Comparison of Routine Glove Use and Contact-Isolation Precautions to Prevent Transmission of Multidrug-Resistant Bacteria in a Long-Term Care Facility

William E. Trick, MD; Robert A. Weinstein, MD; Patricia L. DeMarais, MD; Wanda Tomaska, RN; Catherine Nathan, MS; Sigrid K. McAllister, BS, MT; Jeffrey C. Hageman, MHS; Thomas W. Rice, PhD; Glennis Westbrook, BS, MT; William R. Jarvis, MD

Disclosures

J Am Geriatr Soc. 2004;52(12) 

In This Article

Abstract and Introduction

Objectives: To compare routine glove use by healthcare workers for all residents, without use of contact-isolation precautions, with contact-isolation precautions for the care of residents who had vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus isolated from a clinical culture.
Design: Random allocation of two similar sections of the skilled-care unit to one of the infection-control strategies during an 18-month study period.
Setting: Skilled-care unit of a 667-bed acute- and long-term care facility.
Participants: All residents present or admitted to the skilled-care unit from June 1, 1998, through December 7, 1999.
Measurements: Resident acquisition of four antimicrobial-resistant organisms (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, or extended-spectrum β-lactamase-producing Klebsiella pneumoniae or Escherichia coli). All isolates were strain typed. The facility level costs associated with each strategy were estimated.
Results: Resident acquisition of antimicrobial-resistant organisms was no different in the glove-use and isolation-precautions sections (31 episodes (1.5 per 1,000 resident-days) vs 38 episodes (1.6 per 1,000 resident-days)). Acquisition of either of two prevalent K. pneumoniae strains was more likely (P =.06) in residents in the isolation-precautions section. The estimated costs of contact-isolation precautions were 40% greater than those of routine glove use.
Conclusion: There was a similar frequency of transmission of antimicrobial-resistant bacteria in the two study sections; there was evidence for resident-to-resident K. pneumoniae transmission in the isolation-precautions section. Routine glove use for healthcare workers, which decreases resident social isolation and healthcare facility costs, may be preferable in many long-term care facilities.

The elderly population in the United States has increased dramatically. It is estimated that 43% of persons aged 65 and older enter a nursing home and that 21% of residents remain in the nursing home for 5 years or longer.[1] Residents of long-term care facilities (LTCFs) may be colonized with antimicrobial-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA),[2–6] extended-spectrum β-lactamase (ESBL)-producing gram-negative bacilli,[6,7] and vancomycin-resistant enterococci (VRE).[8,9] Such colonization can increase intra- or interfacility dissemination of these potential pathogens.[10,11]

Recently, interest in antimicrobial resistance in U.S. LTCFs has increased.[12,13] The number of persons receiving care in LTCFs is increasing and exceeds that of hospitals,[14,15] LTCFs are increasingly relied upon to provide care for residents with greater severity of illness,[16] and interfacility transmission of antimicrobial-resistant pathogens between acute-care facilities and LTCFs has been well documented.[7,9,10]

Use of Centers for Disease Control and Prevention (CDC) recommendations for hospital contact-isolation precautions for LTCF residents who are colonized or infected with antimicrobial-resistant bacteria often is impractical because of limited infection-control resources and the logistical and cost implications. In addition, there may be deleterious psychological or social effects due to resident isolation.[17]

After an initial point-prevalence survey to determine resident colonization with several antimicrobial-resistant bacteria,[6] different control measures were evaluated in two similar sections of the skilled-care unit of Oak Forest Hospital, in Oak Forest, Illinois. Contact-isolation precautions were continued in one section, and routine glove use was implemented during resident care without isolation precautions in the other section. Transmission of four antimicrobial-resistant bacteria (MRSA, VRE, and ESBL-producing Escherichia coli or Klebsiella pneumoniae , i.e., study organisms) was evaluated in each section.

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