Giuseppe
Emeritus
Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care (NEJM, abstract, edited)
[Source: The New England Journal of Medicine, full text: <cite cite="http://www.nejm.org/doi/full/10.1056/NEJMoa1000373?query=TOC&">Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care ? NEJM</cite>. Abstract, edited.]
Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care
W. Charles Huskins, M.D., Charmaine M. Huckabee, M.S., Naomi P. O'Grady, M.D., Patrick Murray, Ph.D., Heather Kopetskie, M.S., Louise Zimmer, M.A., M.P.H., Mary Ellen Walker, M.S.N., Ronda L. Sinkowitz-Cochran, M.P.H., John A. Jernigan, M.D., Matthew Samore, M.D., Dennis Wallace, Ph.D., and Donald A. Goldmann, M.D. for the STAR*ICU Trial Investigators
N Engl J Med 2011; 364:1407-1418
April 14, 2011
Background
Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).
Methods
In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative.
Results
During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (?SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4?3.3 and 35.6?3.7 in the two groups, respectively; P=0.35).
Conclusions
The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required.
(Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386.)
Supported by contracts (N01 AI-15440 and N01 AI-15441) from the National Institute of Allergy and Infectious Diseases to the Bacteriology and Mycology Study Group clinical research network and the Bacteriology and Mycology Statistical and Operations Unit data coordinating center; by institutional grants (M01-RR-00585, UL1-RR024150, and M01-RR-00039) from the National Center for Research Resources to the Mayo Clinic Center for Translational Science Activities and the General Clinical Research Center at Emory University; and by Merck, Elan Pharmaceuticals, Roche Diagnostics, and Kimberly Clark.Dr. Huskins reports receiving consulting fees from Roche Diagnostics and serving on an advisory board for GlaxoSmithKline; and Dr. Goldmann, receiving consulting fees from Medegen and serving on an advisory board for BioNeutral Group. No other potential conflict of interest relevant to this article was reported.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
We thank the study coordinators; the physician and nurse directors and the staff in the intensive care units at the participating sites; the technologists at the National Institutes of Health Clinical Center Microbiology Laboratory and at the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention; and the principal investigators of the Bacteriology and Mycology Study Group and members of the Risk Group 4 Research Committee (see the Supplementary Appendix).
Source Information
From the Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN (W.C.H.); Rho Federal Systems Division, Chapel Hill, NC (C.M.H., H.K., L.Z., D.W.); the National Institutes of Health Clinical Center, Bethesda, MD (N.P.O., P.M.); the University of Alabama at Birmingham, Birmingham (M.E.W.); the Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta (R.L.S.-C., J.A.J.); the Veterans Affairs Salt Lake City Health Care System, University of Utah, Salt Lake City (M.S.); Harvard Medical School, Boston (D.A.G.); and the Institute for Healthcare Improvement, Cambridge, MA (D.A.G.).
Address reprint requests to Dr. Huskins at the Mayo Clinic, 200 First Ave. SW, Rochester, MN 55905, or at huskins.charles@mayo.edu.
The investigators and participating centers in the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial are listed in the Supplementary Appendix, available at NEJM.org.
-
-----
[Source: The New England Journal of Medicine, full text: <cite cite="http://www.nejm.org/doi/full/10.1056/NEJMoa1000373?query=TOC&">Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care ? NEJM</cite>. Abstract, edited.]
Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care
W. Charles Huskins, M.D., Charmaine M. Huckabee, M.S., Naomi P. O'Grady, M.D., Patrick Murray, Ph.D., Heather Kopetskie, M.S., Louise Zimmer, M.A., M.P.H., Mary Ellen Walker, M.S.N., Ronda L. Sinkowitz-Cochran, M.P.H., John A. Jernigan, M.D., Matthew Samore, M.D., Dennis Wallace, Ph.D., and Donald A. Goldmann, M.D. for the STAR*ICU Trial Investigators
N Engl J Med 2011; 364:1407-1418
April 14, 2011
Background
Intensive care units (ICUs) are high-risk settings for the transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).
