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Recommendations For Metrics For Multidrug-Resistant Organisms In Healthcare Settings: SHEA/HICPAC Position Paper

  • Adam L. Cohen (a1), David Calfee (a2), Scott K. Fridkin (a3), Susan S. Huang (a4), John A. Jernigan, Ebbing Lautenbach (a5), Shannon Oriola (a6), Keith M. Ramsey (a7), Cassandra D. Salgado (a8), Robert A. Weinstein (a9) and The Society for Healthcare Epidemiology of America and the Healthcare Infection Control Practices Advisory Committee...

Monitoring multidrug-resistant organisms (MDROs) and the infections they cause in a healthcare setting is important to detect newly emerging antimicrobial resistance profiles, to identify vulnerable patient populations, and to assess the need for and effectiveness of interventions; however, it is unclear which metrics are the best, because most of the metrics are not standardized. This document describes useful and practical metrics and surveillance considerations for measuring MDROs and the infections they cause in the practice of infection prevention and control in healthcare settings. These metrics are designed to aid healthcare workers in documenting trends over time within their facility and should not be used for interfacility comparison.

Corresponding author
Division of Bacterial Diseases, Centers For Disease Control And Prevention, 1600 Clifton Road, Ms C-23, Atlanta, Ga30333 (
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1.Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings, 2006. Available at: 2006. Accessed June 24, 2008.
2.Paterson DL. The epidemiological profile of infections with multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species. Clin Infect Dis 2006;43 Suppl 2:S4348.
3.Harris AD, McGregor JC, Furuno JP. What infection control interventions should be undertaken to control multidrug-resistant gram-negative bacteria? Clin Infect Dis 2006;43 Suppl 2:S5761.
4.Jones RN. Global epidemiology of antimicrobial resistance among community-acquired and nosocomial pathogens: a five-year summary from the SENTRY Antimicrobial Surveillance Program (1997-2001). Semin Respir Crit Care Med 2003;24:121134.
5.Falagas ME, Koletsi PK, Bliziotis IA. The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter bau-mannii and Pseudomonas aeruginosa. J Med Microbiol 2006;55:16191629.
6.McDonald LC, Coignard B, Dubberke E, Song X, Horan T, Kutty PK. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol 2007;28:140145.
7.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.
8.Yokoe DS, Noskin GA, Cunnigham SM, et al.Enhanced identification of postoperative infections among inpatients. Emerg Infect Dis 2004;10:19241930.
9.Trick WE, Zagorski BM, Tokars JI, et al.Computer algorithms to detect bloodstream infections. Emerg Infect Dis 2004;10:16121620.
10.Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309332.
11.Klevens RM, Morrison MA, Nadle J, et al.Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007;298:17631771.
12.Sanford MD, Widmer AF, Bale MJ, Jones RN, Wenzel RP. Efficient detection and long-term persistence of the carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 1994;19:11231128.
13.Huang SS, Piatt R. Risk of methicillin-resistant Staphylococcus aureus infection after previous infection or colonization. Clin Infect Dis 2003;36:281285.
14.Pacio GA, Visintainer P, Maguire G, Wormser GP, Raffalli J, Montecalvo MA. Natural history of colonization with vancomycin-resistant entero-cocci, methicillin-resistant Staphylococcus aureus, and resistant gram-negative bacilli among long-term-care facility residents. Infect Control Hosp Epidemiol 2003;24:246250.
15.Byers KE, Anglim AM, Anneski CJ, Farr BM. Duration of colonization with vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol 2002;23:207211.
16.Baden LR, Thiemke W, Skolnik A, et al.Prolonged colonization with vancomycin-resistant Enterococcus faecium in long-term care patients and the significance of “clearance.” Clin Infect Dis 2001;33:16541660.
17.Hindler JF, Stelling J. Analysis and presentation of cumulative antibio-grams: a new consensus guideline from the Clinical and Laboratory Standards Institute. Clin Infect Dis 2007;44:867873.
18.White RL, Friedrich LV, Burgess DS, Brown EW, Scott LE. Effect of removal of duplicate isolates on cumulative susceptibility reports. Diagn Microbiol Infect Dis 2001;39:251256.
