Discontinuing contact precautions for pediatric patients with methicillin-resistant Staphylococcus aureus

Discontinuing contact precautions for pediatric patients with methicillin-resistant Staphylococcus aureus | Image Credit: © John Doe - © John Doe - stock.adobe.com.

A recent study, published in the Journal of the Pediatric Infectious Diseases Society, analyzed a pediatric health system's experience discontinuing contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA), spanning 4 years.

The findings, indicating sustained infection control success, support the potential extension of this approach to other pediatric facilities.

Key factors include strong adherence to horizontal infection prevention measures and early engagement with stakeholders.

To learn more about the study and its findings, our sister publication Infection Control Today® interviewed study authors Michael Sebert, MD, medical director, infection prevention and control, Children's Health Dallas; Zachary Most, MD, assistant professor, Department of Pediatrics, UT Southwestern Medical Center; associate medical director of infection prevention and control, Children’s Health Dallas and serves on the COVID-19 Modeling Group and the Optum Database Research Group at UT Southwestern; and Bethany Phillips, MPH, CIC, MLS (ASCP)CM, director, infection prevention & control at Children's Health, Children’s Health System of Texas, Children’s Medical Center, Dallas, Texas.

Question:

Can you provide an overview of the study's methodology and the specific measures taken when discontinuing contact precautions (CP) for pediatric patients with methicillin-resistant Staphylococcus aureus (MRSA)?

Michael Sebert, MD; Zachary Most, MD; and Bethany Phillips, MPH, CIC, MLS (ASCP)CM: The study was a quasi-experimental retrospective analysis of MRSA infection and colonization rates before and after discontinuation of the requirement for contact precautions for patients with MRSA at our facilities. This change was implemented in September 2019, and outcomes were tracked for 4 years afterwards through August 2023. MRSA infections were measured using the National Healthcare Safety Network’s LabID definition. Statistical analyses were conducted using interrupted time series (ITS) and aggregate rate ratios.

Our infection prevention department conducted an evidence-based practice project as part of preparing to discontinue CP for MRSA. This project included a review of local baseline data on health care-associated MRSA infection and colonization, an evaluation of our current and planned horizontal infection prevention measures, and a review of reported experiences from other facilities following the discontinuation of CP for MRSA. We met in advance with physician and nursing leaders from key areas, including pediatric and neonatal intensive care units (PICU and NICU) and hematology/oncology, to discuss the rationale for the change and plans for implementation. Education on the practice change along with proper use of standard precautions was provided to all staff before the change.

Discussion with the NICU led to the decision that CP for MRSA would be selectively continued in that unit due to concerns about the potential for importation of multidrug-resistant organisms from other NICUs in the region that transfer patients into our unit. The open-bay architecture of our NICU—the only area in our hospitals where not all inpatients have single-patient rooms—also contributed to this decision.

Because our electronic health record (EHR) utilized infection control flags to identify patients with a history of MRSA as requiring CP. These flags persisted between encounters, and therefore assistance from our Informatics team was crucial to implement an automated procedure to remove the MRSA flags from the charts of all patients except those in the NICU. For patients who were currently admitted on the date of the change, the infection preventionists worked with the inpatient units to make sure that CP were removed when appropriate but retained if there was another indication for CP such as a resistant gram-negative pathogen or a respiratory viral infection requiring CP.

Question:

What were the key findings of the study regarding the incidence density rate of LabID health care facility-onset MRSA infections after the discontinuation of CP for MRSA in the pediatric health care system?

Sebert, Most, and Phillips: ITS analysis showed no change in the incidence density rate of LabID health care facility-onset MRSA infections associated with the discontinuation of CP for MRSA. Likewise, there was no change in the aggregate incidence density rate of these infections (rate ratio = 0.98, 95% confidence interval 0.74 to 1.28). This provides long-term data for the safety of this approach using a broad measure of MRSA infections, which had previously been lacking in pediatric health care settings.

Question:

The study mentions a decrease in the prevalence rate of contact isolation days. How did the health care system ensure good adherence to horizontal infection prevention measures after discontinuing CP, and what impact did it have on infection rates?

Sebert, Most, and Phillips:

After providing house-wide education about standard precautions, our infection preventionists solicited and trained health care personnel (HCP) volunteers to perform observations of personal protective equipment (PPE) usage by other HCP starting in May 2019.

These observations and feedback focused on appropriate use as indicated by exposure risks as well as when required by transmission-based precautions. Findings were generally favorable and supported the decision to discontinue CP for MRSA later that fall. These observations continued through the beginning of 2022 to ensure that practice did not drift.