Methods
In a cluster-randomized trial, we evaluated the effect of surveillance for MRSA and VRE colonization and of the expanded use of barrier precautions (intervention) as compared with existing practice (control) on the incidence of MRSA or VRE colonization or infection in adult ICUs. Surveillance cultures were obtained from patients in all participating ICUs; the results were reported only to ICUs assigned to the intervention. In intervention ICUs, patients who were colonized or infected with MRSA or VRE were assigned to care with contact precautions; all the other patients were assigned to care with universal gloving until their discharge or until surveillance cultures obtained at admission were reported to be negative.
Results
During a 6-month intervention period, there were 5434 admissions to 10 intervention ICUs, and 3705 admissions to 8 control ICUs. Patients who were colonized or infected with MRSA or VRE were assigned to barrier precautions more frequently in intervention ICUs than in control ICUs (a median of 92% of ICU days with either contact precautions or universal gloving [51% with contact precautions and 43% with universal gloving] in intervention ICUs vs. a median of 38% of ICU days with contact precautions in control ICUs, P<0.001). In intervention ICUs, health care providers used clean gloves, gowns, and hand hygiene less frequently than required for contacts with patients assigned to barrier precautions; when contact precautions were specified, gloves were used for a median of 82% of contacts, gowns for 77% of contacts, and hand hygiene after 69% of contacts, and when universal gloving was specified, gloves were used for a median of 72% of contacts and hand hygiene after 62% of contacts. The mean (?SE) ICU-level incidence of events of colonization or infection with MRSA or VRE per 1000 patient-days at risk, adjusted for baseline incidence, did not differ significantly between the intervention and control ICUs (40.4?3.3 and 35.6?3.7 in the two groups, respectively; P=0.35).
Conclusions
The intervention was not effective in reducing the transmission of MRSA or VRE, although the use of barrier precautions by providers was less than what was required.
(Funded by the National Institute of Allergy and Infectious Diseases and others; STAR*ICU ClinicalTrials.gov number, NCT00100386.)
Supported by contracts (N01 AI-15440 and N01 AI-15441) from the National Institute of Allergy and Infectious Diseases to the Bacteriology and Mycology Study Group clinical research network and the Bacteriology and Mycology Statistical and Operations Unit data coordinating center; by institutional grants (M01-RR-00585, UL1-RR024150, and M01-RR-00039) from the National Center for Research Resources to the Mayo Clinic Center for Translational Science Activities and the General Clinical Research Center at Emory University; and by Merck, Elan Pharmaceuticals, Roche Diagnostics, and Kimberly Clark.Dr. Huskins reports receiving consulting fees from Roche Diagnostics and serving on an advisory board for GlaxoSmithKline; and Dr. Goldmann, receiving consulting fees from Medegen and serving on an advisory board for BioNeutral Group. No other potential conflict of interest relevant to this article was reported.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
We thank the study coordinators; the physician and nurse directors and the staff in the intensive care units at the participating sites; the technologists at the National Institutes of Health Clinical Center Microbiology Laboratory and at the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention; and the principal investigators of the Bacteriology and Mycology Study Group and members of the Risk Group 4 Research Committee (see the Supplementary Appendix).
Source Information
From the Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN (W.C.H.); Rho Federal Systems Division, Chapel Hill, NC (C.M.H., H.K., L.Z., D.W.); the National Institutes of Health Clinical Center, Bethesda, MD (N.P.O., P.M.); the University of Alabama at Birmingham, Birmingham (M.E.W.); the Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta (R.L.S.-C., J.A.J.); the Veterans Affairs Salt Lake City Health Care System, University of Utah, Salt Lake City (M.S.); Harvard Medical School, Boston (D.A.G.); and the Institute for Healthcare Improvement, Cambridge, MA (D.A.G.).
Address reprint requests to Dr. Huskins at the Mayo Clinic, 200 First Ave. SW, Rochester, MN 55905, or at huskins.charles@mayo.edu.
The investigators and participating centers in the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial are listed in the Supplementary Appendix, available at NEJM.org.
-
-----