19.Horvat RT, Klutman NE, Lacy MK, Grauer D, Wilson M. Effect of duplicate isolates of methicillin-susceptible and methicillin-resistant Staphylococcus aureus on antibiogram data. J Clin Microbiol 2003;41:46114616.
20.Lee SO, Cho YK, Kim SY, Lee ES, Park SY, Seo YH. Comparison of trends of resistance rates over 3 years calculated from results for all isolates and for the first isolate of a given species from a patient. J Clin Microbiol 2004;42:47764779.
21.Lucet JC, Grenet K, Armand-Lefevre L, et al.High prevalence of carriage of methicillin-resistant Staphylococcus aureus at hospital admission in elderly patients: implications for infection control strategies. Infect Control Hosp Epidemiol 2005;26:121126.
22.Furuno JP, McGregor JC, Harris AD, et al.Identifying groups at high risk for carriage of antibiotic-resistant bacteria. Arch Intern Med 2006;166:580585.
23.Binkley S, Fishman NO, LaRosa LA, et al.Comparison of unit-specific and hospital-wide antibiograms: potential implications for selection of empirical antimicrobial therapy. Infect Control Hosp Epidemiol 2006;27:682687.
24.Huang SS, Rifas-Shiman SL, Pottinger JM, et al.Improving the assessment of vancomycin-resistant enterococci by routine screening. J Infect Dis 2007;195:339346.
25.Huang SS, Rifas-Shiman SL, Warren DK, et al.Improving methicillin-resistant Staphylococcus aureus surveillance and reporting in intensive care units. J Infect Dis 2007;195:330338.
26.2005 AHA Annual Survey. Health Forum, L.L.C. Available at: Accessed September 2, 2008.
27.Salgado CD, Farr BM. What proportion of hospital patients colonized with methicillin-resistant Staphylococcus aureus are identified by clinical microbiological cultures? Infect Control Hosp Epidemiol 2006;27:116121.
28.Lucet JC, Chevret S, Durand-Zaleski I, Chastang C, Regnier B. 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.
29.Eveillard M, Lancien E, Barnaud G, et al.Impact of screening for MRSA carriers at hospital admission on risk-adjusted indicators according to the imported MRSA colonization pressure. J Hosp Infect 2005;59:254258.
30.Diekema DJ, Edmond MB. Look before you leap: active surveillance for multidrug-resistant organisms. Clin Infect Dis 2007;44:11011107.
31.Mertz D, Frei R, Jaussi B, et al.Throat swabs are necessary to reliably detect carriers of Staphylococcus aureus. Clin Infect Dis 2007;45:475477.
32.D'Agata EM, Gautam S, Green WK, Tang YW. High rate of false-negative results of the rectal swab culture method in detection of gastrointestinal colonization with vancomycin-resistant enterococci. Clin Infect Dis 2002;34:167172.
33.Lautenbach E, Harris AD, Perencevich EN, Nachamkin I, Tolomeo P, Metlay JP. Test characteristics of perirectal and rectal swab compared to stool sample for detection of fluoroquinolone-resistant Escherichia coli in the gastrointestinal tract. Antimicrob Agents Chemother 2005;49:798800.
34.Marchaim D, Navon-Venezia S, Schwartz D, et al.Surveillance cultures and duration of carriage of multidrug-resistant Acinetobacter baumannii. J Clin Microbiol 2007;45:15511555.
35.Robicsek A, Beaumont JL, Paule SM, et al.Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med 2008;148:409418.
36.Harbarth S, Fankhauser C, Schrenzel J, et al.Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA 2008;299:11491157.
37.Clinical and Laboratory Standards Institute (CLSI). Analysis and presentation of cumulative antimicrobial susceptibility test data: approved guideline. 2nd ed. Vol. 25. No. 28. Wayne, PA: CLSI, 2005:M39A2.
38.Fridkin SK, Edwards JR, Tenover FC, Gaynes RP, McGowan JE Jr. Antimicrobial resistance prevalence rates in hospital antibiograms reflect prevalence rates among pathogens associated with hospital-acquired infections. Clin Infect Dis 2001;33:324330.
39.Bantar C, Alcazar G, Franco D, et al.Are laboratory-based antibiograms reliable to guide the selection of empirical antimicrobial treatment in patients with hospital-acquired infections? J Antimicrob Chemother 2007;59:140143.
