SHEA, APIC: Screening has role, but no laws needed

SHEA, APIC: Screening has role, but no laws needed

Groups warn against regulating clinical practice

Though conceding there is considerable evidence to support the use of active surveillance cultures (ASC) to detect patient colonization with antimicrobial-resistant pathogens such as methicillin-resistant Staphylococcus aureus, the nation's leading infection prevention groups have come out jointly against mandating the practice through legislation.

With states threatening to adopt laws requiring more aggressive measures to detect and control MRSA and vancomycin-resistant enterococci (VRE), the joint position statement was issued by the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology.

"Legislation to mandate active surveillance is not necessary," says Denise Murphy, RN, MPH, CIC, president of APIC and chief patient safety and quality Officer at Barnes-Jewish Hospital in St. Louis. "The evidence is not 100% in support of doing it at this time. Doing it for some patients — high-risk patients — is another issue. But universal active surveillance and screening of every patient — we worry about the cost benefit of that."

The cost benefit equation goes beyond the revenue needed for supplies and labor to conduct ACS, she emphasizes. The larger picture is mandating a practice that could monopolize the time and prevention talents of the nation's ICPs, particularly those based as solo practitioners in small community hospitals across the country.

"I am really talking about the finite amount of time they have to pay attention to their patients and the staff that take care of them," Murphy says. "It is more important that they are out on the floors doing interventions vs. reacting to legislation that is asking them to report every single infection and colonization. That is really our concern."

At least two states — Illinois and Maryland — have had legislative discussions about mandating active surveillance cultures for MRSA. No laws have passed as this issue went to press. The idea behind ASC is that if patients who are asymptomatically colonized with antimicrobial-resistant bacteria are detected, they can be isolated from other patients to prevent transmission. In addition, colonized patients may be offered treatment to attempt to eradicate the antimicrobial-resistant. All well and good, and both SHEA and — to a less enthusiastic degree — the Centers for Disease Control and Prevention have recommended use of ASC to prevent infections with MRSA or other resistant pathogens.

But legal mandates of clinical practice are often unsettling to the medical community, and the position paper listed a host of questions and caveats. "Numerous questions remain about the epidemiological, biological, clinical, and logistical implications of active surveillance," the position paper states. "How are rates of MRSA and VRE colonization and infection most appropriately quantified? How should patients who acquire colonization with MRSA or VRE during one hospitalization but return with infection at a subsequent admission be counted and managed? What is the optimal body site from which to obtain specimens for surveillance, and is this site the same for all patient populations and situations? Does the same hold true for novel or emerging strains of MRSA or VRE? What is the most appropriate microbiological assay to use for surveillance?"¹

Although there is considerable evidence supporting the use of active surveillance cultures as a clinically effective and cost-effective method for combating the spread of antimicrobial resistant microorganisms in specific circumstances, to mandate the strategy as the single infection control intervention to be applied in all circumstances would preclude local risk assessment and the implementation of a broad range of interventions, APIC and SHEA noted in the paper.

"Moreover, legislation in general is not sufficiently flexible to permit rapid response to local epidemiological trends or changes in the understanding of the spread and consequences of antimicrobial resistance," they concluded. "Local experts should be permitted the latitude to assess the risks of, needs for, and priorities in the application of guidelines and recommendations to prevent and control health care-associated infections, including the use of active surveillance cultures."

Both SHEA and APIC stressed in the paper that they support ongoing and additional research to determine the feasibility and cost-effectiveness of using active surveillance cultures to screen both patient populations. "The appropriateness of mandatory performance of active surveillance cultures for both lower-risk as well as high-risk patients can best be ascertained through additional research that not only employs the most appropriate methodology, but also specifically anticipates and addresses the many uncertainties and potential unintended consequences of this strategy," the paper concludes. "Additional funding is required at the federal level to support research so that these critical issues can be addressed."

Reference

1. Weber SG, Huang SS, Oriola S, et al. Legislative Mandates for Use of Active Surveillance Cultures to Screen for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci: Position Statement From the Joint SHEA and APIC Task Force. On the web at www.apic.org