Plan to test health workers may undermine safety

In a move that runs counter to national public health guidelines and may contribute to the rise of drug-resistant pathogens, Pennsylvania has passed a state law that could lead to routinely culturing a wide variety of health care workers for methicillin-resistant Staphylococcus aureus (MRSA) and other multidrug-resistant organisms (MDROs).

Moreover, the Pennsylvania provision for screening health care workers in the absence of an outbreak or ongoing transmission runs directly counter to current guidelines by the Centers for Disease Control and Prevention, potentially putting every hospital in the state out of line with the prevailing standard of care. As a result, the Hospital & Healthsystem Association of Pennsylvania (HAP) is essentially telling member facilities to report they have no way to comply with such a provision because there are no established protocols to do so. Not so fast, says the state health department, which is charged with drawing up some kind of regulations to comply with the law and is in the process of doing just that. The whole thing arose from an ill-fated attempt at political compromise among lawmakers and the governor's office, which originally wanted all health care workers screened.

"These kind of [universal screening] strategies are promoted only by people who are unfamiliar with the biology of MRSA, the antimicrobials available, and the development of resistance," warns William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville. "The less trenchant your knowledge of the subject is, the simpler it appears and the more Draconian the solutions that you find proposed. Then we in infection control find ourselves playing both defense and catch-up. We simply have to be better connected [with the state legislatures]."

In addition to a requirement for active surveillance cultures (ASC) for high-risk patients such as those admitted from long-term care facilities, the Pennsylvania law calls for hospitals to include in their infection control plans "procedures and protocols for staff who may have had potential exposure to a patient or resident known to be colonized or infected with MRSA or MDRO, including cultures and screenings, prophylaxis and follow-up care." The health care worker screening provision has caused an uproar since it was included in the July 12, 2007, law (Senate Bill No. 968).

Sharon Krystofiak, MS, MT(ASCP), CIC, infection control manager at Mercy Hospital in Pittsburgh, says they are struggling. "We have no idea where they pulled this verbiage out of thin air," Krystofiak says. "It says something like `according to established protocols.' There aren't any." It never has been a recommended practice, she says. "Unfortunately, Pennsylvania has taken the tact of passing laws and then figuring out what they mean," Krystofiak says

The infection control community in Pennsylvania is rallying to try to get some reasonable interpretation of the provision as enforcement and compliance mechanisms are honed in the weeks and months ahead. The aspect of culturing staff is particularly broad: any staff that are exposed to MRSA, says Patrick J. Brennan, MD, chief of healthcare quality and patient safety for the University of Pennsylvania Health System in Philadelphia. "You can interpret that to be anybody that takes care of a patient with MRSA," Brennan says. "I'm not sure how they intend to implement that or what the implications are going to be. I think a lot of this is going to be subject to department of health interpretation. If this is strictly and broadly interpreted it could be very onerous."

A cautionary tale

The situation in Pennsylvania is being viewed as a cautionary tale for other states facing increasing involvement of legislatures in the clinical practice of infection control. In particular, more states are considering requiring ASC to identify patients with MRSA before they can spread the bacteria to others. However, it appears Pennsylvania is the first state to include screening health care workers, which is generally done by nasal swab and culture.

"There are exceptions, but the literature on MRSA largely suggests that health care workers' nasal carriage is not the source of spread of MRSA to patients within health care facilities," Schaffner says. "This [Pennsylvania] legislation appears misguided and is unlikely to have a noteworthy impact on MRSA transmission within health care facilities. It will raise all kinds of issues having to do with how frequently institutions should do [screening], who indeed is considered a health care worker in the context of this legislation, and what institutions ought to do after they have identified such an individual."

ASC for high-risk patient groups is controversial in its own right, but is generally seen as a potentially effective way to identify and isolate MRSA colonized patients so they can't spread infection to others. The health care worker screening provision — which sounds reasonable enough in the abstract — is another matter entirely.

Infection control experts have long emphasized that it is generally futile and counterproductive to routinely search for health care workers colonized with staph in the absence of an outbreak. Culturing the nares of health care workers does not address the primary threat to patients, which is the transient colonization of worker's unwashed hands as they go from patient to patient. Thus, hand hygiene between patients is the cardinal rule for health care workers to follow.

"We reserve screening for individuals who have an epidemiological association with some transmission event," explains Michael Bell, MD, medical epidemiologist in the CDC Division of Health Care Quality Promotion. If there is some reason to consider screening, that would be fine, Bell says. But if you screen at random, there is the challenge of interpreting the results, he says. "If somebody comes back with one or two organisms, do you continue to reculture them for some period of time? Do you try to decolonize them? If you can't decolonize, do you fire them?" Bell says. "I don't think you would be allowed to actually. There are all sorts of ramifications of a random culture that makes that a routine practice that we do not normally advise."

Rarely, persistently colonized workers will cause infections in patients, a legitimate issue that does warrant screening to protect patients. The CDC's latest guideline on MDROs includes a section on the issue of colonized workers that states: "Occasionally, HCP [health care personnel] can become persistently colonized with an MDRO, but these HCP have a limited role in transmission, unless other factors are present. Additional factors that can facilitate transmission include chronic sinusitis, upper respiratory infection, and dermatitis."1 In a report published just this year, a neonatal specialist persistently colonized with a MRSA strain that eventually became mupirocin-resistant was implicated as a recurrent source of transmission in a newborn nursery.2

In general, the CDC recommends that hospitals should obtain cultures of health care personnel when there is epidemiologic evidence implicating the worker as a source of ongoing transmission. When decolonization for MRSA is used, perform susceptibility testing for the decolonizing agent, the CDC recommends. Limit decolonization efforts to culture-positive workers who have been epidemiologically linked as a likely source of ongoing transmission to patients. Consider reassignment of workers if decolonization is not successful and transmission to patients persists, the CDC emphasizes. "With MRSA, what we see is that people have skin eruptions, broken skin, eczema, who become colonized on that part of their skin and can be transmittters of infection," Bell says.

References

1. Siegel JD, Rhinehart E, Jackson M, et al. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. On the web at www.cdc.gov.

2. Mean M, Mallaret MR, Andrini P, et al. A neonatal specialist with recurrent methicillin-resistant Staphylococcus aureus (MRSA) carriage implicated in the transmission of MRSA to newborns. Infect Control Hosp Epidemiol 2007; 28:625-628.