Another Tale of Two Guidelines

To the Editor—We agree with Strausbaugh et al. [1] that “aggressive and widespread adoption of control measures for multidrug-resistant organisms is urgently needed” (page 828); however, we doubt that the approach suggested by the Healthcare Infection Control Practices Advisory Committee (HICPAC) isolation guideline [2] would control these organisms, and we disagree with other things that were said. For example, Strausbaugh and colleages said, “Which approach will lead to better control ... remains to be determined by carefully designed studies such as the ongoing National Institutes of Health—sponsored multicenter study of adult intensive care units. In this study, adult intensive care units are randomized either to practice standard precautions or use routine active surveillance cultures and contact precautions for persons harboring MRSA or VRE” (page 833). The National Institutes of Health study [3] does not effectively address this question because, in multiple ways, its active surveillance culture (ASC)/contact precaution (CP) measures fall short of the Society for Healthcare Epidemiology of America (SHEA) guideline recommendations [4]. For example, intervention in only 1 intensive care unit of a large hospital is not optimal to control nosocomial methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), it is not what the SHEA guideline recommends, and it is not associated with rapid control [5, 6]. The National Institutes of Health study of ASC/CP measures are less rigorous than those in recent studies that demonstrate control in intensive care units [6–8] and, as such, favor a false-negative result, especially given expected sample size and power during the study's relatively brief intervention period. By these study parameters, 2 recent studies with dramatically positive results would have been false-negatives [6, 8]. One of these studies, a longer one, reported a 75% reduction in MRSA bacteremia with ASC/CP, compared with no effect on MRSA bacteremia with enhanced standard precautions (i.e., alcohol handrubs and a motivational campaign that increased hand hygiene compliance to 80%) [8]—the type of standard precautions attempted in the National Institutes of Health study. Multiple other studies, including the CDC's National Nosocomial Infections Surveillance System data [9], suggest that standard precautions have failed to control MRSA and VRE (despite the use of standard precautions and mandatory annual health care worker infection control retraining in US health care facilities since 1996). Active detection and isolation of all contagious patients has been used to control important infections, such as tuberculosis, SARS, and smallpox. Multiple northern European countries and Western Australia, which deem MRSA to be important, have used ASC/CP to identify and isolate all colonized patients and control nosocomial MRSA to very low levels [10–13]; at least 3 of these countries require the use of this approach. The same approach has been used in these countries and in other areas to control VRE [7, 14, 15], including throughout an entire health district in Iowa [15]. Areas in the rest of Europe and Australia that do not use this approach have failed to control MRSA [12, 13]. The SHEA guideline cited 45 of ∼100 studies that reported control of MRSA or VRE with ASC/CP—many after failure with standard precautions, and many without the use of eradication therapy [4]. These data demonstrate that ASC/CP can be used to control MRSA and VRE; this is apparently why the HICPAC draft isolation guideline recommends their use as optional components of “a more intensified set of measures to be implemented when baseline measures fail” (pages 832–3) [1, 2]. Standard precautions have already failed as a baseline measure in individual facilities and across the entire US health care system, as shown by the fact that MRSA now accounts for >50% of nosocomial S. aureus infections. Refusal to routinely use ASC/CP will likely doom the MRSA/VRE control efforts that Strausbaugh et al. [1] claim to be “urgently needed,” to failure. Potential conflicts of interest. C.A.M is a member of the speakers' bureau of ViroPharma. W.R.J. is a consultant for BD, Kimberly-Clark, 3M, and Johnson & Johnson (ASP and Ethicon). B.M.F.: no conflicts.