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 ~  Abstract
 ~ Introduction
 ~ Rationale
 ~  Settings Outbrea...
 ~  Types of Surveil...
 ~  Targeted Versus ...
 ~  Is Targeted Scre...
 ~  Frequency of Act...
 ~  Methods for Scre...
 ~ Cost
 ~  Ethical Consider...
 ~  Cons of Active S...
 ~ Conclusion
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  Table of Contents  
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 277-283

Role of surveillance cultures in infection control

Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission27-Mar-2020
Date of Decision20-Jun-2020
Date of Acceptance16-Jul-2020
Date of Web Publication4-Nov-2020

Correspondence Address:
Dr. Manisha Biswal
Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmm.IJMM_20_129

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 ~ Abstract 

Hospital-acquired infections are a known menace to the primary disease, for which a patient is admitted. These infections are twenty times more common in developing countries than in the developed ones. Surveillance for colonised patients can be passive or active process. In many hospitals, active surveillance culture for certain sentinel organisms followed by contact precautions for the same is an important part of infection control policy. Specific measures can be taken on early detection of multidrug-resistant organism, allowing prevention of widespread transmission in hospitals. Cultures are the most conventional and economical microbiological method of detection. The cost of active surveillance is a major challenge, especially for developing nations. These nations lack basic infrastructure and have logistic issues. The guidelines regarding this are not very clearly delineated for developing countries. Each hospital has its own challenges and the process is to be tailor-made accordingly. The following review delineates the various aspects of active surveillance for the colonisation of various organisms and the advantages and disadvantages of the same.

Keywords: Active surveillance cultures, hospital-acquired infections, multidrug-resistant organisms

How to cite this article:
Biswal M, Angrup A, Kanaujia R. Role of surveillance cultures in infection control. Indian J Med Microbiol 2020;38:277-83

How to cite this URL:
Biswal M, Angrup A, Kanaujia R. Role of surveillance cultures in infection control. Indian J Med Microbiol [serial online] 2020 [cited 2021 Jan 17];38:277-83. Available from:

 ~ Introduction Top

Hospital-acquired infections (HAIs) are defined as the infections occurring in a patient during the process of care in the hospital and which was not present or incubating at the time of admission to the healthcare facility. These infections are twenty times more common and pose a huge burden, especially in the low- and middle-income countries.[1] The role of active surveillance cultures (ASCs) for certain sentinel organisms followed by contact precautions (CPs) for the same is an important part of infection control policy in many healthcare facilities. Adequate measures can be taken on early detection of multidrug-resistant organism (MDROs), thus preventing their widespread transmission in hospital. There are many studies published on the scope, focus, usefulness and finally, cost-effectiveness of microbiological surveillance cultures.[2] It has been used as the only intervention or in combination with other measures to reduce HAIs.[3]

The guidelines regarding this are not very clearly delineated for developing countries. Each hospital has its own challenges and the process is to be tailor-made accordingly. The following review delineates the various aspects of active surveillance for colonisation of various organisms and the advantages and disadvantages of the same.

 ~ Rationale Top

According to the Centers for Disease Control and Prevention, ASCs are defined as universal or targeted microbiological screening cultures for patients with the purpose to control the infections due to certain bacteria, mostly MDROs.[4],[5] Patients are prospectively identified to be either infected or colonised with MDROs. ASCs have been performed universally on all the patients or individualised by targeting a special group of patients.[6] The premise for ASCs is based on the fact that the colonised patient gets the invasive infection by the colonising strain. This has been seen in both Gram-positive organisms such as methicillin-resistant Staphylococcus aureus (MRSA)[7] and Gram-negative organisms such as Acinetobacter baumannii and carbapenem-resistant Enterobacteriaceae (CRE) in hospitalised patients.[8],[9],[10]

The colonised patients are also more likely to transmit it to other patients in the same unit.[11] The rationale is that establishing infection control measures such as CP and cohorting for a colonised patient will reduce the chances of cross-transmission of strains. ASC has also been used to guide clinicians for appropriate antimicrobial therapy as it provides a preliminary snapshot of the antibiotic susceptibility of colonising strain.[6],[12]

 ~ Settings Outbreak Versus Endemic Top

ASC has often been used in outbreak situations along with other interventions for outbreak control.[13] After a patient is detected to be colonised, CPs such as hand hygiene and other standard precautions, patient-dedicated equipment, utilisation of single-bed rooms, single-use gowns and gloves for healthcare workers during contacts with carriers or contaminated environment of carriage to ensure compliance can be applied.[14] However, there is also evidence that ASC is useful in endemic scenarios.[15],[16] For instance, in Europe, the incidence of MRSA bacteraemia decreased by 40% and 70% in non-intensive care units (ICUs) (P < 0.008) and ICUs, respectively, after performing routine surveillance cultures followed by contact isolation precautions.

