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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

  • Stephen G. Weber (a1), Susan S. Huang (a2), Shannon Oriola (a3), W. Charles Huskins (a4), Gary A. Noskin (a5), Kathleen Harriman (a6), Russell N. Olmsted (a7), Marc Bonten (a8), Tammy Lundstrom (a9), Michael W. Climo (a10), Mary-Claire Roghmann (a11), Cathryn L. Murphy (a12) and Tobi B. Karchmer (a13)...

Legislation aimed at controlling antimicrobial-resistant pathogens through the use of active surveillance cultures to screen hospitalized patients has been introduced in at least 2 US states. In response to the proposed legislation, the Society for Healthcare Epidemiology of America (SHEA) and the Association of Professionals in Infection Control and Epidemiology (APIC) have developed this joint position statement. Both organizations are dedicated to combating healthcare-associated infections with a wide array of methods, including the use of active surveillance cultures in appropriate circumstances. This position statement reviews the proposed legislation and the rationale for use of active surveillance cultures, examines the scientific evidence supporting the use of this strategy, and discusses a number of unresolved issues surrounding legislation mandating use of active surveillance cultures. The following 5 consensus points are offered. (1) Although reducing the burden of antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), is of preeminent importance, APIC and SHEA do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE, or other antimicrobial-resistant pathogens. (2) SHEA and APIC support the continued development, validation, and application of efficacious and cost-effective strategies for the prevention of infections caused by MRSA, VRE, and other antimicrobial-resistant and antimicrobial-susceptible pathogens. (3) APIC and SHEA welcome efforts by healthcare consumers, together with private, local, state, and federal policy makers, to focus attention on and formulate solutions for the growing problem of antimicrobial resistance and healthcare-associated infections. (4) SHEA and APIC support ongoing additional research to determine and optimize the appropriateness, utility, feasibility, and cost-effectiveness of using active surveillance cultures to screen both lower-risk and high-risk populations. (5) APIC and SHEA support stronger collaboration between state and local public health authorities and institutional infection prevention and control experts.

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University of Chicago Hospitals, 5841 South Maryland Avenue, MC 5065, Chicago, IL 60637 (
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1.National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470485.

2.MD Obritsch , DN Fish , R MacLaren , R Jung . National surveillance of antimicrobial resistance in Pseudomonas aeruginosa isolates obtained from intensive care unit patients from 1993 to 2002. Antimicrob Agents Chemother 2004;48:46064610.

8.S Navon-Venezia , R Ben-Ami , Y Carmeli . Update on Pseudomonas aeruginosa and Acinetobacter baumannii infections in the healthcare setting. Curr Opin Infect Dis 2005;18:306313.

9.SI Blot , P Depuydt , L Annemans , et al. Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections. Clin Infect Dis 2005;41:15911598.

10.JR Zahar , C Clec'h , M Tafflet , et al. Is methicillin resistance associated with a worse prognosis in Staphylococcus aureus ventilator-associated pneumonia? Clin Infect Dis 2005;41:12241231.

11.SE Cosgrove , G Sakoulas , EN Perencevich , MI Schwaber , AW Karchmer , Y Carmeli . Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis 2003;36:5359.

12.CA DiazGranados , SM Zimmer , M Klein , JA lernigan . Comparison of mortality associated with vancomycin-resistant and vancomycin-sus-ceptible enterococcal bloodstream infections: a meta-analysis. Clin Infect Dis 2005;41:327333.

13.Y Carmeli , G Eliopoulos , E Mozaffari , M Samore . Health and economic outcomes of vancomycin-resistant enterococci. Arch Intern Med 2002;162:22232228.

14.JJ Engemann , Y Carmeli , SE Cosgrove , et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592598.

16.C Wendt , C Krause , LU Xander , D Loffler , H Floss . Prevalence of colonization with vancomycin-resistant enterococci in various population groups in Berlin, Germany. J Hosp Infect 1999;42:193200.

18.R Coello , JR Glynn , C Gaspar , JJ Picazo , J Fereres . Risk factors for developing clinical infection with methicillin-resistant Staphylococcus aureus (MRSA) amongst hospital patients initially only colonized with MRSA. J Hosp Infect 1997;37:3946.