Horizontal infection prevention processes at our hospitals that may not be standard everywhere include high-touch surface cleaning by nursing staff of inpatient rooms twice per shift. This process focuses on surfaces such as bedrails and IV pumps that are frequently contacted by patients and/or HCP. Completion of high-touch surface cleaning must be documented, and adherence is reported to unit leadership.

This cleaning is a supplemental measure above and beyond daily cleaning by the environmental services (EVS) department. To monitor the effectiveness of routine cleaning, our infection prevention team has also partnered with EVS to use fluorescent markers as an objective measure of cleaning and to provide feedback to EVS staff.

Other ways that adherence to horizontal infection prevention measures is monitored include hand hygiene observations and audits of prevention bundles for health care-associated infections (HAIs), including central line-associated bloodstream infections and catheter-associated urinary tract infections. Although these measures are subject to bias from the observation process itself (Hawthorne effect), adherence appeared to be high and contributed to our confidence in ending CP for MRSA.

Our observational study cannot address the specific impact of these horizontal infection prevention measures on MRSA infection rates after stopping CP.

The published experiences with successful discontinuation of CP for MRSA at other facilities, however, consistently emphasize the importance of these horizontal measures. Our experience was similar and cannot be extrapolated to facilities where adherence to horizontal infection prevention measures may not be high.

Question:

Were there any unexpected challenges or outcomes observed during the 4-year period after discontinuing CP for MRSA in the pediatric health care settings?

Sebert, Most, and Phillips: The most surprising part of the entire process of discontinuing CP for MRSA was how uneventful it was. Acceptance of the change was high among staff and patient families. Utilizing an evidence-based practice project model for implementing this sort of large-scale change may have assisted in the positive reception from staff. They were engaged throughout the project via questionnaires soliciting feedback on our current practice, participating in the creation of the education, serving as PPE auditors, and, most importantly, they were able to review the rationale behind the practice change. Health care-associated MRSA infection rates were monitored and reported to the hospitals’ infection control committees on a quarterly basis without concerning trends being identified.

Question:

The study suggests that the experience supports considering the discontinuation of CP for MRSA in similar pediatric health care settings. What factors, in your opinion, contributed to the success of this approach, and what considerations should other pediatric facilities keep in mind when making such decisions?

Sebert, Most, and Phillips: As mentioned above, we believe that strong adherence to horizontal infection prevention measures such as hand hygiene, standard precautions, environmental cleaning, and HAI prevention bundle elements were collectively key to the success of this approach. A review of baseline data before implementing the change showed no recent outbreaks or clusters of health care-associated MRSA infections. Other institutions considering a similar discontinuation of CP for MRSA should conduct a risk assessment, evaluate horizontal infection prevention measures, and review surveillance data to ensure that there have not been unrecognized clusters of health care-associated MRSA infections.

In addition to strong adherence to infection prevention measures, engaging key stakeholders early in the process contributed to the successful implementation of the practice change. Employing our infection preventionists together with our medical director as a physician advocate when initiating discussions with the clinical teams allowed our IP team to ensure that we were able to gain the confidence of medical providers while also providing an approachable forum for the frontline staff to provide their valuable input.

Question:

Given the positive outcomes observed in the pediatric health care system, do you believe the findings could be extrapolated to other pediatric facilities, and what implications might this have for the broader approach to managing MRSA in pediatric health care settings?

Sebert, Most, and Phillips:: We are optimistic that our success with discontinuing CP for MRSA might be extended to other pediatric facilities in the setting of good adherence to horizontal infection prevention measures. The strength of our study, however, is qualified in that was a retrospective observational analysis at a single institution. The data supporting this approach in pediatric health care settings remain more limited than what has been published from facilities caring for adults. As more pediatric facilities consider discontinuation of CP for MRSA, multicenter studies—including control sites where CP have been maintained—would shed more light on this still controversial topic.

The issue addressed in our study about the requirement for CP in patients with MRSA is only one aspect of the overall care of these patients.

Timely recognition, diagnosis, and treatment of infection remain critical whether or not an institution has continued CP for MRSA. Unsettled questions also remain regarding whether active surveillance for MRSA in health care settings may provide benefits and about the role for decolonization strategies in patients identified to have MRSA infection or colonization.

The study is titled “Discontinuation of Contact Precautions for Methicillin-resistant Staphylococcus aureus in a Pediatric Healthcare System.”

This interview was initially published by our sister publication, Infection Control Today.