A critical look at the debate around contact precautions for MRSA carriers

Recently, I read a pro/con debate in the New England Journal of Medicine (NEJM) on whether to continue contact precautions for MRSA carriers (1). While the topic itself is highly relevant nowadays, the article left me more confused as both sides seemed to contradict each other. This blog aims to provide a more nuanced analysis of this debate via the following questions:

1) What were the main arguments used in the NEJM pro/con debate?

2) Which additional arguments should be considered?

1) What were the main arguments used in the NEJM pro/con debate?

As the NEJM-article is a good starting point, lets critically analyze the main arguments:

PRO: Contact precautions are supported by randomized trials. (Partially true)

The authors specifically refer to the BUGG trial, a cluster-randomized trial as evidence that contact precautions reduce MRSA-acquisition (1). However, there are some problems with this claim. First all, the primary outcome of the BUGG trial was negative as no difference in MRSA and VRE acquisition was observed by using contact precautions (2). Although it did find a reduction in MRSA acquisition, a secondary outcome, the baseline differed significantly between groups: 10 MRSA acquisitions per 1000 patient-days in the intervention arm versus 7 per 1000 patient-days in the control arm (2). During the study, both groups converged to about 6 MRSA-acquisitions per 1000 patient-days (2). Additionally, three other cluster-randomized trials failed to show a reduction in MRSA with contact precautions (3).

Nevertheless, all cluster-randomized trials conducted to date are likely underpowered. Some researchers have estimated that detecting even a 10% difference in MRSA acquisition due to contact precautions would require randomizing over 540 clusters - a feat hard to pull off (4).

PRO: Contact precautions can lead to significant reduction in MRSA acquisition. (Misleading)

The Veterans Affairs (VA) Healthcare system was used for the largest, observational study to date, involving 2 million unique individuals and over 5.6 million admissions (5). Since 2007, the VA’s i MRSA Prevention Initiative combined contact precautions (a vertical intervention) with multiple horizontal interventions, such as a renewed focus on hand hygiene and MRSA prevention coordinators (3, 5). The initiative led to a 45% reduction in MRSA transmission in the following decade (5). However, this result should be interpreted cautiously. Firstly, contact precautions were already being implemented in several places before 2007 (3). Besides, the effect size may be inflated due to certain modeling assumptions (7). Moreover, similar reductions were observed in hospital-onset Gram-negative bacteremia and candidemia, suggesting that the horizontal interventions drove more of the observed improvements than contact precautions alone (3).

On the other hand, opponents of contact precautions argue that meta-analyses show no increase in MRSA Infections after discontinuing these measures (1,7). This argument is also misleading as most observational studies only tracked infections until discharge (8,9). Yet, the majority of infections with hospital-acquired MRSA manifest after discharge (6,8). Moreover, these studies often involve multiple simultaneous interventions and poorly report adherence, making it difficult to isolate the effect of contact precautions (9).

Perhaps a blog post from 2024 best captures the core issue with observational studies, noting that everyone can cherrypick studies in support of whatever view they hold to begin with (10)

PRO: All professional guidelines recommend contact precautions for MRSA. (Mostly true)

Most professional guidelines continue to recommend contact precautions for MRSA carriers. However, the 2022 update of the SHEA/IDSA/APIC practice recommendations however leaves an opening: hospitals may discontinue these precautions if they determine that doing so would not harm patients (11). This option is specifically suggested for places with low MRSA prevalence and no ongoing outbreaks (3).

CON: Contact precautions can be abandoned due to the availability of effective MRSA treatments. (True)

Nowadays, there are multiple effective treatment options for MRSA infections, including vancomycin, daptomycin, fifth generation cephalosporins, linezolid, clindamycin, trimethoprim-sulphamethoxazole and tetracyclines (13). However, it is important to note that nasal carriers of MRSA still face a fivefold higher risk of healthcare-associated infections (13).

CON: Contact precautions lead to more anxiety and depression among patients. (Partially true) 

A common argument against contact precautions is that they result in higher rates of depression and anxiety (1). While several observational studies have reported this association, most did not account for important confounders such as the severity of illness or pre-existing mental disorders(8). When they did adjust, the association often disappeared (8). Furthermore, the only randomized trial examining the adverse effects of contact precautions found no significant difference in patient outcomes (12).

CON: Contact precautions should be abandoned due to the waste they generate.  (Irrelevant)

While it is true that contact precautions produce a significant amount of waste, this ecological argument only becomes relevant if these measures do not effectively reduce MRSA infections and related mortality. However, in that case, contact precautions should be discontinued anyway.

2) Which additional arguments should be considered?

CON: Use of gloves may compromise hand hygiene.

