Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care — NEJM

Original Article

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; 364:1407-1418April 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.) Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care — NEJM