Having healthcare providers don gloves and gowns in intensive care units is shown to reduce infections of methicillin-resistant Staphylococcus aureus, but without a rise in adverse events, researchers say.
Donning gloves and gowns for all patient contact in intensive care units reduced infections of methicillin-resistant Staphylococcus aureus (MRSA) by 40% compared with care under federal guidelines in a recent study. Government guidelines call for wearing gloves and gowns only with patients with known antibiotic resistant bacteria.
Additionally, while having healthcare personnel take the time to glove and gown did result in fewer times that they attended to patients, it did not result in a rise in adverse events, such as patient falls or pressure ulcers.
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Those are conclusions from a multi-state randomized trial of 20 medical and surgical ICUs and 26,180 patients. The researchers at the University of Maryland School of Medicine attempted to answer the question of whether gloved and gowned personnel actually reduce the most troublesome types of hospital-acquired infections.
"If an intensive care unit or hospital administrator is concerned about the risk of healthcare-associated MRSA infection, I think this shows that the intervention works with no adverse events," says Anthony Harris, MD, the lead author of the multi-center trial.
"The magnitude of the effect we saw in reduction of MRSA infections was very comparable to the magnitude of the effect we see from bathing patients with chlorhexidine washes."
Harris adds that the secondary message of the study, that gloving and gowning works, is extremely important "because there are some infectious disease experts who think we should be moving away from gloves and gowns altogether" because of unintended consequences such as less patient satisfaction and more patient isolation.
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"Our study suggests that would be the wrong thing to do," Harris says.
The Centers for Disease Control and Prevention recommends that healthcare personnel wear gloves and gowns only when caring for patients colonized or infected with antibiotic resistant bacteria.
However, the researchers did not find a statistically significant reduction in another bacteria, vancomycin-resistant Enterococcus, (VRE) or in a combination outcome of either VRE or MRSA,which Harris says was surprising.
"However, different bacteria behave differently. Thus you can't make a conclusion that it (gloves and gowns) should be used in all ICUs in the country, and similarly, you can't conclude that it shouldn't be used in any."
MRSA is generally transmitted from skin to skin while VRE is transmitted via infection in the intestinal tract.
The paper, published in JAMA online Friday to coincide with its release at the IDWeek13 conference in San Francisco, confounds the issue. A paper published this spring in the New England Journal of Medicine suggested that all ICU patients should be presumed infected and treated with both chlorhexidine baths and given an intranasal nasal swab with mupirocin to prevent MRSA.
Harris says that the JAMA paper should be convincing enough to change ICU practice for some. "I have to be honest, if you're a nurse or a doctor, you're much more inclined to say, hey, if I only have to bathe someone with chlorhexidine, I'd much prefer that intervention than having to put on gowns and gloves, which is more labor intensive."
However, there's a potential downside with chlorhexidine, which many worry may promote resistant strains of bacteria in just a few years.
Harris says that in hospitals, "when surgeons decide they need a new robotic instrument for, say, bypass surgery," C-suite leaders don't think that hard about "spending $5 million even though there's no randomized trial data to suggest that the robot will give better surgical efficacy.
"But I don't think wearing gloves and gowns costs more than $150,000 to $250,000 a year for the typical ICU. We agonize over cost issues like that in infection control because generally, we don't have the ear of the C-suite as much as other specialists.
In an accompanying JAMA editorial, Preeti N. Malani, MD, in the Department of Internal Medicine of the University of Michigan Health System, wrote that researchers finding that adverse events were not increased when caregivers took the time to glove and gown was one of the paper's most important points.
"The evidence to support infection prevention efforts is a moving target; contact precautions and decolonization strategies are just a few components of an expanding armamentarium," he wrote.
Even though the study failed to demonstrate an overall benefit in use of gloves and gowns to reduce MRSA or VRE, "this approach may be worth considering in some instances; for example, if MRSA transmission is prevalent in a high-risk setting such as a surgical ICU with a large number of patients with newly implanted medical devices," he wrote.
"If implemented, gloving and gowning should be just part of an overall strategy that includes efforts to optimize hand hygiene and prudent use of antimicrobials."