40.Pakyz AL. The utility of hospital antibiograms as tools for guiding empiric therapy and tracking resistance. Insights from the Society of Infectious Diseases Pharmacists. Pharmacotherapy 2007;27:13061312.
41.Huang SS, Yokoe DS, Hinrichsen VL, 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.
42.Shitrit P, Gottesman BS, Katzir M, Kilman A, Ben-Nissan Y, Chowers M. Active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) decreases the incidence of MRSA bacteremia. Infect Control Hosp Epidemiol 2006;27:10041008.
43.Price CS, Paule S, Noskin GA, Peterson LR. Active surveillance reduces the incidence of vancomycin-resistant enterococcal bacteremia. Clin Infect Dis 2003;37:921928.
44.Fowler VG Jr, Boucher HW, Corey GR, et al.Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med 2006;355:653665.
45.Erbay A, Ergonul O, Stoddard GJ, Samore MH. Recurrent catheter-related bloodstream infections: risk factors and outcome. Int J Infect Dis 2006;10:396400.
46.Fowler VG Jr, Sakoulas G, Mclntyre LM, et al.Persistent bacteremia due to methicillin-resistant Staphylococcus aureus infection is associated with agr dysfunction and low-level in vitro resistance to thrombin-induced platelet microbicidal protein. J Infect Dis 2004;190:11401149.
47.Health Protection Agency. Surveillance of Healthcare Associated Infections Report 2007. Available at: 1158945066450. Accessed June 24, 2008.
48.Merrer J, Santoli F, Appere de Vecchi C, Tran B, De Jonghe B, Outin H. “Colonization pressure” and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit. Infect Control Hosp Epidemiol 2000;21:718723.
49.Bonten MJ, Slaughter S, Ambergen AW, et al.The role of “colonization pressure” in the spread of vancomycin-resistant enterococci: an important infection control variable. Arch Intern Med 1998;158:11271132.
50.Weinstein RA, Kabins SA. Strategies for prevention and control of multiple drug-resistant nosocomial infection. Am J Med 1981;70:449454.
51.Ostrowsky BE, Trick WE, Sohn AH, et al.Control of vancomycin-resistant Enterococcus in health care facilities in a region. N Engl J Med 2001;344:14271433.
52.Rhame FS, Sudderth WD. Incidence and prevalence as used in the analysis of the occurrence of nosocomial infections. Am J Epidemiol 1981;113:111.
53.Berthelot P, Gamier M, Fascia P, et al.Conversion of prevalence survey data on nosocomial infections to incidence estimates: a simplified tool for surveillance? Infect Control Hosp Epidemiol 2007;28:633636.
54.Gastmeier P, Brauer H, Sohr D, et al.Converting incidence and prevalence data of nosocomial infections: results from eight hospitals. Infect Control Hosp Epidemiol 2001;22:3134.
55.Harris AD, Kotetishvili M, Shurland S, et al.How important is patient-to-patient transmission in extended-spectrum beta-lactamase Escherichia coli acquisition. Am J Infect Control 2007;35:97101.
56.Flynn DM, Weinstein RA, Nathan C, Gaston MA, Kabins SA. Patients' endogenous flora as the source of “nosocomial” Enterobacter in cardiac surgery. J Infect Dis 1987;156:363368.
57.Institute for Healthcare Improvement. Institute for Healthcare Improvement. How-to guide: reduce methicillin-resistant Staphylococcus aureus (MRSA) infection, 2006. Available at: Accessed June 24, 2008.
58.Curran ET, Benneyan JC, Hood J. Controlling methicillin-resistant Staphylococcus aureus: a feedback approach using annotated statistical process control charts. Infect Control Hosp Epidemiol 2002;23:1318.
59.Calfee D, Salgado CD. Detection and prevention of methicillin-resistant Staphylococcus aureus (MRSA) in acute care hospitals. Infect Control Hosp Epidemiol 2008, in press.
60.Association for Professionals in Infection Control and Epidemiology (APIC). Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings. Washington, DC: APIC; March 2007.
61.Chaberny IF, Sohr D, Ruden H, Gastmeier P. Development of a surveillance system for methicillin-resistant Staphylococcus aureusin German hospitals. Infect Control Hosp Epidemiol 2007;28:446452.
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