Relative effects of barrier precautions and topical antibiotics on nosocomial bacterial transmission: Results of multi-compartment models

Nosocomial bacterial infections in critically ill patients are generally preceded by asymptomatic carriage (i.e. colonization) at one, or even several, body sites such as the skin, the gastro-intestinal and the respiratory tract. Different routes of transmission between the colonized sites create a complex epidemiology, which is additionally complicated by the smallness of the patient population size and the rapid patient turnover, characteristic for intensive care units (ICUs). Naturally occurring large fluctuations in the prevalence of colonization make it very difficult to determine the efficacy of control measures that aim to reduce the prevalence of antibiotic-resistant bacteria in ICUs. Theoretical models can sharpen our intuition through carefully designed thought experiments. In this spirit, we introduce and investigate two models that incorporate the fact that patients may be colonized at multiple body sites. Our study can be applied to several pathogens commonly found in ICUs, such Pseudomonas Aeruginosa, enteric Gram-negative bacteria, MRSA and enterococci. We evaluate the effects of barrier precautions (improved hygiene, use of gloves and gowns, etc.) and of administration of nonabsorbable antibiotics on the prevalence of colonization in ICUs and find that the effect of the controversial, though widely used, antibiotic prophylaxis can only be substantial if the patient-to-patient transmission has already been reduced to a subcritical level by barrier precautions. Taking into account that the very use of antibiotics may increase the selection for resistant strains and may thereby only add to the ever increasing problem of antibiotic resistance, our findings hence represent a firm theoretical argument against the routine use of topical antimicrobial prophylaxis for infection control.