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

A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens. 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. Disclosure: nothing to disclose. Hypothesis.

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

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  1. A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens 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 Disclosure: nothing to disclose

  2. 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 since compliance with universal gloving will be greater than compliance with contact precautions (gown and glove use).

  3. Methods:Setting • 12-bed medical ICU in an 820-bed, tertiary care, academic medical center • Closed-ICU staffing model with 5 attending intensivists

  4. Concurrent surveillance for nosocomial infections VRE, MRSA surveillance cultures on admission & every 4 days Measure hand hygiene compliance, antimicrobial usage Contact precautions for VRE, MRSA colonized/infected pts Universal gloving; no contact precautions Methods: Study Design Phase I Phase II

  5. Methods:Surveillance • CDC/NNIS NI definitions used; surveillance performed by experienced ICPs • Hand hygiene observations performed by trained observers • Active microbiologic surveillance: nasal and rectal cultures obtained on all patients in the unit

  6. Methods:Microbiologic Studies • One rectal swab culture for VRE and one nasal swab culture for MRSA performed on admission and every 4 days • Once a patient was culture positive, 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 isolates

  7. Methods:Healthcare Worker Questionnaire • 15 item survey was administered at the end of the study protocol • Target: MICU nurses and attending physicians • Focus: • self reported compliance with infection control practice • acceptability of universal gloving vs. standard of care

  8. Methods:Additional Data Elements

  9. Results

  10. Results: Hand Hygiene Compliance A statistically significant reduction in hand-hygiene was observed in phase II

  11. Results: Compliance with Contact Precautions vs. Universal Gloving Greater adherence during universal gloving was observed

  12. Results: VRE screening No difference was observed in the rate of VRE acquisition

  13. Results: MRSA Screening No difference was observed in the rate of MRSA acquisition

  14. Results:MRSA PFGE All MRSA conversions were with clonal or related isolates

  15. Results: VRE PFGE Most VRE conversions were with clonal or related isolates

  16. Results:Nosocomial Infections Rates A statistically significant increase in NIs was observed

  17. Results: Nosocomial Infections

  18. Results:Nosocomial Infections with VRE or MRSA 4 infections with either VRE or MRSA were identified in Phase II

  19. Results:MICU Additional Data Utilization ratio=device days/patient days

  20. Results: Antibiotic UsageDefined daily dose (DDD/1000 patients-days) The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults Example: DDD of levofloxacin is 0.5 grams, 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

  21. 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 contact precautions phase. • No differences were detected between the two study phases for: • LOS, nurse/patient ratio, MICU occupancy rate, invasive device utilization, antibiotic usage

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

  23. Conclusions • 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 led 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

  24. Conclusions • Due to short study period (6 months): • The observed increase in nosocomial infections may have been a result of normal variation and may not have been attributed to the universal gloving intervention.

  25. Criteria for PFGE interpretation Tenover et al.J.Clin Microbiol. 1995.32:2233-2239.

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