Active Surveillance Cultures: Friend or Foe?

Part one of a two-part series.

Whether or not it is mandated by state law, some healthcare institutions are turning to active surveillance cultures (ASC) of all or certain high-risk patients, as well as placing them under contact precautions – all in an effort to curb or eliminate the multidrug-resistant organisms (MDROs) that can trigger healthcare-acquired infections (HAIs). The issue is fraught with emotion, however, as proponents and detractors of ASC each assert what they believe to be strong arguments.

It is also a complex issue. Edmond, et al. (2008a) enumerate the challenges associated with ASC: “Ethical challenges involve a conflict between the interests of the individual patient and the patient population not already colonized with the organism. For healthcare systems, active surveillance increases the complexity of bed management, exacerbating problems with patient placement, patient throughput, emergency department overcrowding and ambulance diversion for some hospitals. It also poses ethical dilemmas regarding societal resource allocation. Investing in an unproven or marginally beneficial quality improvement activity such as this must be balanced against other public health priorities competing for scarce resources.”

The impetus for the debate is methicillin-resistant Staphylococcus aureus (MRSA) and the misery it causes in terms of human life lost and costs associated with the treatment of complications and additional bed days. Calfee and Salgado, et al. (2008) describe the burden of HAIs caused by MRSA in acute-care facilities: “In the United States, the proportion of hospital associated S. aureus infections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63 percent of S. aureus infections in hospitals.” They also describe the risk of a substantial proportion of MRSA colonized patients subsequently developing a MRSA infection: “One study of persons in whom MRSA colonization had been identified during a previous hospital stay reported that the risk of developing an MRSA infection, such as bacteremia, pneumonia or soft tissue infection, within 18 months after detection of MRSA colonization was 29 percent.”

Calfee and Salgado, et al. (2008) also describe the reservoir for MRSA transmission: “In healthcare facilities, antimicrobial use provides a selective advantage for MRSA to survive, and transmission occurs largely through patient to patient spread. MRSA colonized and infected patients readily contaminate their environment, and healthcare personnel coming into contact with patients or their environment readily contaminate their hands, clothing and equipment.” Calfee and Salgado, et al. (2008) further explain that, “The reservoir for transmission of MRSA is largely composed of two groups of patients—those with clinical MRSA infection and a much larger group of patients who are merely colonized. Various detection methods can be used to identify one or both of these groups: Routine review of data from clinical specimens: Clinically infected patients and some asymptomatically colonized patients can be detected when MRSA is isolated from a clinical specimen sent to the microbiology laboratory; and review of active surveillance testing data; active surveillance testing for MRSA is defined as performing diagnostic testing for the purpose of detecting asymptomatic MRSA colonization.”

The easy case for or against ASC can be made from perusing the medical literature, depending on what one wishes to find and how to interpret it. One individual advocating for ASC is Lance Peterson, MD, at NorthShore University Health System in Chicago; he presented research at last fall’s annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) showing that hospital-acquired MRSA can be largely prevented by identifying carriers of the organism when patients are admitted to the hospital and then initiating aggressive isolation procedures, even if patients are not experiencing disease symptoms but are colonized by the bacteria. Peterson says if hospitals are not aggressive in conducting isolation programs with patients carrying MRSA, the facility’s infection control program is doomed to fail. Peterson reports that the ambitious program initiated at his hospitals in 2005 resulted in a 70 percent reduction in MRSA infections rates, and even though the costs associated with the program added to the hospital budget, the resulting savings in preventing infections was triple the cost. (Peterson, 2009)

The study at the three NorthShore system hospitals in Evanston, Ill., revealed that about 7 of every 100 individuals who had MRSA colonization developed a symptomatic infection. “The biggest risk factor for MRSA infection is to be colonized,” Peterson says. The three hospitals used real-time polymerase chain reaction (PCR) testing to screen incoming patients for colonization with MRSA. Upon presentation at the hospital, patients had their nostrils swabbed for pathogens. If MRSA was detected the patients were isolated and treated with mupirocin for five days. Staff treating these patients wore gowns and gloves for contact precautions, and patients were also given two antiseptic baths.