19.M Pujol , C Pena , R Pallares , J Ayats , J Ariza , F Gudiol . Risk factors for nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus. Eur J Clin Microbiol Infect Dis 1994;13:96102.

20.SS Huang , R Platt . Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis 2003;36:281285.

21.KJ Henning , H Delencastre , J Eagan , et al. Vancomycin-resistant Enterococcus faecium on a pediatric oncology ward: duration of stool shedding and incidence of clinical infection. Pediatr Infect Dis J 1996;15:848854.

22.A Zirakzadeh , R Patel . Vancomycin-resistant enterococci: colonization, infection, detection, and treatment. Mayo Clin Proc 2006;81:529536.

23.KM Yeh , LK Siu , JC Chang , FY Chang . Vancomycin-resistant Enterococcus (VRE) carriage and infection in intensive care units. Microb Drug Resist 2004;10:177183.

24.SF Bradley , MS Terpenning , MA Ramsey , et al. Methicillin-resistant Staphylococcus aureus: colonization and infection in a long-term care facility. Ann Intern Med 1991;115:417422.

25.DR Mest , DH Wong , KJ Shimoda , ME Mulligan , SE Wilson . Nasal colonization with methicillin-resistant Staphylococcus aureus on admission to the surgical intensive care unit increases the risk of infection. Anesth Analg 1994;78:644650.

27.D Pittet , S Hugonnet , S Harbarth , et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:13071312.

29.VD Rosenthal , S Guzman , N Safdar . Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Am J Infect Control 2005;33:392397.

30.PC Ng , HL Wong , DJ Lyon , et al. Combined use of alcohol hand rub and gloves reduces the incidence of late onset infection in very low birth-weight infants. Arch Dis Child Fetal Neonatal Ed 2004;89:F336340.

31.SJ Dancer , M Coyne , A Speekenbrink , S Samavedam , J Kennedy , PG Wallace . MRSA acquisition in an intensive care unit. Am J Infect Control 2006;34:1017.

32.AR Tenorio , SM Badri , NB Sahgal , et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin Infect Dis 2001;32:826829.

33.GJ Moran , A Krishnadasan , RJ Gorwitz , et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006;355:666674.

34.JC Lucet , S Chevret , I Durand-Zaleski , C Chastang , B Regnier . Prevalence and risk factors for carriage of methicillin-resistant Staphylococcus aureus at admission to the intensive care unit: results of a multicenter study. Arch Intern Med 2003;163:181188.

36.DP Calfee , ET Giannetta , LJ Durbin , TP Germanson , BM Farr . Control of endemic vancomycin-resistant Enterococcus among inpatients at a university hospital. Clin Infect Dis 2003;37:326332.

37.EM Mascini , A Troelstra , M Beitsma , et al. Genotyping and preemptive isolation to control an outbreak of vancomycin-resistant Enterococcus faecium. Clin Infect Dis 2006;42:739746.

38.LA Puzniak , T Leet , J Mayfield , M Kollef , LM Mundy . To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Clin Infect Dis 2002;35:1825.

39.JA Jernigan , MG Titus , DH Groschel , S Getchell-White , BM Farr . Effectiveness of contact isolation during a hospital outbreak of methicillin-resistant Staphylococcus aureus. Am J Epidemiol 1996;143:496504.

40.BM Farr . Prevention and control of methicillin-resistant Staphylococcus aureus infections. Curr Opin Infect Dis 2004;17:317322.

41.MA Montecalvo , H Horowitz , C Gedris , et al. Outbreak of vancomycin-, ampicillin-, and aminoglycoside-resistant Enterococcus faecium bacteremia in an adult oncology unit. Antimicrob Agents Chemother 1994;38:13631367.

42.LL Livornese Jr, S Dias , C Samel , et al. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112116.

43.LV Karanfil , M Murphy , A Josephson , et al. A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol 1992;13:195200.

44.JM Boyce , LA Mermel , MJ Zervos , et al. Controlling vancomycin-resistant enterococci. Infect Control Hosp Epidemiol 1995;16:634637.

