What is your opinion of active surveillance as an infection control strategy?

Issue: June 2009

Screening alone does not work.

This program is the first nationwide program in the United States to undertake a single screening methodology, which is exciting to see.

There are two major things about this program that are remarkable, given the current state of affairs: One is that MRSA is an extremely important, popular issue in the news. The other is that rapid, easy-to-use technology is now allowing for more effective use of active surveillance.

People tend to feel quite strongly one way or the other about active surveillance. The current VA program casts a huge net, utilizes lots of resources and efforts are required to accomplish the goals of the initiative. Some of the criticisms of active surveillance are being addressed by the VA study, but some still question the effectiveness of the strategy.

There will be skepticism until peer-reviewed data are published. But even then people will wonder if the decrease in MRSA can be directly attributed to the screening initiative or whether it is simply a natural reduction in infection rates unrelated to screening.

Another problem is that resources are limited, and this may have prevented some VA sites from fully implementing surveillance programs and isolation processes that are the critical component of reducing MRSA results. As a result, the numbers we see may not even be a true reflection of the intended “by the book” active surveillance initiative and associated processes. There is a lot of disparity among hospitals across the healthcare system and how processes and programs are implemented, and this program is subject to that disparity as well.

The impact of active surveillance depends on what you do with the surveillance results. Screening alone will have no impact on MRSA rates; hand hygiene, contact precautions and dedicated equipment are key components of control. I am not sold on the cost-effectiveness of broadly screening everyone who walks through the hospital doors for MRSA. There is a role for targeted active surveillance, but I am not yet a believer in universal screening.

Keith Kaye, MD, MPH, is an Infectious Disease News Editorial Board member

Infection control requires many approaches.

The VA has adopted a program designed to address arguably one of the most important antimicrobial resistance problems we have in hospitals in this country: MRSA. The VA has included, as part of its multifaceted strategy, the controversial practice of screening all admitted patients for MRSA carriage.

Although this approach has drawn criticism, preliminary reports suggest that it may be having favorable effect . The flagship hospital for the program, the Pittsburgh VA, has reported significant reduction not only in the incidence of MRSA, but also significant improvement in the susceptibility of S. aureus to beta-lactam antibiotics since introducing the program. We would all agree that these are desirable public health outcomes that give us hope that even in the absence of near term help from the antibiotic development pipeline, something can be done now to address even the very toughest antimicrobial resistance problems.

It remains to be seen whether these same results can be achieved across the entire VA system, or whether similar results can be achieved by taking a different approach to the problem. I agree with those who argue we must emphasize the importance of a broad-based infection control program that is built on a foundation of standard precautions and practices designed to prevent as many device and procedure related infections as possible. But it seems to me a false choice to suggest that healthcare facilities must choose between a broad-based infection control approach and special infection control strategies tailored for key pathogens of epidemiologic importance. I believe the two approaches are not mutually exclusive, but rather complementary.

John A. Jernigan, MD, MS, is employed with the Division of Healthcare Quality Promotion, CDC.