Peterson acknowledges the additional costs related to the program, explaining that the PCR test is more expensive than traditional tests, and additional nursing care precautions also added costs to the program. “The bottom line for us is that if you want to have a successful MRSA reduction program, you have to have a very aggressive, very rapid, and broad MRSA screening program.”

Peterson and colleagues studied 37,179 consecutive patients who underwent MRSA-testing at admission. The prevalence of MRSA was 8.5 percent, but two-thirds of the individuals were not aware they were carriers of MRSA. “Successful control of any epidemic relies on detection of those harboring the pathogen and limiting further spread,” Peterson says. “The approach to control of the MRSA pandemic is no different. Most persons harboring MRSA do not exhibit signs of infection and thus to detect all spreaders some surveillance must be done.”

Sometimes, what ASC can do is remind clinicians of the potential for colonized patients to become infected, and the need for continued vigilance in evidence-based practices to control transmission. Harbarth et al. (2008) sought to determine the effect of an early MRSA detection strategy on hospital-acquired MRSA infection rates in surgical patients. In a prospective, interventional cohort study conducted between July 2004 and May 2006 among 21,754 surgical patients at a Swiss teaching hospital, the researchers compared two MRSA control strategies (rapid screening on admission plus standard infection control measures versus standard infection control alone). Twelve surgical wards including different surgical specialties were enrolled according to a pre-specified agenda, assigned to either the control or intervention group for a nine-month period, then switched over to the other group for an additional nine months.

During the rapid screening intervention periods, patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid, multiplex polymerase chain reaction. For both intervention and control periods, standard infection control measures were used for patients with MRSA in all wards and consisted of contact isolation of MRSA carriers, use of dedicated material (such as gown, gloves, mask if indicated), adjustment of perioperative antibiotic prophylaxis of MRSA carriers, computerized MRSA alert system, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing) for five days.

Harbarth et al. (2008) report that 10,193 of 10,844 patients (94 percent) were screened during the intervention periods. Screening identified 515 MRSA-positive patients (5.1 percent), including 337 previously unknown MRSA carriers. Median time from screening to notification of test results was 22.5 hours. In the intervention periods, 93 patients developed hospital-acquired MRSA infection compared with 76 in the control periods. The rate of MRSA surgical site infection and hospital-acquired MRSA acquisition did not change significantly. Fifty-three of 93 infected patients (57 percent) in the intervention wards were MRSA-free on admission and developed MRSA infection during hospitalization. The researchers conclude that a universal, rapid MRSA admission screening strategy did not reduce hospital-acquired MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection.

Peterson, et al. (2008) observe, ”We do believe, as our data suggest, that preventing transmission of MRSA infection so that fewer patients become colonized with this pathogen is a worthwhile goal for infection control programs. Another example of this is the recent publication by Harbarth and colleagues. This group demonstrated that targeted surveillance for MRSA infection in their surgical patients showed no benefit in lowering overall surgical site infections. However, they documented the important risk associated with MRSA colonization by showing that 5 percent to 13 percent of MRSA-colonized patients developed infection compared with 0 percent to 0.5 percent of noncarriers.”

And then there are those who believe that ASC is not warranted – especially if healthcare professionals observe the tenets of good infection prevention and control practices in the first place.

Edmond et al. (2008b) analyzed data on device-associated MRSA infections in the intensive care unit setting over a four-year period during which multiple evidence-based interventions to reduce hospital-acquired infections were introduced without performing active surveillance cultures for MRSA. The researchers observed reductions in all infections, including those caused by MRSA, and assert that control of MRSA in the critical care setting does not require active surveillance cultures.

