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J. Clin. Microbiol.-2011-Diekema-S57-60 PDF
J. Clin. Microbiol.-2011-Diekema-S57-60 PDF
0095-1137/11/$12.00 doi:10.1128/JCM.00690-11
Copyright © 2011, American Society for Microbiology. All Rights Reserved.
Health care-associated infections (HAIs) represent one of relatedness, which requires maintenance of an organism bank
the most common complications of care, affecting 5 to 10% of (Table 1). The laboratory should also act in a consultative
patients admitted to acute-care hospitals worldwide. These capacity with the IPP to help determine whether an outbreak
HAIs are associated with enormous morbidity and mortality, is “real” or a potential pseudo-outbreak due to contamination
resulting in more than 90,000 deaths each year in the United of specimens outside or within the laboratory. In addition, the
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S58 CAMP CLIN MICRO J. CLIN. MICROBIOL.
TABLE 1. Steps in nosocomial outbreak investigation and the role of the laboratory at each stepa
Investigative step Role of the clinical microbiology laboratory
Recognize problem.............................................................Surveillance and early warning system, ideally part of the laboratory information system;
notify infection control personnel of infection clusters, unusual resistance patterns,
possible patient-to-patient transmission
Establish case definition ....................................................Assist and advise regarding inclusion of laboratory diagnosis in case definition
Confirm cases......................................................................Perform laboratory confirmation of diagnosis
Complete case finding........................................................Characterize isolates with accuracy, store all sterile-site isolates and epidemiologically
important isolates, search laboratory database for new cases
Establish background rate of
disease and compare to attack rate
during suspected outbreak ............................................Provide data for use in ongoing surveillance, which provide baseline rates for selected
units and infection sites; search laboratory database for all prior cases of the entity if
baseline rate is not prospectively monitored
Characterize outbreak (descriptive
epidemiology)..................................................................Perform typing of involved strains, compare to previously isolated endemic strains to
determine if the outbreak involves a single strain (this can be done only if selected
pathogens are routinely stored 关see above兴)
Infection control committee participation. It is paramount situation of many hospitals. Who pays for the time and effort
that the clinical microbiologist participates on the infection required to deliver this educational content?
prevention/control committee and acts as a consultant to in-
fection preventionists. He or she is the best person to provide DISCUSSION
expertise in the interpretation of culture results, advice about
the utility of microbiological approaches to an infection control As a starting point, the discussants agreed that CMLs should
problem, and input regarding the CML resources needed to no longer be viewed as merely playing supportive roles for
accomplish the goals of the committee. He or she should de- infection prevention but rather should be seen as an essential
scribe how changes in the methods used for detection, identi- element of the IPP at every health care facility. Viewing the
fication, and susceptibility testing of nosocomial pathogens will CML as part and parcel of the IPP may help health care
impact the IPP. administrators understand the importance of adequate funding
The benefits of close collaboration and interaction between for the CML, particularly as CML activities increase to meet
the CML and the IPP are difficult to measure but are real. One infection prevention priorities. Effective prevention saves not
large survey of CML directors found that those hospitals with only lives but money, and these savings are rarely credited to
CML directors on the infection prevention/control committee the CML.
were more likely to have CML involvement in formulary de- Additional discussion focused upon specific aspects of the
cisions, to produce an annual antibiogram, and to provide CML activities outlined above, including (i) increasing calls for
molecular typing support (6). active surveillance cultures (ASCs) to detect multidrug-resis-
Several ongoing trends challenge these valuable personal tant organism (MDRO) carriers, (ii) a more standardized ap-
interactions between CML and IPP personnel. Consolidation proach to immediate or urgent notification of IPP personnel,
of CML services, off-site moves of CML laboratories, and total (iii) a uniform definition for multiply drug-resistant Gram-
reliance on the electronic medical record to the exclusion of negative rods (MDR-GNRs) of infection control significance,
first-hand observation (e.g., review of plates or Gram stains) and (iv) limitations inherent in current approaches to antibi-
too often keep clinicians and infection preventionists out of the ogram generation.