46.RK Malik , MA Montecalvo , MR Reale , et al. Epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit. Pediatr Infect Dis J 1999;18:352356.

52.KA Murray-Leisure , S Geib , D Graceley , et al. Control of epidemic methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 1990;11:343350.

54.NA Back , CC Linnemann Jr, JL Staneck , UR Kotagal . Control of methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit: use of intensive microbiologic surveillance and mupirocin. Infect Control Hosp Epidemiol 1996;17:227231.

60.JA Jernigan , MA Clemence , GA Stott , et al. Control of methicillin-resistant Staphylococcus aureus at a university hospital: one decade later. Infect Control Hosp Epidemiol 1995;16:686696.

62.RL Thompson , I Cabezudo , RP Wenzel . Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann Intern Med 1982;97:309317.

63.M Farrington , C Redpath , C Trundle , S Coomber , NM Brown . Winning the battle but losing the war: methicillin-resistant Staphylococcus aureus (MRSA) infection at a teaching hospital. QJM 1998;91:539548.

64.RW Haley , NB Cushion , FC Tenover , et al. Eradication of endemic methicillin-resistant Staphylococcus aureus infections from a neonatal intensive care unit. J Infect Dis 1995;171:614624.

65.S Harbarth , Y Martin , P Rohner , N Henry , R Auckenthaler , D Pittet . Effect of delayed infection control measures on a hospital outbreak of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2000;46:4349.

66.AH Siddiqui , AD Harris , J Hebden , PD Wilson , JG Morris Jr, MC Roghmann . The effect of active surveillance for vancomycin-resistant enterococci in high-risk units on vancomycin-resistant enterococci incidence hospital-wide. Am J Infect Control 2002;30:4043.

67.SS Huang , DS Yokoe , VL Hinrichsen , et al. Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis 2006;43:971978.

68.AI Hidron , EV Kourbatova , IS Halvosa , et al. Risk factors for colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to an urban hospital: emergence of community-associated MRSA nasal carriage. Clin Infect Dis 2005;41:159166.

69.JA Jernigan , AL Pullen , L Flowers , M Bell , WR Jarvis . Prevalence of and risk factors for colonization with methicillin-resistant Staphylococcus aureus at the time of hospital admission. Infect Control Hosp Epidemiol 2003;24:409414.

70.S Harbarth , H Sax , C Fankhauser-Rodriguez , J Schrenzel , A Agostinho , D Pittet . Evaluating the probability of previously unknown carriage of MRSA at hospital admission. Am J Med 2006;119:275 e15-23.

71.BE Ostrowsky , WE Trick , AH Sohn , et al. Control of vancomycin-resistant Enterococcus in health care facilities in a region. N Engl J Med 2001;344:14271433.

72.CS Price , S Paule , GA Noskin , LR Peterson . Active surveillance reduces the incidence of vancomycin-resistant enterococcal bacteremia. Clin Infect Dis 2003;37:921928.

74.BS Cooper , GF Medley , SP Stone , et al. Methicillin-resistant Staphylococcus aureus in hospitals and the community: stealth dynamics and control catastrophes. Proc Natl Acad Sci U S A 2004;101:1022310228.

75.MC Bootsma , O Diekmann , MJ Bonten . Controlling methicillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing. Proc Natl Acad Sci USA 2006;103:56205625.

76.EN Perencevich , DN Fisman , M Lipsitch , AD Harris , JG Morris Jr, DL Smith . Projected benefits of active surveillance for vancomycin-resistant enterococci in intensive care units. Clin Infect Dis 2004;38:11081115.

78.J Verhoef , D Beaujean , H Blok , et al. A Dutch approach to methicillin-resistant Staphylococcus aureus. Eur J Clin Microbiol Infect Dis 1999;18:461466.

79.CM Vandenbroucke-Grauls . Methicillin-resistant Staphylococcus aureus control in hospitals: the Dutch experience. Infect Control Hosp Epidemiol 1996;17:512513.