Those researchers, three Virginia Commonwealth University epidemiologists, downplay the value of mandatory universal nasal screening of patients for MRSA, arguing that evidence-based, hospital-wide infection prevention and control practices can prevent more infections. In their study published in Infection Control and Hospital Epidemiology, the team, composed of Richard Wenzel, MD, Gonzalo Bearman, MD, and Michael Edmond, MD, of the VCU School of Medicine, say “hospitals get more bang for their buck with evidence-based infection control prevention.”

“The key safety question today, since it is possible to reduce the total risk of hospital infections by half with a broad-based infection control program, is what is the incremental benefit of a component focusing on a single antibiotic-resistant pathogen?” Wenzel says.

Using epidemiological principles and focusing on deadly bloodstream infections, the team modeled a focused-screening program that was assumed to be effective in reducing MRSA rates by 50 percent and compared it to a hospital-wide program designed to reduce the rates of all infections by half. According to Wenzel, chair of internal medicine at the VCU School of Medicine and a past president of the International Society for Infectious Diseases, MRSA infections cause only 14 percent of hospital infections, and investing huge resources into their control would be less effective than implementing programs that would reduce the burden of all infections by 50 percent. Also in the model, the MRSA screening was inferior to the general infection control programs, preventing fewer infections, fewer deaths and was also less effective in reducing years of life lost from infections. The MRSA screening tests have false positives – leading to the isolation of patients who are non-MRSA carriers – as well as false negatives – missing some true carriers. Further, the cost of nasal swabbing tests for all patients in a screening program was estimated to be two to three times that of adding additional infection control nurses for a broad infection control program. The VCU epidemiologists acknowledge that there are some instances in which MRSA screening and topical antibiotic treatment of nares of carriers may add incremental benefit to a hospital wide, evidence-based program. For example, in a patient going for open heart surgery who is a MRSA carrier, a post-operative infection would be devastating.

Wenzel and his colleagues’ broad perspective is that a focused screening program would have made more sense in the late 1980s and early 1990s since MRSA was the key in antibiotic-resistant pathogen. However, in the last 15 years hospitals are facing multiple bacteria with broad resistance (Vancomycin-resistant enterococci, imipenem-resistant pseudomonas, totally drug-resistant Acinetobacter and others), and efforts need to be broad-based with a goal of reducing the overall burden of infections.

It has been two years since Michael Edmond, with his colleagues, published his aforementioned paper and says that he still has not changed his mind about hospitals not needing to conduct ASC in the face of other, more proven interventions. “This is partly because when I look at our own internal data, we are continuing to see further reductions of MRSA and we don’t do active surveillance,” Edmond says. “In fact, we have seen about a 90 percent reduction in our rates, and I think we are the exemplar of how to reduce MRSA without active surveillance. There are ways to control MRSA other than doing all of these cultures. We continue to argue that if you just focus on basic infection control, if you drive your hand hygiene compliance rates to very high levels – and ours are above 90 percent –and bathe patients with chlorhexidine gluconate, you probably can reduce your MRSA rates without resorting to active surveillance.”

“I think it is still an unanswered question,” Edmond continues. “In some people’s minds it’s settled but most people are still not sure what the best way to control MRSA is. It might be that there are multiple ways that it could be accomplished. Much of what is in the literature is the experience of the investigator who is reporting on what they have done and the impact they had with their intervention. A lot of facilities have tried active surveillance and they see some results and they decide to publish them.”

But these studies are controversial. Edmond dismisses many of them as lacking scholarly conclusions and robust evidence. “It’s a difficult issue to resolve because there aren’t a lot of good studies to give us a definitive answer and that’s part of the problem,” Edmond says. “You don’t see anyone arguing about preoperative antibiotics or using CHG instead of betadine because the data really are pretty good and there’s not a lot of room for argument. Here, because we have very little experimental data – most of the data we do have is from observational studies and so nobody has really been able to answer the question. Barry Farr will say there are more than 100 studies that say it’s working, and Dick Wenzel said 100 uncontrolled studies isn’t science. So we’re back to the same point where we don’t have the data to answer the question. And Barry tried to circumvent that by saying, ‘Well it doesn’t matter if a randomized controlled trial were to show ASC doesn’t work, we should do it anyway.’”

