Less contact isolation is more in the ICU: not sure
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LESS IS MORE IN INTENSIVE CARE
Less contact isolation is more in the ICU: not sure J. C. Lucet1, A. D. Harris2 and B. Guidet3* © 2019 Springer-Verlag GmbH Germany, part of Springer Nature
The debate over the use of standard precautions (SPs) versus contact precautions (CPs) for stopping the spread of multidrug-resistant organisms (MDROs) has been controversial for years [1–5] and still persists, despite recent high-quality cluster-randomized studies [6–9]. SPs are based on a universal (also called “horizontal”) approach to all patients, whether or not they are known to be as MDRO carriers; SPs include compliance with hand hygiene and cleaning the environment. CPs with a so-called “vertical” approach still include compliance with SPs for all patients, additional control barriers for colonized patients, i.e. gloves and gown, and placement in a single room if possible. Identification of MDRO carriage through screening is frequently associated with CPs. The introduction of alcoholic handrub (AHR) in the early 2000s has been a major step in improving compliance with hand hygiene in healthcare settings. Many studies have demonstrated that including AHR in a multifaceted strategy, based on education, observation and feedback, and other bundled measures, is necessary for effective AHR implementation. Since CPs and SPs both aim to interrupt transmission, SPs now including AHR (as compared to handwashing) show higher efficacy, likely closer to that of CPs, thus fueling the debate between CPs and SPs. The epidemiology of MDROs is rapidly changing. MDROs comprise methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum betalactamase-producing enterobacteriacae (ESBL-PE), *Correspondence: [email protected] 3 Medical ICU, Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, 184 rue du Faubourg Saint Antoine, 75012 Paris, France Full author information is available at the end of the article
vancomycin-resistant enterococci (VRE), carbapenemase-producing enterobacteriacae (CPE), and carbapenemase-producing Gram negative bacilli, Pseudomonas aeruginosa and carbapenem-resistant Acinetobacter baumannii (CRAB). In some countries, in the late 2010s, the latter, i.e. CPE, carbapenemase-producing Gram-negative bacilli, and VRE, were classified as extensively resistant. In ICUs facing multiple endemic MDROs, placing a large proportion of patients to CPs may result in lower compliance for interrupting cross-transmission from each of these patients [10]. Priorities must be defined in order to select the most dangerous MDROs, in terms of the individual consequences of infection and the collective risk of dissemination, and thus the appropriate infection control practices can be selected. This complexification of epidemiology and control measures, together with legal mandates issued in several countries, may have the effect of obscuring the central question relating to efforts to control the spread of MDROs: what is the most effect
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