Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU

A randomized trial

Anthony D. Harris, Lisa Pineles, Beverly Belton, J. Kristie Johnson, Michelle Shardell, Mark Loeb, Robin Newhouse, Louise Dembry, Barbara Braun, Eli N. Perencevich, Kendall K. Hall, Daniel J. Morgan, Syed K. Shahryar, Connie S. Price, Joseph J. Gadbaw, Marci Drees, Daniel H. Kett, L. Silvia Muñoz-Price, Jesse T. Jacob, Loreen A. Herwaldt & 11 others Carol A. Sulis, Deborah S. Yokoe, Lisa Maragakis, Matthew E. Lissauer, Marcus J. Zervos, David K. Warren, Robin L. Carver, Deverick J. Anderson, David P. Calfee, Jason E. Bowling, Nasia Safdar

Research output: Contribution to journalArticle

156 Citations (Scopus)

Abstract

IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcomewas acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. RESULTS: From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95%CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95%CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95%CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95%CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, -1.71 acquisitions per 1000 person-days, 95%CI, -6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95%CI, -4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, -2.98 acquisitions per 1000 persondays; 95%CI, -5.58 to -0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, -0.96; 95%CI, -1.71 to -0.21, P = .02), increased room-exit hand hygiene compliance (78.3%vs 62.9%, difference, 15.4%; 95%CI, 8.99%to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, -15.7; 95%CI, -40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821.

Original languageEnglish (US)
Pages (from-to)1571-1580
Number of pages10
JournalJAMA - Journal of the American Medical Association
Volume310
Issue number15
DOIs
StatePublished - 2013
Externally publishedYes

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Intensive Care Units
Methicillin-Resistant Staphylococcus aureus
Anti-Bacterial Agents
Bacteria
Hand Hygiene
Delivery of Health Care
Patients' Rooms
Cross Infection
Vancomycin-Resistant Enterococci
Patient Care
Morbidity
Mortality

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU : A randomized trial. / Harris, Anthony D.; Pineles, Lisa; Belton, Beverly; Johnson, J. Kristie; Shardell, Michelle; Loeb, Mark; Newhouse, Robin; Dembry, Louise; Braun, Barbara; Perencevich, Eli N.; Hall, Kendall K.; Morgan, Daniel J.; Shahryar, Syed K.; Price, Connie S.; Gadbaw, Joseph J.; Drees, Marci; Kett, Daniel H.; Muñoz-Price, L. Silvia; Jacob, Jesse T.; Herwaldt, Loreen A.; Sulis, Carol A.; Yokoe, Deborah S.; Maragakis, Lisa; Lissauer, Matthew E.; Zervos, Marcus J.; Warren, David K.; Carver, Robin L.; Anderson, Deverick J.; Calfee, David P.; Bowling, Jason E.; Safdar, Nasia.

In: JAMA - Journal of the American Medical Association, Vol. 310, No. 15, 2013, p. 1571-1580.