Barry Farr, MD, has been vocal about pointing to the studies that embrace ASC and demonstrate its merit, and himself has published a number of papers; Farr showed that 85 percent of MRSA patients at his facility have no positive clinical culture during a hospital stay and thus would go un-isolated without active detection and isolation (ADI). Farr, who has been quoted in a 2004 news interview as remarking, “If you’re not taking this approach, there’s a cost to not doing it, which is having high rates of more expensive infections,” believes that the use of standard precautions has failed. Farr (2006) notes, “Infection control professionals in U.S. hospitals tend to follow CDC guidelines, which have never explicitly recommended routine performance of active surveillance culture to identify colonized patients and isolation of all such patients in order to control nosocomial MRSA infection, as has been done in multiple nations that have controlled it to exceedingly low levels for decades. It should have been obvious for many years to infection control professionals and to CDC officials that isolation of only the small fraction of MRSA-colonized patients identified on the basis of clinical cultures (as has been done by most U.S. hospitals since 1983) and use of standard precautions (as has been done by most U.S. hospitals since 1996) have failed miserably to control nosocomial MRSA and VRE infections. How many deaths will it take till they know that too many people have died and that these controllable infections should start being controlled?”

The proof is in a facility’s overall infection rates, Edmond asserts. “Without being pathogen-specific, we are actually lowering all of the infections in our hospital. We’ve had about an 85 percent reduction in all nosocomial infections with our method. Even the people who do active surveillance, one of the arguments they make in favor of it, is that their MSSA rates don’t go down, that’s how they knew the active surveillance for MRSA worked. My argument is that’s exactly why you don’t want to do that -- you ought to be driving all of your infections down.” Edmond continues, “Where we do conduct ASC is preoperatively for CABG patients, for joint replacements, for surgical patients, because you can offer those patients an intervention by trying to decolonize them preoperatively and also by changing their preoperative prophylaxis to vancomycin. For those people, it is a worthwhile thing to do because if they get infected, the results can be quite bad. I think that’s the appropriate place to do ASC, and certainly in an outbreak situation, you may want to do it. But to do it across the board is not a wise use of resources. I can lower my MRSA rates and at the same time lower all of my infections, and do it much more cheaply than I would have had I paid for all the culturing, which for us would be about $1 million a year for MRSA.”

Edmond adds, “Everything we have done to lower our infection rates would be considered an evidence-based practice, including hand hygiene and chlorhexidine bathing. I don’t think we’ve done anything out of the ordinary, I just think that we’ve driven hard on compliance with those practices. We’re also pretty open about sharing our data; for example, for every ICU every quarter we make posters which provide infection rates and their trended data as well. We post them at the employee entrances of the hospital so everyone can see how we’re doing. We also provide weekly feedback on hand hygiene; you have to keep it on people’s radar screens continuously. It’s hard and there’s a lot of input of energy, but it’s less energy than trying to chase a bunch of cultures.”

Some experts are staying on the sidelines of the issue for now, waiting for more evidence. As Dancer (2008) notes, “As with many other interventions imposed in the name of infection control, the evidence for benefit remains controversial.” Dancer says that in addition to resource requirements, there are practical difficulties and consequences associated with active screening that may not have been fully considered, including staff recruitment and working time arrangements in the laboratory; specificity and sensitivity of selected screening sites and laboratory methods; lack of isolation facilities on the wards; timely and continuing management of MRSA-infected and/or -colonized patients; and ethical issues raised by screening patients without considering the role of colonized staff. Dancer (2008) adds, “We should remember that it is the precipitant actions from finding a new MRSA patient that aids control, not the simple act of screening by itself. There is no doubt that universal screening should be explored as a mechanism for controlling MRSA, but more evidence is required before it becomes routine.”