 ~ Types of Surveillance Passive, Active and Virtual Top

Surveillance for colonised patients can be passive or active process. In the passive surveillance method, only those patients who are known to be positive for MDROs on the basis of previously obtained clinical cultures are targeted for infection control practices according to individual hospital guidelines.[10],[12] Problems with passive surveillance include underreporting, lack of classification and timeliness of data. A study by Ostrowsky et al. on the detection of vancomycin-resistant Enterococcus (VRE) concluded that passive surveillance if done alone had a low sensitivity for the detection of VRE colonisation at the time of ICU admission.[17] Hence, very few cases of VRE infections could be prevented. Similarly, Heipel et al. observed that passive surveillance had a poor sensitivity for detecting surgical site infections (SSIs).[18] This method of surveillance is detection by fortunate chance observation which offers little benefit and can give a falsely low rate of colonisation. It is the least desirable method for tracking nosocomial infections because it is inherently unreliable. Even after above-mentioned disadvantages, majority of the hospitals still practice passive surveillance to constrain MDRO transmission in high-risk populations.[19]

Active surveillance, on the other hand, requires an active search of patients with risk of colonisation and performing surveillance cultures. It necessitates the involvement of trained infection control and laboratory professionals with information from all sources, including from the wards, ICUs and the microbiology laboratory. Surveillance cultures (usually nasal, pharyngeal, skin or rectal) are taken from patients in this approach. By this approach, silent reservoirs of MDROs can be identified, and thus, patient-to-patient transmission can be curtailed.[17],[20] Perencevich et al. created a mathematical model to estimate the benefits of active surveillance of VRE transmission in the ICU. This model predicted that in comparison to no surveillance, active surveillance reduced the annual incidence of VRE colonisation by 39%.[19] Decolonisation regimen and ASCs can also be effective in decreasing S. aureus infections. Following a similar approach, Popoola et al. noticed more than 60% reduction in the mean quarterly incidence rate of methicillin-sensitive S. aureus cultures in neonatal intensive care unit (NICU).[21] Another study by Li et al. revealed 72.3% of the patients in ICUs to be at high risk of CRE infection after assessing their individual clinical characteristics. Therefore, this approach led to an overall decrease in monthly infection rate.[22]

Guidelines laid down by the Society for Healthcare Epidemiology of America for the control of nosocomial VRE transmission active surveillance is recommended for high-risk patients at the time of admission.[23] In case of multidrug-resistant Gram-negative bacilli (MDR-GNB) also, both American and European guidelines recommend that an ASC program and the implementation of CPs be followed in carriers of MDR-GNB, including extended-spectrum beta-lactamases (ESBLs) producing Enterobacteriaceae, for ICUs with an on-going outbreak or high endemicity.[6] However, only a minority of institutions implement these guidelines. This can be attributed to the substantial cost incurred by ASCs.[24]

Virtual surveillance offers another method of performing surveillance. This type of surveillance involves the application of mathematical models to predict and detect outbreaks of infection. In this method, existing laboratory information system (LIS) is used to keep a track of the healthcare-associated infections.

Hacek et al. were able to identify three nosocomial infection outbreaks using the available data from the LIS as well as from the clinical microbiology laboratory (D. M. Hacek, R. Cordel, G. A. Noskin and L. R. Peterson, Abstr. 4thDecen. Int. Conf. Nosocom. Healthcare-Associated Infect., abstr. P-T1-29, 2000). Surprisingly, these infections were not picked up by the hospital infection control and prevention department. Even though there are few studies showing promising results using these methods, they lack proper standardisation and sensitivity to be considered as a primary surveillance tools.[25] Further, more studies are required in future to validate this method of surveillance and utilise its efficacy in preventing healthcare-associated infections.

