Another tale of two guidelines.

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To the Editor—We agree with Strausbaugh et al. [1] that “aggressive and widespread adoption of control measures for multidrug-resistant organisms is urgently needed” (page 828); however, we doubt that the approach suggested by the Healthcare Infection Control Practices Advisory Committee (HICPAC) isolation guideline [2] would control these organisms, and we disagree with other things that were said. For example, Strausbaugh and colleages said, “Which approach will lead to better control ... remains to be determined by carefully designed studies such as the ongoing National Institutes of Health—sponsored multicenter study of adult intensive care units. In this study, adult intensive care units are randomized either to practice standard precautions or use routine active surveillance cultures and contact precautions for persons harboring MRSA or VRE” (page 833). The National Institutes of Health study [3] does not effectively address this question because, in multiple ways, its active surveillance culture (ASC)/contact precaution (CP) measures fall short of the Society for Healthcare Epidemiology of America (SHEA) guideline recommendations [4]. For example, intervention in only 1 intensive care unit of a large hospital is not optimal to control nosocomial methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), it is not what the SHEA guideline recommends, and it is not associated with rapid control [5, 6]. The National Institutes of Health study of ASC/CP measures are less rigorous than those in recent studies that demonstrate control in intensive care units [6–8] and, as such, favor a false-negative result, especially given expected sample size and power during the study's relatively brief intervention period. By these study parameters, 2 recent studies with dramatically positive results would have been false-negatives [6, 8]. One of these studies, a longer one, reported a 75% reduction in MRSA bacteremia with ASC/CP, compared with no effect on MRSA bacteremia with enhanced standard precautions (i.e., alcohol handrubs and a motivational campaign that increased hand hygiene compliance to 80%) [8]—the type of standard precautions attempted in the National Institutes of Health study. Multiple other studies, including the CDC's National Nosocomial Infections Surveillance System data [9], suggest that standard precautions have failed to control MRSA and VRE (despite the use of standard precautions and mandatory annual health care worker infection control retraining in US health care facilities since 1996).