In the meantime, states have seen fit to legislate the control of MRSA even as they continued to require hospitals to collect and report data on HAIs. And last summer, California Congresswoman Jackie Speier introduced HR 2937, the MRSA Infection Prevention and Patient Protection Act, which, in its current configuration, requires hospitals to screen all patients entering high-risk units for MRSA infection; mandates the adoption of best practices including contact precautions among healthcare professionals to prevent MRSA’s spread within hospitals; requires that patients testing positive for MRSA must be informed of the result and given instructions on how to prevent the spread of their infection when discharged; and requires hospitals to report the number of cases of hospital-acquired MRSA that occur within their facilities.

“At a time when we are focused on expanding healthcare coverage to include all Americans and making our overall healthcare system more efficient, it is absolutely necessary that the care provided is safe, smart and cost-effective,” said Speier in a statement. “Screening for and preventing MRSA infections in our hospitals will not only save tens of thousands of lives and billions of dollars each year, but will increase patients’ confidence in the ability of their local hospitals to make them well.”

According to the bill, it directs the secretary of the Health and Human Services (HHS) department to promulgate regulations relating to MRSA, including regulations that provide a list of best practices for preventing MRSA infections and such other antibiotic resistant pathogens as the HHS secretary determines appropriate. Specifically, the bill would require every acute-care hospital to screen each patient entering an intensive care unit or other high-risk hospital department. It also directs the HHS secretary to establish a process and a timetable for extending the screening requirements to patients admitted to all hospitals, and report to Congress on whether payment adjustments should be made under Medicare to assist certain hospitals in defraying the cost of screening for, and the subsequent treatment of, MRSA or other infections. The bill would also require all hospitals to: comply with specified MRSA best practices, including contact precautions and patient notification and report hospital-acquired MRSA and other infections that occur in the facility. The HHS secretary would have to establish systems for identifying infected transferred patients and for promptly informing any facility that has transferred an infected patient, and publish the names of providers who fail to take steps to reduce the incidence of MRSA infections. It would permits a hospital to apply to the HHS secretary for a one-year increase in the amount of the capital-related costs payment made to the hospital under the prospective payment system to provide for the rapid implementation of MRSA screening programs and initiatives. And finally, the bill would requires the director of the CDC to award a grant for a pilot program to develop a rapid, cost-effective method for testing for MRSA using a molecular testing method.

“Certainly the end point for this issue could be that it gets legislated federally, which I believe would be the wrong thing to do,” Edmond says. “Legislation would achieve the goal of getting everyone to do it, as some individuals wish. But I think that’s the wrong approach because it forces hospitals to do this one thing that maybe they don’t even need to do. I would make a strong argument if they tried to do that, I’d say, ‘Look how my MRSA rates are without that investment, and here’s what I can do with that million dollars I’d have to spend on ASC.’ If you are having problems with Acinetobacter, for example, well that’s because all you are doing now is looking for MRSA. I am hoping that some of that will come to light in not focusing too much on MRSA. There was a report coming out of the UK last year that basically said ‘We took our eye off the ball because we were so focused on MRSA and Clostridium difficile that all the other infections have gone up.’ When you legislate something, you get tunnel vision on that problem and you’re not giving enough energy to anything else.”

In 2007, when Illinois and New Jersey passed legislation requiring all patients to be tested for MRSA when they are admitted to the hospital, but the Society for Healthcare Epidemiology of America (SHEA) and the Association of Professionals in Infection Control and Epidemiology (APIC) opposed legislative mandates for universal surveillance. In a joint statement they asserted that an intervention that is appropriate in one healthcare institution may not be right in another and that how to assess risk and use limited resources to maximize infection control should be left to the institutions to decide. In the paper by Weber and Huang, et al. (2007), the SHEA/APIC task force reviewed the rationale for use of ASC, examined the scientific evidence supporting the use of this strategy and discussed a number of unresolved issues surrounding legislation mandating use of ASC. The paper offered five consensus points:

1. Although reducing the burden of antimicrobial-resistant pathogens, including 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 the 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 HAIs.

