2 tables omitted
Emerging mechanisms of antimicrobial resistance have clinical, microbiologic, and infection-control implications for health-care providers. Antimicrobial resistant organisms include Staphylococcus aureus with reduced susceptibility to vancomycin (minimum inhibitory concentration [MIC] ≥4 µg/mL), including vancomycin intermediate S. aureus (VISA; vancomycin MIC = 8-16 µg/mL)1- 4 and Enterobacteriaceae that produce extended spectrum β-lactamases (ESBLS), which result in resistance to a broad range of β-lactam antibiotics.5 Detecting VISA and ESBLs-producing gram-negative pathogens can be difficult for clinical microbiology laboratories. Although CDC1- 3,6 and the National Committee for Clinical Laboratory Standards (NCCLS)7- 9 have published screening and confirmatory methods for these pathogens, the extent of use of these methods is unknown. This report summarizes results from a survey of microbiology laboratories that participate in the Active Bacterial Core Surveillance (ABCs)/Emerging Infections Program (EIP) Network to assess the capacity of clinical microbiology laboratories to detect VISA and ESBL-producing pathogens; findings indicate that despite adequate capacity for proper testing, many laboratories do not have appropriate methodology to detect these resistant pathogens.
A survey of laboratory practices was sent to the primary contact for participating ABCs/EIP Network laboratories during August-September 1998. Follow-up was conducted by site coordinators.
As of June 1999, 416 (93%) of 447 ABCs/EIP Network laboratorians from eight states (California, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee) had responded to the survey. Of the 416 respondents, 369 (89%) performed clinical microbiologic services (i.e.,"study laboratorians"). Of the 369 study laboratorians, 44 (12%) were from referral laboratories. The other 325 (88%) served health-care facilities that had a median of 121 (range:5-2506) licensed beds. Seventy-six (36%) of the laboratorians served health-care facilities that were part of a health-maintenance organization.
In reviewing the susceptibility testing methods for S. aureus, 278 (84%) of 329 laboratorians used methods that allowed them to detect an isolate with reduced susceptibility to vancomycin. Fifty-two (16%) laboratorians used methods that would not identify these isolates, such as disk diffusion with no additional method (n = 13), Microscan® Walkaway Rapid* panels (which provides <24 hours incubation) (n = four), and Vitek systems (bioMerieux, Hazelwood, Missouri) with a vancomycin MIC of ≥8 µg/mL as the indicator for additional testing (Vitek software typically did not report isolates of S. aureus with an MIC >4 µg/mL) (n = 25). Of 369 study laboratorians, 216 (59%) reported performing confirmatory testing of suspected isolates that were possibly VISA (candidate strains). Of the 204 study laboratorians who reported criteria for selecting strains of S. aureus as candidates for confirmatory susceptibility testing to vancomycin, 173 (85%) used recommended criteria. Of the 201 study laboratorians who reported methodology for confirming S. aureus with reduced susceptibility to vancomycin, 135 (67%) used an acceptable methodology.
Of the 369 study laboratorians, 117 (32%) reported performing tests to identify ESBL-producing organisms. Of the 112 laboratorians who described their methods, 93 (83%) used adequate methods for ESBL screening, and 19 (17%) reported performing definitive confirmatory tests for ESBL production (i.e., E-Test, MIC susceptibility testing of ceftazidime, alone and in combination with clavulanic acid). One hundred eight laboratorians commented on interpretation and clinical reporting of extended-spectrum cephalosporin and other susceptibility to β-lactam agents: 76 (70%) reported isolates identified as ESBL-producers as resistant to all extended-spectrum cephalosporins; 57 (53%) reported that these isolates also were resistant to aztreonam.
Variability in practices occurred based on demographics and characteristics of laboratories. Within the ABCs/EIP Network, the percentage of study laboratories confirming S. aureus with reduced susceptibility to vancomycin or testing for ESBL-producing organisms varied from 39% to 100% and 18% to 84%, respectively. Laboratories performing services for hospitals with >200 beds were significantly more likely to confirm S. aureus with reduced susceptibility to vancomycin (odds ratio [OR] = 8.2; p = 0.0001) or test for ESBL-producing organisms (OR = 2.1; p = 0.002) than were other laboratories surveyed. Managed-care-based laboratories were significantly less likely to confirm S. aureus with reduced susceptibility to vancomycin than were laboratories that were not part of a managed-care organization (OR = 0.3; 95% confidence interval = 0.2-0.6).
W Baughman, M Farley, K Toomey, P Daily, G Rothrock, L Gelling, N Mokerjee, N Barrett, M Pass, K White, J Rainbow, B Damaske, K Stefonek, B Barnes, S Zansky, C Morin, Q Phan, P Moshar, J Hadler, Active Bacterial Core Surveillance/Emerging Infections Program Network. Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases; Hospital Infections Program, National Center for Infectious Diseases; and an EIS Officer, CDC.
The findings in this report indicate that most ABCs/EIP Network laboratories were using routine methods that would allow detection of VISA or ESBL-producing pathogens; however, approximately 40% of the laboratories were not performing confirmatory testing of S. aureus for reduced susceptibility to vancomycin and even fewer laboratories tested Enterobacteriaceae for ESBL production. Smaller hospital-based laboratories, managed-care-based laboratories, and laboratories from specific ABCs/EIP state locations did not report testing for these resistant pathogens.
Recent reports of S. aureus with reduced susceptibility to vancomycin underscore the importance of increasing awareness of clinical microbiology laboratory personnel on proper testing methods.1- 4 The testing of isolates of S. aureus for reduced susceptibility to vancomycin requires that laboratorians know the appropriate susceptibility testing methods and strategies for selecting candidate strains. Despite the national recommendations for testing, many laboratorians may not be aware of the need to perform confirmatory testing on candidate VISA strains. Manufacturers should be aware of the difficulties in resistance identification. For example, Vitek systems software typically did not report MICs >4 µg/mL for S. aureus isolates. Therefore, a laboratory that used this system and the criteria for additional testing of 8 µg/mL may not have reliably detected isolates. In November 1999, Vitek upgraded its software to improve detection and reporting of S. aureus isolates with reduced susceptibility to vancomycin.
The recommendations and guidelines for testing for ESBL-producers have evolved over several years, and this may explain the variations in practices among ABCs/EIP laboratories. In January 1999, NCCLS attempted to clarify this topic by publishing new recommendations,10 including methods to confirm ESBL production.
The findings in this report are subject to at least two limitations. First, the data were self reported. The degree of correlation between actual practice and such reports is unknown. Second, the sample was not random and results may not be representative of other facilities. Despite these limitations, the survey indicates a need to increase awareness among clinical microbiology laboratory and related personnel about evolving practices of susceptibility testing for antimicrobial resistant bacteria.
Additional information about survey results or resistance testing is available from CDC's Hospital Infections Program, telephone (404) 639-6413. In addition, information about testing for these resistant organisms is available on CDC's National Center for Infectious Diseases, Hospital Infections Program World-Wide Web site, http://www.cdc.gov/ncidod/hip.htm, click on "Laboratory."
Laboratory Capacity to Detect Antimicrobial Resistance, 1998. JAMA. 2000;283(5):599-600. doi:10.1001/jama.283.5.599-JWR0202-4-1