CDC breaks with SHEA on active surveillance issue

ICPs have until Aug. 13th to comment

Despite calls for aggressive action by some epidemiologists, new draft federal guidelines on multidrug-resistant organisms (MDROs) "argue against adoption of the most comprehensive methods as the sole approach to this problem."1

In taking that position, the Centers for Disease Control and Prevention (CDC) officially breaks from the policy of active surveillance cultures and contact isolation for MDROs that is strongly recommended by the nation’s leading group of hospital epidemiologists.

The Society for Healthcare Epidemiology of America (SHEA) has urged the CDC to take a more aggressive approach to MDROs. Study after study presented at the SHEA 2004 meeting recently in Philadelphia showed that active surveillance cultures are effective for rapidly identifying and isolating patients with MDROs.

Infection control professionals have until Aug. 13, 2004, to weigh in on the controversy or otherwise comment on the new draft patient isolation guidelines by the CDC’s Healthcare Infection Control Advisory Committee (HICPAC).

HICPAC acknowledged the controversy and the merits of the SHEA approach, but ultimately said it could not give it a blanket endorsement.

"[SHEA] advocates an aggressive approach, especially in acute care facilities, with an emphasis on routine use of active surveillance cultures and contact precautions," the CDC guidelines state.

"The magnitude of the MDRO problem, especially the emergence of vancomycin-resistant S. aureus (VRSA) that resulted from the transfer of the van A resistance gene from a VRE strain to an MRSA strain, understandably motivates those advocating the most aggressive approach, and in many situations, this approach is needed and appropriate. Notwithstanding, the many factors that influence strategies to control MDROs, discussed below, argue against adoption of the most comprehensive methods as the sole approach to this problem. In addition, data are lacking to validate the necessity for an aggressive approach in long-term care facilities and outpatient healthcare settings. Therefore, individualized decisions to implement control programs that rely heavily on active surveillance cultures to define the MDRO reservoir must be made based on validated principles of MDRO epidemiology and control," the guidelines add.

The CDC guidelines establish a two-tiered approach to the problem, calling for more aggressive measures in the face of ongoing transmission or if prevalence exceeds institutional goals.

According to the HICPAC guidelines, factors that influence selection of MDRO control measures include:

  • Differences in the specific MDRO prevalent within the institution.

Some facilities have an MRSA problem, while others have ESBL-producing Klebsiella pneumoniae. Some facilities have no VRE colonization or disease; others have high rates of VRE colonization without disease; and still others have ongoing VRE outbreaks.

  • Variability in colonization and infection rates.

The experiences of health care facilities with any given MDRO ranges from no prior identification of MDROs to prolonged, extensive outbreaks. Between these extremes, facilities may have low or high levels of endemic colonization and variable levels of infection.

  • Differences in risk factors based on type of facility and/or the patient population served.

Larger, tertiary care hospitals have more patients at high risk for VRE and/or MRSA infection and the associated complications than do smaller, rural hospitals. Similarly, nursing home residents appear less likely to develop MDRO infections, despite high colonization rates, than do patients in acute care facilities. . . . [However], emergence of VRSA within the ambulatory setting demonstrates an important role for this setting in detection and prevention of transmission.

  • Levels of available infection control personnel (e.g., full time or part time) and microbiology laboratory resources (e.g., on-site or off-site) and competing priorities for those resources.

An administrative decision to allocate necessary resources for control often requires demonstration of the potential or actual negative impact of MDROs within the institution.

[Editor’s note: The Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004 is available on the web at www.cdc.gov/ncidod/hip/isoguide.htm. Comments on the document should be submitted by Aug. 13, 2004 to the ResourceCenter, Attention: ISO Guide, Division of Healthcare Quality Promotion, CDC, Mailstop E–68, 1600 Clifton Road, N.E., Atlanta, GA 30333. Fax: (404) 498–1244. E-mail: isocomments@cdc.gov. Web: www.cdc.gov/ncidod/hip/isoguide.htm.]

Reference

 1. Centers for Disease Control and Prevention. Healthcare Practices Infection Control Advisory Committee (HICPAC). Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004. Atlanta: 2004. Web: www.cdc.gov/ncidod/hip/isoguide.htm.