CML and keep CML personnel confined to the laboratory. Active surveillance. The role of broadly applied active sur-
Education. CMLs also play an essential role in the education veillance cultures (ASCs) in detection of MDRO carriers re-
of future hospital epidemiologists and infection preventionists. mains unclear. Nonetheless, many hospitals have adopted this
Most hospital epidemiologists are trained in infectious diseases approach for control of methicillin-resistant Staphylococcus
(though some are also laboratorians and CML directors). The aureus (MRSA), often in response to legislative mandates. The
ACGME requirements for training in infectious diseases re- issue of MRSA active surveillance is addressed in another
quire structured clinical microbiology training, and infection paper in this series. Therefore, our discussion was focused on
preventionists also require microbiology training. The trends surveillance for MDR-GNRs, which continue to emerge as a
referred to above (CML consolidation and off-site moves) major threat in the health care environment (14).
complicate this educational role, as does the difficult financial Can our experience thus far with MRSA inform our future
VOL. 49, NO. 9 SUPPL., 2011 CONVENTIONAL VERSUS MOLECULAR METHODS S59
TABLE 2. Can the MRSA experience inform screening for MDR Bacillus anthracis, Yersinia pestis, and orthopox viruses). How-
Gram-negative rods? ever, the discussants pointed out that the list of organisms for
Parameter MRSA MDR-GNR immediate IP notification differs from one institution to an-
other and that it would be appropriate to establish more uni-
Transmissibility of key resistance Low High
determinant(s)
formity. We recognize that some institutions may wish to in-
Complexity of resistance Low High clude organisms or results that others do not (for example, an
mechanism(s) MDRO may have become endemic in one hospital, to the
Lab methods for detection of Yes In development point that the IP program no longer requires immediate noti-
carrier state fication, while another hospital has not yet had introduction of
Established/effective Yes No
decolonization protocols the MDRO and needs such notification). Nonetheless, com-
Literature base assessing Abundant Scant piling a standard list of “critical” infection prevention results
screening approaches should be a fairly straightforward matter and would start with
a simple survey of laboratories to determine what current prac-
tice is at a wide range of facilities.
Standardizing the MDR-GNR definitions. In addition to
approach to MDR-GNR active surveillance? As outlined in optimizing communication with the IPP, the discussants agreed
or tenth!) may provide a very different susceptibility profile. Healthcare Epidemiol. Am. 2011 Annu. Sci. Meet. 1 to 4 April 2011, Dallas,
TX. http://shea.confex.com/shea/2011/webprogram/Paper4335.html.
Again, a multilaboratory collaborative study to produce anti-
4. Dellit, T. H., et al. 2007. IDSA and SHEA guidelines for developing an
biograms using alternative approaches may help determine institutional program to enhance antimicrobial stewardship. Clin. Infect. Dis.
whether this problem is clinically important. 44:159–177.
5. Diekema, D. J., and M. A. Pfaller. 2007. Infection control epidemiology and
clinical microbiology, p. 118–128. In P. R. Murray, E. J. Baron, J. H. Jor-
SUMMARY gensen, and M. A. Pfaller (ed.), Manual of clinical microbiology, 9th ed.
ASM Press, Washington, DC.
The CML is an essential element of the IPP in every health 6. Diekema, D. J., et al. 2001. Clinical microbiology laboratory support for
infection control and antimicrobial resistance control, abstr. K-1213. Abstr.
care facility, playing critical roles in surveillance, outbreak de- 41st Intersci. Conf. Antimicrob. Agents Chemother., Chicago, IL, 22 to 25
tection and management, antimicrobial stewardship, risk as- September 2001.
sessment and planning (through participation on the infection 7. Harris, D. P., J. C. McGregor, and J. P. Furuno. 2006. What infection
control interventions should be undertaken to control multidrug-resistant
control committee), and education. Close collaboration be- Gram-negative bacteria. Clin. Infect. Dis. 43(Suppl. 2):S57–S61.
tween CML and IPP personnel is required to ensure optimal 8. Klevens, R. M., et al. 2007. Estimating healthcare associated infections and
HAI prevention, which saves money and lives. deaths in U.S. hospitals, 2002. Public Health Rep. 122:160–166.
9. Leverstein-Van Hall, M. A., et al. 2010. Global spread of New Delhi metallo-
Session discussants: Eileen Burd, David W. Craft, Gary V. Doern, beta-lactamase 1. Lancet Infect. Dis. 10:830–831.
W. Michael Dunne, Jr., Gina L. Ewald, Betty Forbes, George Goede- 10. Maragakis, L. L., and T. M. Perl. 2010. How can we stem the rising tide of