80.MF Kluytmans-Vandenbergh , JA Kluytmans , A Voss . Dutch guideline for preventing nosocomial transmission of highly resistant microorganisms (HRMO). Infection 2005;33:309313.

81.MD King , BJ Humphrey , YF Wang , EV Kourbatova , SM Ray , HM Blumberg . Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue infections. Ann Intern Med 2006;144:309317.

82.U Seybold , EV Kourbatova , JG Johnson , et al. Emergence of community-associated methicillin-resistant Staphylococcus aureus USA300 genotype as a major cause of health care-associated blood stream infections. Clin Infect Dis 2006;42:647656.

83.TB Karchmer , LJ Durbin , BM Simonton , BM Farr . Cost-effectiveness of active surveillance cultures and contact/droplet precautions for control of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2002;51:126132.

85.C Chaix , I Durand-Zaleski , C Alberti , C Brun-Buisson . Control of endemic methicillin-resistant Staphylococcus aureus: a cost-benefit analysis in an intensive care unit. JAMA 1999;282:17451751.

87.MD Sanford , AF Widmer , MJ Bale , RN Jones , RP Wenzel . Efficient detection and long-term persistence of the carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 1994;19:11231128.

89.E Tacconelli , Y Carmeli , A Aizer , G Ferreira , MG Foreman , EM D'Agata . Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clin Infect Dis 2003;37:16291638.

90.KB Laupland , JM Conly . Treatment of Staphylococcus aureus colonization and prophylaxis for infection with topical intranasal mupirocin: an evidence-based review. Clin Infect Dis 2003;37:933938.

91.CA Kauffman , MS Terpenning , X He , et al. Attempts to eradicate methicillin-resistant Staphylococcus aureus from a long-term-care facility with the use of mupirocin ointment. Am J Med 1993;94:371378.

92.MT Wong , CA Kauffman , HC Standiford , et al. Effective suppression of vancomycin-resistant Enterococcus species in asymptomatic gastrointestinal carriers by a novel glycolipodepsipeptide, ramoplanin. Clin Infect Dis 2001;33:14761482.

93.TM Perl , JJ Cullen , RP Wenzel , et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:18711877.

94.TJ Walsh , HC Standiford , AC Reboli , et al. Randomized double-blinded trial of rifampin with either novobiocin or trimethoprim-sulfamethoxazole against methicillin-resistant Staphylococcus aureus colonization: prevention of antimicrobial resistance and effect of host factors on outcome. Antimicrob Agents Chemother 1993;37:13341342.

95.IS Roccaforte , MI Bittner , CA Stumpf , LC Preheim . Attempts to eradicate methicillin-resistant Staphylococcus aureus colonization with the use of trimethoprim-sulfamethoxazole, rifampin, and bacitracin. Am J Infect Control 1988;16:141146.

97.MA Miller , A Dascal , J Portnoy , J Mendelson . Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996;17:811813.

99.KE Mondy , W Shannon , LM Mundy . Evaluation of zinc bacitracin capsules versus placebo for enteric eradication of vancomycin-resistant Enterococcus faecium. Clin Infect Dis 2001;33:4736.

101.MO Vernon , MK Hayden , WE Trick , RA Hayes , DW Blom , RA Weinstein . Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med 2006;166:306312.

104.HT Stelfox , DW Bates , DA Redelmeier . Safety of patients isolated for infection control. JAMA 2003;290:18991905.

105.HL Evans , MM Shaffer , MG Hughes , et al. Contact isolation in surgical patients: a barrier to care? Surgery 2003;134:180188.

106.KB Kirkland , JM Weinstein . Adverse effects of contact isolation. Lancet 1999;354:11771178.

107.S Saint , LA Higgins , BK Nallamothu , C Chenoweth . Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control 2003;31:354356.

108.KA Davis , JJ Stewart , HK Crouch , CE Florez , DR Hospenthal . Methicillin-resistant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effect on subsequent MRSA infection. Clin Infect Dis 2004;39:776782.

110.P Kotilainen , M Routamaa , R Peltonen , et al. Eradication of methicillin-resistant Staphylococcus aureus from a health center ward and associated nursing home. Arch Intern Med 2001;161:859863.

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