Impact of elimination of contact precautions on noninfectious adverse events among MRSA and VRE patients

To the Editor—We read with great interest the article by Martin et al ¹ published online in May 2018 in Infection Control and Hospital Epidemiology. ¹ We previously reported on the impact of elimination of contact precautions (CP) in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) patients on noninfectious complications, although our analysis was limited to falls and pressure ulcers. ² Our findings differed from those of Martin et al; we observed no statistically significant difference in the rate of falls or pressure ulcers among MRSA/VRE patients in the years before and after eliminating CP. The rate of falls among MRSA/VRE patients in the year before eliminating CP was 4.57 per 1,000 patient days, and it was 4.82 per 1,000 patient days in the year after eliminating contact precautions (P = 074). Similarly, the rate of pressure ulcers in the year before eliminating CP was 4.87 per 1,000 patient days, and it was 4.17 per 1,000 patient days in the year after eliminating contact precautions (P = .33).

Martin et al report a significant drop in the number of noninfectious adverse events among MRSA/VRE patients in the year after eliminating CP (21.4 per 1000 admissions vs 6.08 per 1000 admissions; P < .001). In contrast to our study, the study summarized by Martin et al not only included falls and pressure ulcers but also hemorrhage, postoperative respiratory failure, wound dehiscence, and pulmonary embolism or deep vein thrombosis. Although the composite index of all noninfectious adverse events showed a significant drop, the authors did not present a breakdown by individual adverse events in MRSA/VRE and non-MRSA/VRE patients.

We reported 2 additional important findings in our study. First, MRSA/VRE patients had a statistically significant higher Charlson comorbidity index (CCI) compared with non-MRSA/VRE patients (mean CCI, 3.32 vs 2.75; P = .002). This was not examined by Martin et al. Second, compared to non-MRSA/VRE patients, we found that MRSA/VRE patients had significantly higher rates of falls (4.57 per 1,000 patient days vs 2.04 per 1,000 patient days) and pressure ulcers (4.87 per 1,000 patient days vs 1.22 per 1,000 patient days), both in the year before and in the year after eliminating CP. Based on figure 2 from Martin EM et al, the rate of noninfectious adverse events were much higher in MRSA/VRE patients than in non-MRSA/VRE patients in the year prior to elimination of CP. However, in the year thereafter, there seems to be no difference.

The reason for the discrepancy in the findings between the 2 studies is unclear. However, we have identified 2 differences between the studies. First, the rate of individual adverse events between the MRSA/VRE and non-MRSA/VRE patients in Martin et al are not included. Second, for rate calculation, we calculated the rate per 1,000 patient days, whereas Martin et al considered the rate per 1,000 admissions. Whether this had any influence on outcomes is unknown.

Similar to the previous study by Martin et al ³ that indicated no change in the healthcare associated infection (HAI) rates of MRSA/VRE after elimination of CP, we also reported no significant change in HAI rates in MRSA/VRE patients after eliminating CP in our study. ² Thus, eliminating CP for MRSA/VRE patients is not associated with increased HAI rates with MRSA/VRE and could improve patient safety outcomes. Our observation that MRSA/VRE patients are at higher risk of noninfectious adverse events argues the need for serious consideration of eliminating CP among MRSA/VRE patients.