The MRSA active surveillance debate continues...

A few days ago, I blogged about sources of bias in the MRSA active surveillance debate. Drs. Barry Farr and Bill Jarvis, two supporters of active surveillance for MRSA, responded to my posting. Please click here to see their comments, to which I respond.

First, let me state that I am not an ageist. Epidemiologists of all ages should actively participate in debates on important topics in our field. My point was that academic societies should not develop guidelines, which are increasingly viewed as mandates by regulators and accrediting agencies, with individuals chosen on the basis of a single viewpoint. It is much more likely that former trainees will agree with their mentors on controversial issues, which should not come as a surprise to anyone. While I might prefer the outcome of a guideline written by Dick Wenzel (my mentor and an opponent of active MRSA surveillance) and his former trainees, such a committee composition would be just as inappropriate.

Next, I want to point out an irrefutable fact: not all epidemiologists agree with the viewpoint of Drs. Farr and Jarvis on active surveillance, despite all of us having access to the same literature on the topic. I don’t see the issue as a single, yes or no question of effectiveness, but rather my thinking about active MRSA surveillance can best be encapsulated by a series of questions:

(1) Is active surveillance for MRSA effective in reducing infections due to MRSA in the inpatient setting?
(2) Is MRSA active surveillance associated with adverse unintended consequences?
(3) If implemented, does MRSA active surveillance control other important pathogens in the hospital (e.g., MSSA, multidrug resistant gram-negative rods)?
(4) Even if active surveillance is effective at reducing MRSA infections, are there other interventions that may be equally effective, or more effective, perhaps at a lower cost? Might these other interventions, also reduce infections due to other organisms? Could other interventions reduce MRSA infections with fewer adverse unintended consequences?
(5) Could it be that the effect of active surveillance is modulated by the level of hand hygiene compliance (i.e., what is the incremental effect of active surveillance if hand hygiene compliance is >90%)?
(6) Are contact precautions (with or without active MRSA surveillance) even necessary if hand hygiene compliance is driven to very high levels?

Drs. Farr and Jarvis and I differ on the fundamental issue of certainty: I readily admit that the holy grail for controlling multidrug resistant pathogens in the hospital has not yet been determined, and I remain open to the possibilities. They argue that their way (active surveillance) is the only way—an argument that I reject based on my own experiences. In looking at the data for the first half of 2009, we again demonstrate a progressive decline in MRSA infection rates in my hospital without the use of active surveillance. In a nutshell, I see active surveillance as an intervention that may be sufficient to control MRSA, but clearly not necessary. So at my hospital we continue to pour our time, talent and resources into interventions that have the capacity to reduce all infections, not just those caused by MRSA, namely high rates of hand hygiene compliance, increasing use of chlorhexidine for patient bathing, and removing healthcare worker contaminated clothing (e.g., ties, sleeve cuffs, lab coats) from the inpatient setting. I have always stated that if active surveillance for MRSA works at your hospital and you can demonstrate that there’s no harm, then continue with that intervention. Hospitals are highly complex organizations in which differing effects of interventions can be seen from one institution to another. As such, perhaps there is no holy grail. To those that are implementing active surveillance, I would simply ask that you keep your mind open to the possibility of other effective, cheaper, and/or broader spectrum interventions. Most importantly, mandates ought to be reserved for interventions in which there is no doubt as to safety and effectiveness, and for which equally or more effective and safe alternatives do not exist.

Lastly, the active surveillance debate has become more complicated now that companies that make rapid pathogen detection technologies (e.g., Cepheid, Becton Dickenson) have much to gain when hospitals adopt active surveillance and particularly when it is mandated by states. Some patient advocates, infection control experts, and even professional societies (e.g., APIC) are the recipients of funds from these companies, which raises at least the appearance of conflict of interest.

Thanks again to Drs. Farr and Jarvis for taking the time to post their comments and keeping the theme of this blog true to its title.


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