Should Methicillin-resistant Staphylococcus epidermidis (MRSE) infection in a Neonatal Intensive Care Unit (NICU) be managed with contact precautions or standard precautions?

From the Guidelines

Methicillin-resistant Staphylococcus epidermidis (MRSE) infections in a Neonatal Intensive Care Unit (NICU) should be managed with contact precautions rather than standard precautions alone. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of bundle interventions, including contact isolation, in preventing the spread of multidrug-resistant organisms in hospital settings 1.

Key Considerations

• Contact precautions require healthcare workers to wear gloves and gowns when entering the patient's room and during all patient interactions.
• Proper hand hygiene before and after patient contact is crucial, using alcohol-based hand sanitizer or soap and water.
• Equipment should be dedicated to the infected infant when possible, and all shared equipment must be properly cleaned and disinfected between patients.
• MRSE is a multidrug-resistant organism that can spread easily in the NICU environment through direct contact with healthcare workers' hands or contaminated equipment.
• Neonates are particularly vulnerable to infections due to their immature immune systems, and MRSE can cause serious complications including bacteremia, meningitis, and device-associated infections.

Implementation

The precautions should be maintained for the duration of the infant's NICU stay or until multiple negative cultures confirm clearance of the infection, as determined by the infection control team. While the evidence specifically addressing MRSE is not directly provided, the principles of infection control for multidrug-resistant organisms, as outlined in the guidelines for the diagnosis, treatment, prevention, and control of infections caused by carbapenem-resistant gram-negative bacilli 1, support the use of contact precautions to prevent the spread of such infections in a NICU setting.

Rationale

The rationale for this recommendation is based on the understanding that bundle management schemes, including contact isolation, have been shown to reduce the rate of infection or colonization in hospitalized patients, even though the quality of evidence for critical outcomes is low 1. Given the potential severity of MRSE infections in neonates and the importance of preventing their spread, adopting contact precautions is a prudent approach, aligning with the principle of prioritizing morbidity, mortality, and quality of life outcomes.

From the Research

MRSE Infection Precautions in Neonatal ICU

• The decision to use contact precautions or standard precautions for MRSE infection in a Neonatal ICU is crucial in preventing the spread of the infection.
• According to 2, hand hygiene remains the cornerstone of sound infection control practice, and colonization often leads to systemic infection, with smaller neonates at greatest risk.
• The study 3 highlights the complexity of MRSA epidemiology in NICU, where outbreaks can overlap endemic circulation, making it difficult to trace transmission routes.
• Research 4 suggests that contact precautions may not be effective in reducing MRSA transmission, with an estimated change in transmission attributed to contact precautions of -16% (95% credible interval, -38% to 15%).
• However, a multifaceted program combining cross-transmission prevention and antimicrobial stewardship, as described in 5, can lead to a significant decrease in acquired MRSA bacteremia.
• The importance of strict infection control practices, including considerate antibiotic use, is emphasized in 6, as a responsibility shared by all healthcare workers to reduce antimicrobial resistance in ICUs.

Key Considerations

• The effectiveness of contact precautions in preventing MRSE transmission is still a subject of debate, with some studies suggesting limited evidence of their effectiveness.
• A multifaceted approach, including hand hygiene, patient surveillance and isolation, and patient cohorting, may be more effective in reducing the spread of MRSE infection.
• The local epidemiology of MRSA and the specific characteristics of the NICU should be taken into account when developing infection control strategies.
• Antimicrobial stewardship and strict infection control practices are essential in reducing the risk of antimicrobial resistance in NICUs.