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With 3 prospective trials, a retrospective trial, and an editorial focusing on measures to reduce nosocomial colonisations and infections in the ICU, it appears this burdensome sequalae of modern health care is in the spotlight. Time for a Culture Change? (NEJM editorial, Platt) The NEJM editorial succinctly discusses the measures to reduce nosocomial burden in the ICU, including - barrier precautions - hand hygiene - prevention bundles - environmental decontamination - decolonisation of asymptomatic carriers The 2 associated studies in the NEJM report different findings in response to increased barrier precautions, and prevention bundles. The remaining 2 studies report different findings following enhance cleaning. So where does this leave us? Perhaps there are a few points (some made in NEJM editorial) to consider; 1. Enhanced barrier precautions after positive test vs for all? Huskins reported a delay in implementation of precautions until culture positive report of 5.2 days. During this period barrier precautions were not universal, ie had to be culture positive to get escalated precautions. This approach to enhanced barrier precautions was the same in all studies, meaning the patient acts as a"nosocomial reservoirs" with reduced precautions until this occurs. Perhaps it should be the opposite, maximal precautions until proven clean? 2. Culture change Jain aimed for culture change, and introduced other components (VAP and CLABSI bundles, and MRSA de-colonisation advice). In the studies that looked at compliance , it improved, but was not fantastic. 3. The whole package? The study that came the closed to "looking at everything" , barrier, hand hygiene, bundles, cleaning, decolonization of carriers (?role of impregnated body wash), antibiotic stewardship, and culture change, was Jain, which had the most success. This is a big ask, but perhaps that is what it will take. THE PAPERS Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care (Huskins) This cluster randomised trial set out to evaluate the effect of an expanded use of barrier precautions vs existing practice on the incidence of MRSA and VRE infection and colonisation in an adult ICU. To be eligible had to have >1200 patient days per 6-months (roughly 10 ventilated beds in Australia), and at least 9-events of MRSA or VRE per 1000 patient days. Interventions: nasal swabs for MRSA and perianal/stool swabs for VRE within 2 days of admit, weekly thereafter, and within 2 days of ICU discharge. If patient returned positive culture within previous year or during ICU, patient assigned to contact precautions and remained for whole stay. All other patients were assigned to universal gloving until ICU entry surveillance swabs were returned negative, after which they had standard precautions Control: same swabs, results blinded. Existing hospital procedures used to identify pts colonised or infected, who were assigned to care with isolation precautions. All other patients had standard precautions. Contact precautions included hand hygiene, clean gloves, gown. 19 ICU's were involved, with over 8000 admissions. No difference in distribution of surveillance cultures. Results were no difference in MRSA/VRE events. Veterans Affairs Initiative to Prevent Methicillin- Resistant Staphylococcus aureus Infections (Jain) This study is a combined effort of VA Pittsburgh, Pittsburgh Regional Healthcare Inititiative, and the CDC to eliminate health-case associated MRSA infections with the use of a MRSA bundle. The bundle consisited of universal nasal surveillance, contact precautions for carriers, hand hygiene, institutional culture change "positive deviance". Pilot data reported a reduction MRSA infection 60% surgical ward, 75% SICU within 4 years of implementation All VA acute care units nationwide involved except 3 involved, implemented bundle in acute care units. They reported an increase in screening at admission and discharge, the prevalence on admission remained similar, the ICU Incident colonisation decreased, ICU incident infections decreased, and VAP, CLABSI, VRE rates decreased. Environmental Cleaning Intervention and Risk of Acquiring Multidrug-Resistant Organisms From Prior Room Occupants (Datta) A retrospective cohort study conducted in 10 ICU's to evaluate the effect of enhanced environmental cleaning reports a decrease in MRSA and VRE acquisition. The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: A randomized crossover study in critical care units in two hospitals (Wilson) A prospective randomised crossover trial investigating the effect of enhanced cleaning (additional twice-daily cleaning ) reported a significant decrease in environmental MRSA and no significant decrease in patient MRSA. Cleaning: ultramicrofiber with copper biocide Precautions: standard contact for patients with known colonisation. Hand hygiene 52-54%, aporn 93-96%, gloves 42-45% References 1. Platt R. Time for a culture change. New England Journal of Medicine 2011;364:1464-5. 2. Huskins WC, Huckabee CM, O'Grady NP, Investigators SIT. Intervention to Reduce Transmission of Resistant Bacteria in Intensive Care. New England Journal of Medicine 2011;364:1407-18. 3. Jain R, Kralovic SM, Evans ME, Ambrose M, al. e. Veterans Affairs Initiative to Prevent Methicillin- Resistant Staphylococcus aureus Infections. New England Journal of Medicine 2011;364:1419-30. 4. Datta R, Platt R, Yokoe D, Huang SS. Environmental Cleaning Intervention and Risk of Acquiring Multidrug-Resistant Organisms From Prior Room Occupants. Arch Intern Med 2011;171:491-4. 5. Wilson PR, Smyth D, Moore G, al e. The impact of enhanced cleaning within the intensive care unit on contamination of the near-patient environment with hospital pathogens: A randomized crossover study in critical care units in two hospitals. Crit Care Med 2011;39:651-8.