Targeted Contact Precaution Use to Prevent MRSA Transmission

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Background: There remains tremendous controversy surrounding the pros and cons of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). The rationale for this application is that more knowledge is needed to identify which patients need to be placed on transmission-based contact precautions (gloves and gowns used by healthcare workers); and when and which patients may not require contact precautions to prevent the spread of MRSA. Significance and Impact: Antibiotic resistance is one of the biggest public health challenges of our time. The application is significant in that it recognizes and addresses the barrier to institutionalizing contact precautions for all patients with MRSA when busy healthcare personnel (HCP) feel that they may not have time to continuously don and doff gowns and gloves as they transition from one room to another. If the study results provide guidance on when contact precautions are most necessary (and when they are not), it may be safe to recommend reducing the number of times when gowns and gloves are used unnecessarily, while also providing new evidence on when contact precautions remain essential. Innovation: The work is innovative in that we are aiming for precision public health to be brought into the field of antibiotic resistance and all VA medical centers (VAMCs) in the country: the right type of precautions, for the right type of encounter at the right time. Specific Aims: Aim 1: Perform a multi-site, geographically diverse cohort study at VA facilities and enroll patients with MRSA to determine the rate of MRSA transmission to healthcare personnel gloves and gowns in the ICU and non-ICU setting. Aim 2: Determine which patient risk factors, including comorbid conditions and severity of illness markers, which patient care interactions and which healthcare personnel types are associated with greater transmission of MRSA. Aim 3: Develop a dynamic transmission model to compare the cost-effectiveness of different contact precaution strategies. Methodology: Across six VAMCs, we will enroll 800 patients who have MRSA in the intensive care unit (ICU) and non-ICU setting. Research coordinators will randomly observe five healthcare personnel-patient interactions per patient. Research coordinators will gather data on the patient level factors and on healthcare personnel patient interaction factors. When the healthcare personnel leave the room, research coordinators will culture the healthcare personnel's gloves and gown upon room exit. Thus, five healthcare personnel glove and gown cultures per patient will be obtained, leading to 4,000 glove culture outcomes and 4,000 gown culture outcomes. The cost-effectiveness aim will use the results from aims 1 and 2 to build a dynamic transmission model to assess the effectiveness of different contact precaution strategies. For each strategy, costs will include both direct medical and indirect (i.e., productivity losses) costs. Implementation/next steps: We will publish our findings in appropriate peer-reviewed scientific journals and present the results at national scientific forums such as the VA HSR&D Conference, the SHEA Spring Meeting and IDSA’s IDWeek annual meeting. To ensure successful study implementation and appropriate knowledge dissemination and translation of findings into policy, we have established an interdisciplinary advisory board and study site co-investigators with years of expertise in VAMCs. The advisory board members are leaders in infectious disease in the VHA who have developed and guided the VA MRSA Prevention Initiative over the years and can implement findings into VA policy. As well, Dr. Harris is a former president of the Society of Healthcare Epidemiology of America and current member of the CDC HICPAC Advisory group. He will use these connections to help guide SHEA and CDC policies relative to contact precautions. The VA is an ideal place to perform this study and have it widely implemented due to its agility in making national policies.