4. APIC and SHEA support ongoing additional research to determine and optimize the appropriateness, utility, feasibility and cost-effectiveness of using ASC 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.

Weber and Huang, et al. (2007), emphasize, “Even if the available evidence supporting the use of active surveillance cultures for lower-risk populations was already as strong as that for high-risk patients, a number of unresolved issues and potential unintended consequences would still argue against legislation mandating the implementation of this strategy.”

ASC is an issue lacking definitive guidance currently. Calfee and Salgado, et al. (2008) state, “The effectiveness of active surveillance testing in the prevention of MRSA transmission is currently an area of controversy, and optimal implementation strategies (including timing and target populations) are unresolved ... Because of conflicting results from studies and the differences among acute-care hospitals and their associated patient populations, a specific recommendation regarding universal screening for MRSA cannot be made. However, active surveillance testing as a single intervention in the absence of a multifaceted approach to MRSA transmission prevention is unlikely to be uniformly effective across healthcare institutions. Active surveillance testing may, however, be useful in facilities that have implemented and optimized adherence to basic MRSA transmission prevention practices but continue to experience unacceptably high MRSA rates.”

“I think SHEA is paralyzed and has been for a long time on this issue,” Edmond says. “I am a member of SHEA and I have been critical about the society not having a definitive approach to ASC. It doesn’t help hospitals when the leading professional society doesn’t provide enough guidance.”

In the SHEA/APIC position statement, Weber and Huang, et al. (2007) state, “Active surveillance cultures have been identified as an important tool for the control of MRSA and VRE in many settings. The most recent SHEA guideline on prevention of nosocomial transmission of these organisms advocates the use of active surveillance cultures for controlling their spread. This guideline also emphasizes the importance of integrating use of active surveillance cultures with other basic infection control practices, including hand hygiene, compliance with the use of gown and gloves when needed, healthcare worker education, antimicrobial stewardship, environmental cleaning, and appropriate tracking and monitoring of infection control and prevention initiatives. Similarly, the Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline for the control of multidrug-resistant bacteria also promote the use of active surveillance cultures for high-risk patients when other measures have failed to control the spread of antimicrobial-resistant bacteria.”

Some practitioners are worried that legislating ASC results in a bug-of-the-month mentality. As Weber and Huang, et al. (2007) explain, “Legislation mandating use of active surveillance cultures or any other infection control strategy neither recognizes the need for flexible allocation of resources to the most critical hospital-specific challenges nor allows for a timely response when significant new information becomes available. In addition, legislation mandating any single infection control and prevention strategy that exclusively targets specific antimicrobial-resistant pathogens may be counterproductive, compared with integrated infection prevention and control strategies that result in a greater overall reduction in the number of HAIs caused not only by MRSA and VRE but by all antimicrobial-resistant and antimicrobial-susceptible pathogens.”

What may make the most sense of all is an evidence-based practice approach to MRSA infection prevention and control. Calfee and Salgado, et al. (2008) reference the infrastructure requirements of a MRSA transmission prevention program, which include the following:

An active infection prevention and control program staffed by a sufficient number of trained personnel to allow implementation and continuation of MRSA surveillance and infection prevention efforts without compromising other infection prevention and control activities.

Information technology systems to allow rapid notification of clinical personnel and infection prevention and control personnel of new MRSA isolates, collection of data needed for MRSA surveillance and rate calculations, and identification of MRSA colonized patients on readmission.

