Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU A Randomized Trial
Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU A Randomized Trial
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DOI：
10.1001/jama.2013.277815
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发表时间：
2013-10-16
影响因子：
120.7
通讯作者：
Morgan, Daniel J.
中科院分区：
文献类型：
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作者：
Harris, Anthony D.;Pineles, Lisa;Morgan, Daniel J.
重要性抗生素耐药菌与患者发病率和死亡率增加相关。目前尚不清楚在重症监护室（ICU）中所有患者接触时戴手套和穿隔离衣是否会减少耐甲氧西林金黄色葡萄球菌（MRSA）或耐万古霉素肠球菌（VRE）的获得。和参与者2012年1月4日至2012年10月4日在美国20家医院的20个内科和外科ICU中进行的随机对照试验。所有医护人员在接触病人和进入病房时都必须戴手套和穿长袍。主要结果和指标是根据ICU入院和出院时收集的监测培养物获得MRSA或VRE。次要结果包括个体VRE采集、MRSA采集、医护人员就诊频率、手部卫生依从性、医护相关感染和不良事件。结果从纳入的26180例患者中，收集了92241份拭子用于主要结果。干预ICU的MRSA或VRE的主要结局从每1000患者-天21.35次采集减少（95% CI，17.57 - 25.94）从基线期至16.91次采集/1000患者-天（95% CI，14.09至20.28），而对照ICU的MRSA或VRE从每1000患者-天19.02次采集（95% CI，14.20 - 25.49）从基线期至16.29次采集/1000患者-天（95% CI，13.48 - 19.68），变化差异无统计学意义（差异：-1.71次采集/1000人日，95% CI：-6.15至2.73; P = 0.57）。对于关键次要结局，VRE采集与干预无差异（差异：0.89次采集/1000人日; 95% CI：-4.27至6.04，P = 0.70），而对于MRSA，干预组的采集较少（差异：-2.98次采集/1000人日; 95% CI：-5.58至-0.38; P = 0.046）。通用手套和长袍的使用也减少了卫生保健工作者的房间进入（4.28 vs 5.24次/小时，差异，-0.96; 95% CI，-1.71至-0.21，P = 0.02），增加了房间出口手部卫生依从性（78.3% vs 62.9%，差异：15.4%; 95% CI：8.99%-21.8%; P = 0.02），对不良事件发生率无统计学显著影响（58.7起事件/1000患者日vs 74.4起事件/1000患者日;差异，-15.7; 95% CI，-40.7至9.2，P = 0.24）结论和相关性：与内科和外科ICU患者的常规护理相比，在所有患者接触中使用手套和隔离衣不会导致获得MRSA或VRE的主要结局的差异。虽然单独MRSA感染的风险较低，且不良事件无差异，但在得出明确结论之前，这些次要结局需要重复。
IMPORTANCE Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.OBJECTIVE To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.INTERVENTIONS In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.MAIN OUTCOMES AND MEASURES The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events.RESULTS From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, -1.71 acquisitions per 1000 person-days, 95% CI, -6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95% CI, -4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, -2.98 acquisitions per 1000 person-days; 95% CI, -5.58 to -0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, -0.96; 95% CI, -1.71 to -0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, -15.7; 95% CI, -40.7 to 9.2, P = .24).CONCLUSIONS AND RELEVANCE The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.