compliance
Phase I Phase I Phase II Phase II
Variable N Obs N Obs P-value
Hand Hygiene before patient contact 228 18.7 126 11.4 lt0.001
Hand Hygiene after patient contact 704 57.7 578 52.5 0.011
A statistically significant reduction in
hand-hygiene was observed in phase II
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ResultsCompliance with Contact Precautions vs.
Universal Gloving
Variable Phase I Phase I Phase II Phase II P
Variable N N P
Compliance with gloving for patients on contact precaution 387 89.4 N/A N/A N/A
Compliance with gowns for patients on contact precaution 335 77.4 N/A N/A N/A
Gowns and gloves for patients on contact precaution 328 75.7 N/A N/A N/A
Total Compliance (Contact Precautions vs. Universal Gloving) 328 75.7 959 87.0 lt0.001
Greater adherence during universal gloving was
observed
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Results VRE screening
Variable Phase I Phase II P value
Total Patients Screened for VRE 192 257
Patients VRE positive upon admission to ICU 3 (1.5) 3 (1.1) 0.70
Patients with VRE conversion during ICU stay 39 (20) 35 (14) 0.31
Days to acquire VRE (median) 8 9 0.79
No difference was observed in the rate of VRE
acquisition
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Results MRSA Screening
Variable Phase I Phase II P value
Total Patients Screened for MRSA 228 301 -
Patients MRSA positive upon admission to ICU 11 (4.8) 6 (2.0 ) 0.11
MRSA conversion during ICU stay 13 (5.7) 15 (5.0) 0.92
Days to acquire MRSA (median) 8 9 0.95
No difference was observed in the rate of MRSA
acquisition
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Results MRSA PFGE
MRSA Phase I Phase II
Number of Strains 21 25
Conversion negative to positive 13 13/13 clonal (100) Type A1, A2, A3, A4 15 15/15 clonal (100) Type A1, A5
PFGE Types A113/21 (62) A2 5/21 (23) A3 1/21 (5) A41/21 (5) B 1/21 (5) A118/25 ( 72) A5 2/25 (8) C 3/25 (12) D2/25 (8)
ALL MRSA conversions were with clonal isolates
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Results VRE PFGE
VRE Phase I Phase II
Number of Strains 40 35
Conversion negative to positive 39 20/40 clonal (50) Type A, B 35 28/35 clonal (80) Type A, AA, AB
PFGE Types Type A 16/40 (34) Type B 4/40 (11) Type D2/40 Type G 3/40 Type H2/40 Type J2/40 Type K 2/36 Type C,E,I, L,M,Q,R S,T 1 each 9/40 Type A 18/35 (51) Type AA 4/35 (11) Type AB4/35 (11) Type H 2/35 (6) Types F,G,I,J,U,V,M1 each 7/35 (20)
Most VRE conversions were with clonal isolates
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ResultsNosocomial Infections Rates
Outcome Phase I Phase II P
BSI/1000 catheter days 6.2 14.1 Plt0.001
UTI/1000 catheter days 4.3 7.4 Plt0.001
Pneumonia 0 2.3 Plt0.001
A statistically significant increase in NIs was
observed
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Results Nosocomial Infections
Phase I Phase I Phase II Phase II
Infection Organisms Organisms
BSI 5 P. aeruginosa (1) E. cloacae (1) K. pneumoniae (1) Prevotella species (1) C. glabrata (1) 16 Coag. negative staph (6) Enterococcal species (3) VRE (1) MRSA(2) P. aeruginosa (1) K. pneumoniae (1) C. parapsilosis (1) C. albicans (1)
UTI 6 E. coli (2) E. cloacae (1) C. albicans (3) 9 Coag. negative staph (1) Enterococcal species (1) P. aeruginosa(2) E. coli (1) C. albicans (2) C. non-albicans (2)
VAP 0 NA 2 MRSA(1) P.aeruginosa (1)
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Results Nosocomial Infections with VRE or MRSA
Phase I Phase I Phase II Phase II
Infection VRE MRSA VRE MRSA
BSI 0 0 1 2
UTI 0 0 0 0
VAP 0 0 0 1
4 VRE and MRSA infections were identified in
Phase II
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MRICU Demographics
Phase I Phase II P value Variable
5.3 6.8 0.07 Average length of stay
87 92 0.36 MRICU occupancy rate per month
11.9 11.9 NS Nurse to patient ratio
Device utilization ratio Phase I Phase II P
Urinary Catheter 0.85 0.87 0.83
Central line 0.74 0.72 0.87
Ventilator 0.56 0.62 0.47
Utilization ratiodevice days/patient days
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Results Antibiotic UsageDefined daily dose
(DDD/1000 patients-day)
Antibiotic DDD Phase I DDD Phase II P value
B-lactams 391.6 352.9 0.075
B-lactam/inhibitor 210.1 211.5 1.0
Aminoglycosides 68.2 118.2 lt0.001
Glycopeptides 190.1 226 0.079
Metronidazole 127.0 118.6 0.582
Quinolones 385.7 359.0 0.206
Total 1372.7 1386.2 0.806
The DDD is the assumed average maintenance dose
per day for a drug used for its main indication
in adults ExampleDDD of levofloxacin is
0.5grams, if 200 grams were dispensed in a period
with 4,500 patient days(200g/0.5g)/4,500 pt days
X 1000 89 DDD/1000 PD
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ResultsQuestionnaire about IC compliance During
Universal Gloving Study

