HIV and ID Observations

The stalking MRSA monster, circa the year 2000.

Back in the early 2000s, I heard about a local hospital that eliminated contact precautions while caring for patients with methicillin-resistant Staphylococcus aureus (MRSA). No more required gowns and gloves, or warning signs on the doors, or private rooms for patients known to have MRSA. They planned to track MRSA cases carefully over the next 2 years, and then decide, based on these results, whether the contact precautions should be resumed.

Alas, cases of MRSA increased — increased a lot. Back came the gowns, the infection control signs, and the general hassle.

Of course we know now, looking back, that this had nothing to do with their policy change. Their mistake was not appreciating that the community epidemiology would override anything they were doing within their walls.

The rising incidence of MRSA starting around 2000 was a universal phenomenon during that period, at least here in the United States. It happened in every clinical setting and every region — inpatient, outpatient, long-term care facilities, emergency rooms, urgent care centers, intensive care units, you name it. I remember telling our head of infection control back then that I wouldn’t be surprised if one day we’d look back on methicillin-sensitive staph (MSSA) with as much nostalgia as we do the penicillin-sensitive strains from the pre-antibiotic era. MRSA would become that dominant.

For the record, that was one of the wrongest predictions I’ve ever made — right up there with my lack of appreciation of the show Friends (“too cliched, will never catch on” after briefly watching one episode), and my stance that football will eventually no longer be America’s favorite sport (“parents won’t want their kids to play, too dangerous — it will become like boxing”).

So how wrong was I about the future of MRSA? Rates stopped increasing in the mid 2000s, and have been gradually declining ever since — and no one knows precisely why. In a large VA study, MRSA accounted for 39% of Staph aureus isolates in 2019, down from 54% in 2010.

(I have still never watched a full episode of Friends. And I’m also hoping that one day, my prediction about football comes true.) 

I bring up this up now because many hospitals (including ours) still have contact precautions for MRSA, a policy we share with roughly two-thirds of U.S. hospitals, and by some guidelines is considered “essential”. Bright yellow disposable gowns replaced the cloth ones we once sent to the laundry; there are stacks of gowns and boxes of gloves sitting right outside the rooms of all patients with MRSA (even asymptomatic colonization), and there are precaution signs on the doors.

But there’s still a viable escape route for this policy. Another teaching hospital right across the street stopped MRSA contact precautions years ago. Several other Boston and New England hospitals have done the same. Instead, they’ve redoubled their efforts in the importance of hand hygiene, to the benefit of all. Communicating with their infection control directors, I’ve learned that nothing has changed in their MRSA incidence. And, dear readers, rest assured, it’s not as if those hospitals’ MRSA strains — one is literally a single block away! — are any different from ours.

What’s driving these starkly divergent approaches? To answer this question, it’s helpful to look at the evidence motivating the differences. Such a review is expertly outlined by Dr. Daniel Diekema and colleagues in a viewpoint entitled, “Are Contact Precautions ‘Essential’ for the Prevention of Healthcare-associated Methicillin-Resistant Staphylococcus aureus?” They summarize the studies looking at the effectiveness of this approach in reducing within-hospital transmission of this pesky bug, and find that the data are far from clear. Indeed, this is one of those murky areas in clinical practice where anyone could cherry pick a study to support whatever view they held to begin with.

On the other hand, how about the  potential harms and costs? These are easier to outline, so let me count the ways, with an obvious half-dozen:

1. Patient care. I’d argue they’re called “barrier” precautions for two reasons — both the obvious barrier the gown put between you and the patient, and the psychological barrier it puts on clinicians before going in the room and seeing the patient. In short, patients on MRSA precautions are seen and examined less often than those not on precautions. Anyone who does hospital-based care will confirm this obvious fact.

2. Patient satisfaction. While a fraction of patients might prefer that providers don gowns and gloves before entering the room, it’s been my experience that a majority don’t like the stigma associated with the label. They fear for their family and friends who visit, who usually do not wear the gowns or gloves. They’re thrilled if we can clear them from MRSA precautions, though this process is cumbersome and inefficient, especially when they’re outpatients.

3. Cost. No surprise, it costs money to send cloth gowns out to institutional laundry services; same story for purchasing and disposing of the paper ones.

4. Environmental impact. I’ve heard the disposable gowns are net neutral in environmental impact compared to washable gowns; confess I haven’t looked into this carefully. But neither type of gown can be good, right? And is there anything more “universal” in the MRSA precautions rooms than the overstuffed bins with these bulky gowns? What an awful look.

5. Bed management. Covid-19 disrupted so much of our healthcare system that it’s hard to choose a single thing it changed the most, but one of the candidates is the broad category sometimes labeled “patient disposition.” In short, essentially every hospital is dealing with overflowing emergency rooms, record-high hospital census and emergency room borders, and difficulty finding places for patients to go. (For a memorable personal account from a local journalist, read about her experience with the current state of affairs.) MRSA precautions in those institutions that still have shared patient rooms only further slow down the process of finding the right bed for the right patient.

6. Illogical inconsistencies in the policy. I could choose many, but let me highlight one:  Inpatient care for those with MRSA means gowns, gloves, and precaution signs; outpatient care, we rarely do any of the above, even if the clinician doing the outpatient care later that day will move to the inpatient setting. What’s up with that? If you’ll excuse the baseball metaphor, it reminds me of the designated hitter rule that for decades applied only to the American League. It never made sense to me that we had to endure the clueless pitcher at bat in the National League, leading to all but an automatic out. Baseball eventually came to its senses, instituting the designated hitter rule in both leagues starting in 2020.

I reached out to Dan and to senior author Dr. Daniel Morgan before posting this piece, and the latter reminded me of a planned cluster randomized clinical trial which we hope will give more definitive evidence about whether this practice is worth continuing. Here’s hoping the study gives us solid data one way or another.

In the meantime, like other medical interventions that should only be instituted if the benefits clearly outweigh the risks, costs, and hassle, I’d argue strongly that a policy of contact precautions for MRSA no longer meets these criteria.

And by the way, nobody misses those lame pitcher at bats now that the designated hitter is universal.