The problem of patients acquiring antibiotic-resistant bacterial infections during hospitalization has been growing in recent years. To minimize the spread of these infections, US hospitals are instituting methods such as glove and gown use by health care workers when entering patient rooms and chlorhexidine bathing of patients, but the effectiveness of these interventions is unknown.
A study released in JAMA today suggests that “universal” glove and gown use by all health care workers when entering all patient rooms in intensive care units (ICUs) may not reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), 2 common antibiotic-resistant bacteria acquired in the hospital.
In the study, researchers randomly assigned health care workers in 20 medical and surgical ICUs across the United States to either universal glove and gown use or “usual care,” which involves using gloves and gowns only for patients with known prior MRSA or VRE infection or colonization.
Results showed that when looked at together, the rates of acquisition of MRSA and VRE by patients did not differ between the 2 groups. However, when looked at separately, MRSA acquisition was lower in the universal glove and gown ICUs, while VRE acquisition was unchanged. The researchers also found that in the universal glove and gown ICUs, health care workers entered patient rooms less than in the usual care ICUs.
Lead author Anthony Harris, MD, MPH, an infectious disease specialist and epidemiologist at the University of Maryland in Baltimore, discusses the findings of this study.
news@JAMA: Why did you conduct this study? What were you expecting to find?
Dr Harris: We wanted to understand if wearing gowns and gloves for all patient contact in the ICU could help prevent the spread of antibiotic-resistant bacteria such MRSA and VRE. Secondarily, we wanted to make sure this type of patient isolation did not result in any harm to patients. We were hoping that the intervention would decrease the acquisition of antibiotic-resistant bacteria without increasing adverse events, but we were not certain this would be the case, given inconclusive results from previous nonrandomized studies.
news@JAMA: Why do you think there was a difference between the MRSA and VRE outcomes?
Dr Harris: Bacteria are complex. Interventions that work to decrease one antibiotic-resistant bacteria may not work for others. For example, a recent randomized trial showed that chlorhexidine bathing had an effect on VRE acquisition but not on MRSA acquisition. In our study, we think differences may have been due to differences in transmission mechanisms between MRSA and VRE. However, another explanation is that the intervention did have an effect on VRE but this was not identified because of the overwhelming effect of antibiotic use on surveillance test results for VRE. Antibiotics may kill off most bacteria so that VRE that was not detected on admission was detected on discharge in patients who were already colonized on admission.
news@JAMA: Why did you look at the frequency of health care worker entry into patient rooms? Do you think the fact that it was lower in the intervention group may have an effect on patient care?
Dr Harris: Numerous nonrandomized studies have shown that glove and gown precautions may lead to a decrease in health care worker visits [into the patient rooms]. We wanted to validate this result in a randomized trial. While our findings suggest that health care workers may not enter patient rooms as often when gowns and gloves were required, this did not lead to an increase in adverse events. It is possible that health care workers required to wear gowns and gloves are “bundling” their patient visits so that they go in less often but spend more time and accomplish more on the same visit.
news@JAMA: In the accompanying editorial, JAMA associate editor Dr Preeti Malani suggests that when it comes to universal glove and gown precautions, “one size does not fit all,”—meaning one rule should not apply to all hospital settings. What are your personal thoughts about universal glove and gown precautions in light of the findings of this study?
Dr Harris: We agree with Dr Malani and believe that many infection control interventions, including active surveillance, chlorhexidine bathing, and decolonization, should not follow one policy or rule that fits all. We have seen evidence that gowning and gloving along with chlorhexidine bathing are effective in certain settings and for certain problems. We believe that universal gown and gloving is a feasible intervention across a range of ICUs. We think that ICUs should consider adoption of universal gown and gloving policies, especially in units that have higher rates of MRSA.
news@JAMA: What do you think are the next steps for clinical trials in this area?
Dr Harris: Next steps are to continue to encourage funding agencies to fund these types of trials. In hospital epidemiology, we are finally raising the bar of evidence-based studies. This leads to the development and implementation of interventions that can decrease health care–associated infections and decrease the spread of antibiotic-resistant bacteria. As well, we would like to see more of these pragmatic-type trials to assess other other infection control interventions, such as environmental cleaning and antimicrobial stewardship.