• 34 respondents
• 30 MRICU Nurses (45 eligible)
• 4 Attending Physicians (7 eligible)
• Overall survey compliance 65

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ResultsQuestionnaire about IC compliance
Questionnaire Item Proportion
Proportion of respondents indicating that universal glove use was impractical 12
Proportion of respondents reporting good compliance with infection control measures 97
Proportion of respondents reporting good compliance with Hand hygiene 97
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ResultsQuestionnaire about IC compliance
Questionnaire Item Proportion
HCWs reporting less frequent entry into a patient room because of contact precautions 48
Belief that proper glove use is more important than hand hygiene to limit the spread of nosocomial organisms 6
Belief that the use of gloves is associated with decreased risk of cross-transmission of nosocomial organisms 94
HCWs reporting no difference in skin problems (e.g., chapping, dryness, cracking) 93
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ResultsQuestionnaire about IC compliance During
Universal Gloving Study
Overall better care is delivered when
Majority of respondents felt that better care was
delivered during the Universal Gloving Phase of
the study
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Universal Gloving Conclusions

• Observed compliance with universal gloving was
  significantly greater than compliance with
  contact precautions (gowns and gloves).
• However, greater compliance with hand hygiene was
  observed in the standard of care phase.
• No differences were detected between the two
  study phases for
• LOS, nursepatient ratio,MRICU occupancy rate,
  invasive device utilization, and antibiotic usage
  

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Universal Gloving Conclusions

• No differences in VRE and MRSA colonization was
  observed between the two study phases.
• In both phases, the majority of VRE and MRSA
  conversions were of a clonal isolate
• However, an increase in nosocomial infection
  rates was observed during the universal gloving
  phase of the study
• 4 VRE and MRSA nosocomial infections were
  observed during the universal gloving phase

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Universal Gloving Conclusions

• HCWs found gloving acceptable and believed that
  the use of universal gloving is associated with
  decreased risk of cross-transmission of
  nosocomial organisms
• HCWs believed that better care was delivered
  under the universal gloving phase
• Although universal gloving was highly accepted by
  the staff, its implementation should proceed with
  caution given the observed increase in nosocomial
  infection rates
• The use of universal gloving may have lead to a
  misperception of decreased cross transmission
  risk
• This may have lead to decreased hand hygiene
  compliance and a consequent increase in the rates
  of nosocomial infections

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After a long, hard day at the SHEA Conference,
2004