Sufficient supplies for hand hygiene and contact precautions (gowns and gloves)

Resources to provide appropriate education and training to healthcare personnel, patients and visitors

Calfee and Salgado, et al. (2008) also outline the basic practices for prevention of MRSA transmission:

Conduct an MRSA risk assessment to provide a baseline for subsequent assessments and other data comparisons and use the findings to develop the hospital’s surveillance, prevention and control plan and to develop goals to reduce MRSA acquisition and transmission.

Implement a MRSA monitoring program to identify and track patients from whom MRSA has been isolated from any clinical or active surveillance testing specimen.

Promote compliance with CDC and/or World Health Organization (WHO) hand hygiene recommendations.

Use contact precautions for MRSA colonized or infected patients to help reduce patient to patient spread of the organism within the hospital.

Ensure cleaning and disinfection of equipment and the environment.

Educate healthcare personnel about MRSA, including risk factors, routes of transmission, outcomes associated with infection, prevention measures, and local epidemiology.

Implement a laboratory-based alert system that immediately notifies infection prevention and control personnel and clinical personnel of new MRSA-colonized or -infected patients

Implement an alert system that identifies readmitted or transferred MRSA colonized or infected patients.

Provide MRSA data and outcome measures to key stakeholders, including senior leadership, physicians, and nursing staff.

Educate patients and their families about MRSA, as appropriate.

If your facility must engage in ASC, it should heed what Calfee and Salgado, et al. (2008) suggest:

Implement an MRSA active surveillance testing program as part of a multifaceted strategy to control and prevent MRSA transmission when evidence suggests that there is ongoing transmission of MRSA despite effective implementation of basic practices.

Select and identify the patient population(s) to be screened.

Develop and implement a system to identify and screen patients who meet the screening program criteria.

Determine when to perform screening tests.

Determine the anatomic sites to include in screening program.

Identify the anatomic site(s) to be tested (nares, wounds, etc.).

Determine laboratory methods and assess resource requirements.

Clarify how to manage patients while awaiting the results of screening tests.

Implement co-horting and contact precautions at the time of receipt of a positive screening test result and assess the availability of personal protective equipment and other supplies.

Assess compliance with the screening protocol.

References:

Calfee DP and Salgado CD, et al. SHEA/IDSA practice recommendation: Strategies to prevent transmission of methicillin resistant Staphylococcus aureus in acute care hospitals. Infect Control Hosp Epidemiol. 29:S62-S80. 2008.

Dancer SJ. Considering the introduction of universal MRSA screening. J Hosp Infect. Aug;69(4):315-20. 2008.

Edmond M, Lyckholm L and Diekema D. Ethical implications of active surveillance cultures and contact precautions for controlling multidrug resistant organisms in the hospital setting. Pub Health Ethics. 1(3): 235-245. 2008a.

Edmond MB, Ober JF, Bearman G. Active surveillance cultures are not required to control MRSA infections in the critical care setting. Am J Infect Control. Aug;36(6):461-3.2008.

Farr BM. Doing The right thing (and figuring out what that is). Coalition for Patients Rights. Sept. 21, 2006. Accessed at: http://www.coalitionforpatientsrights.org/editorial.shtml

Farr BM. Unnecessary Illness: Four Steps to Save patients’ Lives. Ivanhoe Broadcast News Inc. interview. 2004.

Harbarth S, Fankhauser C, Schrenzel J, Christenson J, MD; Gervaz P, Bandiera-Clerc C, Renzi G, Vernaz N, Sax H and Pittet D. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299(10):1149-1157.

Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR, Boyce JM, Farr BM. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol. May;24(5):362-86. 2003.

Peterson L. Debate: Is Molecular Screening for MRSA Colonization Worth the Cost? Case in Favor. Abstract 408, 49th annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). Sept. 12, 2009.

Peterson LR,et al.. Letter: Benefits and drawbacks of universal surveillance of methicillin-resistant staphylococcus aureus. Ann Intern Med. vol. 149 no. 1 68-69. July 1, 2008.

Weber S, Huang 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. Am J Infect Control. 35(2):73-85. 2007.