Research output: Contribution to journalArticle

Harris, AD, Pineles, L, Belton, B, Johnson, JK, Shardell, M, Loeb, M, Newhouse, R, Dembry, L, Braun, B, Perencevich, EN, Hall, KK, Morgan, DJ, Shahryar, SK, Price, CS, Gadbaw, JJ, Drees, M, Kett, DH, Muñoz-Price, LS, Jacob, JT, Herwaldt, LA, Sulis, CA, Yokoe, DS, Maragakis, L, Lissauer, ME, Zervos, MJ, Warren, DK, Carver, RL, Anderson, DJ, Calfee, DP, Bowling, JE & Safdar, N 2013, 'Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: A randomized trial', JAMA - Journal of the American Medical Association, vol. 310, no. 15, pp. 1571-1580. https://doi.org/10.1001/jama.2013.277815
Harris, Anthony D. ; Pineles, Lisa ; Belton, Beverly ; Johnson, J. Kristie ; Shardell, Michelle ; Loeb, Mark ; Newhouse, Robin ; Dembry, Louise ; Braun, Barbara ; Perencevich, Eli N. ; Hall, Kendall K. ; Morgan, Daniel J. ; Shahryar, Syed K. ; Price, Connie S. ; Gadbaw, Joseph J. ; Drees, Marci ; Kett, Daniel H. ; Muñoz-Price, L. Silvia ; Jacob, Jesse T. ; Herwaldt, Loreen A. ; Sulis, Carol A. ; Yokoe, Deborah S. ; Maragakis, Lisa ; Lissauer, Matthew E. ; Zervos, Marcus J. ; Warren, David K. ; Carver, Robin L. ; Anderson, Deverick J. ; Calfee, David P. ; Bowling, Jason E. ; Safdar, Nasia. / Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU : A randomized trial. In: JAMA - Journal of the American Medical Association. 2013 ; Vol. 310, No. 15. pp. 1571-1580.
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abstract = "IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcomewas acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. RESULTS: From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95{\%}CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95{\%}CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95{\%}CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95{\%}CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, -1.71 acquisitions per 1000 person-days, 95{\%}CI, -6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95{\%}CI, -4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, -2.98 acquisitions per 1000 persondays; 95{\%}CI, -5.58 to -0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, -0.96; 95{\%}CI, -1.71 to -0.21, P = .02), increased room-exit hand hygiene compliance (78.3{\%}vs 62.9{\%}, difference, 15.4{\%}; 95{\%}CI, 8.99{\%}to 21.8{\%}; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, -15.7; 95{\%}CI, -40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821.",
author = "Harris, {Anthony D.} and Lisa Pineles and Beverly Belton and Johnson, {J. Kristie} and Michelle Shardell and Mark Loeb and Robin Newhouse and Louise Dembry and Barbara Braun and Perencevich, {Eli N.} and Hall, {Kendall K.} and Morgan, {Daniel J.} and Shahryar, {Syed K.} and Price, {Connie S.} and Gadbaw, {Joseph J.} and Marci Drees and Kett, {Daniel H.} and Mu{\~n}oz-Price, {L. Silvia} and Jacob, {Jesse T.} and Herwaldt, {Loreen A.} and Sulis, {Carol A.} and Yokoe, {Deborah S.} and Lisa Maragakis and Lissauer, {Matthew E.} and Zervos, {Marcus J.} and Warren, {David K.} and Carver, {Robin L.} and Anderson, {Deverick J.} and Calfee, {David P.} and Bowling, {Jason E.} and Nasia Safdar",
year = "2013",
doi = "10.1001/jama.2013.277815",
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TY - JOUR

T1 - Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU

T2 - A randomized trial

AU - Harris, Anthony D.

AU - Pineles, Lisa

AU - Belton, Beverly

AU - Johnson, J. Kristie

AU - Shardell, Michelle

AU - Loeb, Mark

AU - Newhouse, Robin

AU - Dembry, Louise

AU - Braun, Barbara

AU - Perencevich, Eli N.

AU - Hall, Kendall K.

AU - Morgan, Daniel J.

AU - Shahryar, Syed K.

AU - Price, Connie S.

AU - Gadbaw, Joseph J.

AU - Drees, Marci

AU - Kett, Daniel H.

AU - Muñoz-Price, L. Silvia

AU - Jacob, Jesse T.

AU - Herwaldt, Loreen A.

AU - Sulis, Carol A.

AU - Yokoe, Deborah S.

AU - Maragakis, Lisa

AU - Lissauer, Matthew E.

AU - Zervos, Marcus J.

AU - Warren, David K.

AU - Carver, Robin L.

AU - Anderson, Deverick J.

AU - Calfee, David P.

AU - Bowling, Jason E.

AU - Safdar, Nasia

PY - 2013

Y1 - 2013

N2 - IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcomewas acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. RESULTS: From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95%CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95%CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95%CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95%CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, -1.71 acquisitions per 1000 person-days, 95%CI, -6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95%CI, -4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, -2.98 acquisitions per 1000 persondays; 95%CI, -5.58 to -0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, -0.96; 95%CI, -1.71 to -0.21, P = .02), increased room-exit hand hygiene compliance (78.3%vs 62.9%, difference, 15.4%; 95%CI, 8.99%to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, -15.7; 95%CI, -40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821.

AB - IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcomewas acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. RESULTS: From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95%CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95%CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95%CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95%CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, -1.71 acquisitions per 1000 person-days, 95%CI, -6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95%CI, -4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, -2.98 acquisitions per 1000 persondays; 95%CI, -5.58 to -0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, -0.96; 95%CI, -1.71 to -0.21, P = .02), increased room-exit hand hygiene compliance (78.3%vs 62.9%, difference, 15.4%; 95%CI, 8.99%to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, -15.7; 95%CI, -40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821.

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EP - 1580

JO - JAMA - Journal of the American Medical Association

JF - JAMA - Journal of the American Medical Association

SN - 0002-9955

IS - 15

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