APPROACHES TO INFECTION CONTROL
Active Surveillance Culture as a Promising New Tool
By Gerri Hall, PhD, and Diane Flayhart, MT (ASCP), MS
A horrific experience is Michael Bennetts description of his fathers four-month stay in five hospitals in 2004. Mark Bennett was a victim of at least seven strains of hospitalacquired infection (HAI), resulting in the loss of his leg and, ultimately, his life. These infections were caused by pathogens including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycinresistant Enterococcus (VRE).
Michael Bennett, now a patient advocate and president of the Coalition for Patients Rights in Maryland, believes that legislation is essential to protect other patients from the same fate his father suffered. He is actively lobbying the Maryland state legislature on this subject. This is a matter of life and death, and education alone is not enough.
This single case history illustrates the vast human cost of HAIs. Prevalence of HAIs has been increasing for the past two decades in the United States and many other countries. The Centers for Disease Control and Prevention (CDC)s National Nosocomial Infections Surveillance system (NNIS) which collects data from some 300 hospitals estimates that in U.S. hospitals there are 2 million HAIs each year, causing 90,000 deaths and $4.5 billion in excess healthcare costs.
The rising incidence of HAIs caused by MRSA is of particular concern. In 1980, MRSA accounted for only 2 percent of all S. aureus HAIs reported in NNIS system hospitals. Today, MRSA accounts for more than 60 percent of S. aureus infections.
As public awareness increases, healthcare institutions will face ever-increasing pressure to take action. Although there is currently no federal legislation in place, the National Quality Forum (NQF) will soon begin crafting a national consensus standard for HAI reporting. In the meantime, seven states have passed legislation requiring mandatory public reporting of HAIs at a state level, and Pennsylvania has already begun reporting. More than 30 states are considering similar legislation (updated information on state activities is available on the Web site of the Association for Professionals in Infection Control and Epidemiology (APIC) at: www.apic.org/Content/NavigationMenu/GovernmentAdvocacy
Active Surveillance: a Highly Promising Strategy
A highly promising new strategy to help prevent and control HAIs is the use of active surveillance cultures (ASCs) to screen patients for nasal carriage of MRSA, coupled with appropriate barrier precautions for colonized or infected patients. This approach is endorsed in a guideline from the Society for Healthcare Epidemiology of America (SHEA): ASCs are essential to identify the reservoir for spread of MRSA and vancomycin-resistant Enterococcus and make control possible using the CDCs long-recommended transmission-based precautions. For more details, go to:
Some have argued that the SHEA guideline approach is too costly, notes infectious disease expert and SHEA guidelines author William R. Jarvis, MD, of Emory University School of Medicine, and president of Jason and Jarvis Associates. In fact, all of the published studies evaluating the clinical efficacy and cost-efficiency of this approach have concluded that preventing spread of MRSA and VRE using ASCs and isolation of colonized patients actually ends up saving money (after an initial investment) by preventing infections which would be more costly to the patient and the healthcare institution. Other entities also endorse measures to control MRSA.
Additionally, there has been a more focused effort to prevent all HAIs. Facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are required to follow the 2005 Patient Safety Goals, complying with the CDCs hand hygiene recommendations. JCAHO also requires reporting cases of unanticipated death or major permanent loss of function from an HAI as a sentinel event (www.jcaho.org/accredited+organizations/sentinel+event/se_index.htm). In addition, APIC supports use of infection surveillance data in performance improvement activities, favoring a national standard rather than individual state-based systems.
Most Colonized Patients are Undetected and Unisolated
While most facilities in the United States have a policy of requiring additional precautions for patients colonized or infected with MRSA, they generally have not actively identified colonized patients with surveillance cultures, leaving most colonized patients undetected and unisolated, the SHEA guideline notes. Many studies have shown control of endemic and/or epidemic MRSA and VRE infections using ASCs and contact precautions. Jarvis notes, Many, if not most, healthcare facilities rely exclusively on clinical cultures to detect MRSA/VRE colonized/infected patients, despite the fact that clinical cultures have been shown in numerous studies to detect less than 30 percent of such patients.
The SHEA guideline further states, Success in controlling MRSA has been greatest in countries that adhere to rigorous transmission-based control policies that include ASCs ... and strict application of barrier precautions. In several northern European countries, the prevalence of MRSA is low despite repeated introductions. In Denmark, the prevalence of methicillin resistance among S. aureus blood isolates reached a peak of 33 percent in the 1960s, but declined steadily after introduction of a policy to control transmission, and has been maintained at less than 1 percent for 25 years. In Finland and in the Netherlands, the prevalence of MRSA has been maintained at lower than 0.5 percent. This approach has also been used successfully in Canada.
UPMC Reports 90 Percent Decrease in Infection Rate
Carlene A. Muto, MD, MS, director of hospital epidemiology/ infection control at the University of Pittsburgh Medical Center (UPMC), and the lead author of the SHEA guideline, agrees that use of ASCs, barrier precaution, and hand hygiene measures are the key to success in tackling MRSA. Muto reports that UPMC has achieved a 90 percent decrease in the MRSA infection rate in the medical intensive care unit since implementing a program of ASCs and barrier precaution four years ago. In addition, the proportion of Staphylococcus aureus isolates resistant to methicillin at UPMC has fallen from 62 percent at the start of the program to 48 percent today.
Near-perfect implementation of the program has been needed to achieve this, along with necessary resources, support, and leverage, Muto notes. Providing the resources proved to be a wise choice, as the program is extremely cost-effective. The program was endorsed at all levels, with every employee understanding the importance of halting disease transmission, and a rigorous process was put in place to ensure success of the program, which included feedback and support from top hospital administrators.
Based on the success of the existing program, the UPMC Health Systems 16 hospitals will all implement similar programs in intensive care units in fiscal 2006. A community-wide initiative involving 23 Pennsylvania hospitals is also being launched, with each hospital selecting one high-risk area in which to implement a program of ASC and barrier precaution.
MUSC Program Reduces Incidence of MRSA Bacteremia
Significant success has also been achieved at the Medical University of South Carolina in Charleston (MUSC) with a voluntary ASC program testing atrisk patients for MRSA colonization upon admission. Patients found to be colonized with MRSA are isolated, and a door sign directs healthcare professionals and visitors to gown up appropriately and wash hands when leaving the colonized patients room. As a result, the facility has reduced its incidence of MRSA bacteremia significantly.
In January 2005, a new technology was introduced to perform ASCs, BBLTM CHROMagar MRSA. At MUSC, this test offered improved speed and accuracy, and required less technologist time than traditional MRSA testing algorithms or other types of rapid MRSA detection systems.
For the future, many healthcare quality organizations feel that national HAI control standards will soon be a reality possibly based on the SHEA guidelines. Maryland is considering legislation requiring publication of MRSA infection rates. An approach based on the SHEA guideline is strongly supported by Michael Bennett of the Coalition for Patients Rights: If there is a magic bullet to fix the problems with American healthcare, a program like the SHEA guideline to control MRSA and VRE is it. Incredibly, many people in health care have adopted an attitude of inevitability to HAIs. Would we be so fatalistic if doctors and nurses were the victims?
Gerri Hall, PhD, is staff microbiologist at The Cleveland Clinic Foundation. Diane Flayhart, MT (ASCP), MS, is microbiology laboratory supervisor at the Johns Hopkins Medical Institutions.
1. Davis et al. CID 2004; 39: 776.