2018 Updated Guidelines C.diff. Contact Precautions

New guidelines issued on contact precautions for C. diff, resistant infections

The Society for Healthcare Epidemiology of America advises discontinuing contact precautions after obtaining between one and three negative cultures in certain cases of drug-resistant infections, among other recommendations.

New expert guidance from the Society for Healthcare Epidemiology of America (SHEA) offers recommendations on the appropriate duration of contact precautions for hospitalized patients with Clostridium difficile and resistant infections.

The guidance recommends that hospitals using contact precautions establish discontinuation policies. In certain cases of drug-resistant infections, SHEA recommends discontinuing contact precautions after obtaining between one and three negative cultures.*

The recommendations were published online on Jan. 11 by Infection Control & Hospital Epidemiology.

The guidance was endorsed by the Society of Hospital Medicine, the Association for Professionals in Infection Control and Epidemiology, and the Association of Medical Microbiology and Infectious Disease Canada. It was based on available evidence, theoretical rationale, practical considerations, a survey of SHEA members, author opinion, and consideration of potential harms.

Key recommendations include the following:

C. difficile

  • Continue contact precautions in patients with C. difficile infection for at least 48 hours after diarrhea is resolved.
  • Consider extending the duration throughout hospitalization if C. difficile infection rates are elevated despite the presence of proper infection prevention and control measures.
  • There is insufficient evidence to recommend whether patients with C. difficile infection should be placed on contact precautions if they are readmitted.

Methicillin-resistant Staphylococcus aureus (MRSA)

  • Negative screening cultures should guide contact-precaution discontinuation decisions in patients who are not on antimicrobial therapy with activity against MRSA. Hospitals often use one to three negative cultures, although the optimal number remains unclear.
  • The duration of contact precautions should be extended from the last MRSA-positive culture for high-risk patients (e.g., those with chronic wounds or those from long-term care facilities).
  • Unless there is an outbreak, a hospital with low endemic rates of MRSA infection may consider the alternative of using contact precautions for patients with active MRSA infection during the hospital stay and discontinuing them at discharge. If rates increase, a facility should instead use a screening-culture-based approach.

Vancomycin-resistant enterococci (VRE)

  • After VRE infection treatment, hospital staff should use negative stool or rectal swab cultures to guide decisions about discontinuing contact precautions. The optimal number is unclear, but one to three negative cultures (each at least one week apart) are often used.
  • Consider extending contact precautions in patients with VRE infection who are highly immunosuppressed, receiving broad-spectrum systemic antimicrobial therapy without VRE activity, receiving care in protected environments (e.g., burn units), or receiving care at a facility with high rates of VRE infection.
  • Hospitals with low endemic rates of VRE infection may use the alternative approach outlined for MRSA infection.

Multidrug-resistant Enterobacteriaceae (MDR-E)

  • MDR-E includes Enterobacteriaceae that are ESBL-producing (ESBL-E), carbapenem-resistant (CRE), or resistant to multiple classes of antibiotics.
  • Contact-precaution duration policies for patients with MDR-E should include 1) maintaining contact precautions for ESBL-E and CRE for the duration of hospitalization at the first detection of infection or colonization and 2) considering discontinuation on a case-by-case basis.
  • Maintain contact precautions indefinitely for patients with extensively drug-resistant Enterobacteriaceae (e.g., carbapenemase-producing CRE or Enterobacteriaceae with very limited treatment options).