- This expert guidance document provides recommendations regarding discontinuation of contact precautions (CP) at the individual patient level in acute-care hospitals employing CP for 1 or more of the following organisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Clostridium difficile (CDI), and multidrug-resistant Enterobacteriaceae (MDR-E), including carbapenem-resistant Enterobacteriaceae (CRE) and extended-spectrum β-lactamase (ESBL)–producing organisms.
- Recommendations herein are based on synthesis of limited evidence, theoretical rationale, current practices, practical considerations, the opinion of the writing group, consideration of potential harms, and a survey of 134 institutions within the SHEA Research Network, 26% of which are outside the United States and Canada.
Methicillin-Resistant Staphylococcus aureus (MRSA)
- If a hospital uses CP for patients previously colonized or infected with MRSA, SHEA recommends establishing a policy for the discontinuation of CP for MRSA.
- For patients not on antimicrobial therapy with activity against MRSA, SHEA recommends negative screening cultures to guide decisions about discontinuation of CP.
- The optimal number of negative cultures needed is unclear, though 1–3 negative cultures are often used.
- The anterior nares are a common site of culture sampling, though the literature is unclear regarding the optimal site and the role of extra-nasal sampling.
- For high-risk patients, such as those with chronic wounds or patients from long-term care facilities, SHEA recommends extending CP from the last MRSA-positive culture, prior to assessing for CP discontinuation.
- Outside an outbreak setting, if a facility’s endemic rates of MRSA infection are low, the hospital may consider the alternative approach of using CP for patients with active MRSA infection for the duration of the index admission and discontinuing CP on hospital discharge.
- In adopting this approach, a hospital should monitor facility MRSA infection rates, maximize and consider monitoring use of standard precautions, and minimize patient cohorting to avoid intrafacility transmission.
- If the hospital’s MRSA infection rates increase, the hospital should transition to a screening culture–based approach for discontinuation of CP.
Vancomycin-Resistant Enterococci (VRE)
- If a hospital uses CP when caring for patients colonized or infected with VRE, SHEA recommends establishing a policy for discontinuation of CP for VRE.
- SHEA recommends that, following treatment of VRE infection, the hospital use negative stool or rectal swab cultures to guide decisions about the discontinuation of CP.
- The optimal number of negative cultures needed is unclear, though 1–3 negative cultures, each at least 1 week apart if multiple cultures are obtained, are often used.
- Hospitals should consider extending CP prior to assessing for CP discontinuation in VRE infected patients who are:
- highly immunosuppressed
- receiving broad spectrum systemic antimicrobial therapy without VRE activity
- receiving care in protected environments (e.g., burn units, bone marrow transplant units or settings with neutropenic patients), or
- receiving care at institutions with high rates of VRE infection.
- Outside an outbreak setting and if facility endemic rates of VRE infection are low, the hospital may consider the alternative approach of using CP for patients with active VRE infection for the duration of the index admission and discontinuing CP on hospital discharge.
- In adopting this approach, hospitals should monitor VRE infection rates, maximize and consider monitoring use of standard precautions, and minimize patient cohorting to avoid intrafacility transmission.
- If institutional VRE infection rates increase, the hospital should transition to a screening culture–based approach for discontinuation of CP.
Multidrug-Resistant Enterobacteriaceae (MDR-E)
- If a hospital uses CP for patients infected or colonized with MDR-E (ESBL-E and/or CRE), SHEA recommends establishing a policy for discontinuation of CP for MDR-E that includes the following:
- Maintaining CP for ESBL-E and CRE for the duration of the index hospital stay when infection or colonization with these bacteria is first detected.
- Considering discontinuation of CP on a case-by-case basis, taking into account the following criteria:
- at least 6 months have elapsed since the last positive culture
- presence of a clinical infection and ongoing antibiotic use, where discontinuation of CP should be discouraged in the setting of suspected or known infection with ESBL-E or CRE, and concurrent broad spectrum antibiotic use that may select for these organisms, and
- procurement of an adequate number of screening samples, with at least 2 consecutive negative rectal swab samples obtained at least 1 week apart to consider an individual negative for ESBL-E or CRE colonization.
- SHEA recommends that for extensively drug-resistant Enterobacteriaceae, such as carbapenemase-producing CRE, or Enterobacteriaceae with very limited treatment options (susceptible to ≤2 antibiotic classes used to treat that organism), hospitals should maintain CP indefinitely.
- SHEA recommends that patients with C. difficile infection (CDI) receive care with CP for at least 48 hours after resolution of diarrhea.
- Hospitals should consider extending CP through the duration of hospitalization if elevated rates of CDI are present despite appropriate infection prevention and control measures.
- At this time, insufficient evidence exists to make a formal recommendation as to whether patients with CDI should be placed on CP if they are readmitted to the hospital.
Microbiological Screening and Molecular Testing
- At this time, insufficient evidence exists to make a formal recommendation supporting the use of molecular testing for the purpose of discontinuation of CP for MDROs.