The use of gloves and gowns can create a false sense of security, resulting in poorer hand hygiene practices among healthcare workers (14). For instance, in one observational study, only 18.5% of staff performed hand hygiene before donning non-sterile gloves and just 65% after removing them (15). This neglect has been shown to contaminate glove boxes, leading to the transmission of pathogens (14). Hand hygiene remains the cornerstone of any infection control program: healthcare staff should not be distracted by the reliance on gloves and gowns.

CON: MRSA rates continue to decline despite several places discontinuing contact precautions.

Proponents of contact precautions often credit these measures for the global decline in MRSA infections (8). A closer examination, however, reveals that the latest epidemic wave of MRSA reached its peak in 2005 (3), before many countries implemented specific programs (5,8). Moreover, hospital-onset MRSA rates have continued to decline in several regions even after many hospitals ceased the use of contact precautions for MRSA carriers (3).

My Key Takeaways:

• Definitive evidence for the efficacy of contact precautions in MRSA will most likely never be obtained. As a consequence, contact precautions will continue to rely on expert-based opinion.

• Contact precautions should always be part of a broader infection control program that prioritizes active surveillance and hand hygiene.

• Hospitals with a low MRSA prevalence may have the opportunity to discontinue or scale back contact precautions, at least in selected wards.

Further reading:

Link to the original article: https://pubmed.ncbi.nlm.nih.gov/41406451/

References:

 1. Pearl A, Karaba SM, Uhlemann AC. Contact Precautions for MRSA and Vancomycin-Resistant Enterococcus. N Engl J Med. 2025 Dec 18;393(24):2475-2477.

 2. Harris AD, Pineles L, Belton B, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA. 2013 Oct 16;310(15):1571-80.

 3. Diekema DJ, Nori P, Stevens MP, et al. Are Contact Precautions "Essential" for the Prevention of Healthcare-associated Methicillin-Resistant Staphylococcus aureus? Clin Infect Dis. 2024 May 15;78(5):1289-1294.

 4. Blanco N, Harris AD, Magder LS, et al. Sample Size Estimates for Cluster-Randomized Trials in Hospital Infection

 5. Khader K, Thomas A, Stevens V, et al. Association Between Contact Precautions and Transmission of Methicillin-Resistant Staphylococcus aureus in Veterans Affairs Hospitals. JAMA Netw Open. 2021 Mar 1;4(3):e210971.

 6. Goto M, Harris AD, Perencevich EN. Contact Precautions and Methicillin-Resistant Staphylococcus aureus-Modeling Our Way to Safety. JAMA Netw Open. 2021 Mar 1;4(3):e211574.

 7. Kleyman R, Cupril-Nilson S, Robinson K, et al. Does the removal of contact precautions for MRSA and VRE infected patients change health care-associated infection rate?: A systematic review and meta-analysis. Am J Infect Control. 2021 Jun;49(6):784-791.

 8. Maragakis LL, Jernigan JA. Things We Do For Good Reasons: Contact Precautions for Multidrug-resistant Organisms, Including MRSA and VRE. J Hosp Med. 2019 Mar;14(3):194-196.

 9. Browning S, White NM, Raby E, et al. Which trial do we need? Gown and glove use versus standard precautions for patients colonized or infected with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus. Clin Microbiol Infect. 2024 Aug;30(8):973-976. doi: 10.1016/j.cmi.2024.05.009. Epub 2024 May 15. PMID: 38759870.

 10. Sax P. Should We Continue to Use Contact Precautions for Patients with MRSA? HIV and ID Observations. 2024 Jul 14. https://blogs.nejm.org/hiv-id-observations/index.php/should-we-continue-to-use-contact-precautions-for-patients-with-mrsa/2024/07/14/ (Accessed on 6th of January 2026).

 11. Popovich KJ, Aureden K, Ham DC, et al. Reply to Diekema et al. Clin Infect Dis. 2024 Aug 16;79(2):576-577.

 12. Bearman GM, Harris AD, Tacconelli E. Contact precautions for the control of endemic pathogens: Finding the middle path. Antimicrob Steward Healthc Epidemiol. 2023 Mar 24;3(1):e57.

 13. Tobin EH, Jogu P, Koirala J. Methicillin-Resistant Staphylococcus aureus. [Updated 2025 Dec 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

 14. Vilar-Compte D, Garciadiego-Fossas P, Ibanes-Gutiérrez C. Gloving in medicine: a boon for infection prevention or a hindrance? Antimicrob Steward Healthc Epidemiol. 2025 Oct 29;5(1):e288.

 15. Imhof R, Chaberny IF, Schock B. Gloves use and possible barriers - an observational study with concluding questionnaire. GMS Hyg Infect Control. 2021 Feb 22;16:Doc08.