 ~ Targeted Versus Universal Screening Top

Critical organism-based target surveillance

There are various organisms targeted for ASC [Table 1]. Conventionally, it was started for MRSA and then VRE. Now, with the increasing menace of MDR Gram-negatives, ASC is also being carried out for carbapenem-resistant A. baumannii, carbapenem-resistant Pseudomonas aeruginosa and ESBL-producing or CRE and colistin-resistant organisms. Recently, the multidrug-resistant (MDR) yeast Candida auris has also been included in this ambit due its peculiar characteristics and transmission dynamics.[21] Mostly, these organisms have a high competence to colonise readily and getting transmitted from one patient to another by health caregivers. They are usually MDR and are often difficult to treat infections.
Table 1: List of organism and site for taking active surveillance cultures

Click here to view

Obtaining ASC from the site possibly colonised by the organism is important since every organism has its own typical niche and colonises a particular site in the body [Table 1]. The sampling of more than one site results in a better yield.[31]

High-risk population-based surveillance

Performing surveillance for all patients in a hospital is a tedious and cost-ineffective procedure. Therefore, targeted surveillance in critical care areas is a valid possibility as the patients admitted here, in particular, often become colonised with MDROs and can serve as the focus for hospital-wide transmission of bacterial resistance.[32] Certain high-risk–category patients (transplant recipients, patients on chemotherapy, ICUs, etc.) can be screened routinely for colonisation.[33] For instance, in Japanese hospitals, active surveillance is routinely implemented in all NICUs.[34] Thus, ASC plays a pivotal role in outbreak setting to understand the origin of infection,[35] helps to trace the colonised patient and gives an early identification of new resistance pattern developing in an area (e.g., vancomycin-resistant S. aureus).[36]

Other high-risk groups are those with a previous history of treatment at some healthcare facility. These transferred patients have a high probability of being colonised with MDROs and should be considered for active surveillance. Recent publications suggest that the risk factors for MRSA colonisation at the time of hospital admission may be identified within a population and may reduce the number of required screening cultures at admission by half.[37],[38] However, whether to perform ASCs for MRSA routinely for all patients at the time of admission to a healthcare facility or to a high-risk–patient care unit remains controversial.

Skin is the most common route for MDRO transmission among patients. Hence, CPs should be followed if patients are suspected to be colonised or infected with MDROs. The culture specimens are obtained from these patients and isolation and CPs are continued until culture results are negative for the target organism.[39]

Tormo et al. gathered information on the current microbiological practices for active surveillance of carriage of MDR bacteria in Spanish hospitals in the form of a questionnaire. The survey included information on various aspects such as targeted population, targeted sites and microbiological methods used for detection. Their study revealed striking differences across centres, likely attributable to the lack of consensus on optimal protocols for sampling, body sites for screening and microbiological testing, thus underscoring the need for consensus guidelines on these issues.[40] A bundle-based approach in Cairo, for reducing SSI caused by MDR A. baumannii using ASC, leads to a significant reduction of colonisation from 24% to 15% (P < 0.001) and a subsequently reduction of SSI from 27% to 15% (P = 0.02).[3]

 ~ Is Targeted Screening Better? Top

Targeted screening of patients with pre-specified risk factors, such as recent antimicrobial exposure and transfer from long-term care facilities, can miss the patients who directly come from home and have predisposing factor for MDR carriage.[41] Thus, there is an increasing need to implement an active surveillance system to detect and monitor the HAI rates which would be vital to implement infection control measures in a proactive manner rather than reactive.[42]

 ~ Frequency of Active Surveillance Culture Top

Different hospital settings follow different protocols. The ASC can be performed only once at admission or transfer to another unit or hospital. The duration of performing ASC in a particular patient is not well defined. Carriage of MDR-GNB can last up to several weeks to months. Serial weekly cultures until patient discharge or death from the healthcare facility have also been taken in some studies. For instance, for early detection and prevention of ventilator-associated pneumonia, serial monitoring and quantitative assessment of endotracheal aspirate (Q-ETA) were performed by Michael et al.[43] This was done to identify MDR pathogens before the development of clinical disease. Depuydt et al. reported that taking weekly Q-ETA specimens led to the appropriate antibiotic therapy in 96% of patients.[44] In an Indian study by Ray et al., daily surveillance cultures were taken for ventilator-associated tracheobronchitis (VAT) till the patient was extubated, discharged or died. They could identify VAT cases earlier and in higher frequency.[45] Different hospitals follow different protocols based on their colonisation and infection rates. Thus, one needs to tailor the frequency of surveillance cultures based on the surveillance data of their hospital and setting.

 ~ Methods for Screening Active Surveillance Culture Top

Cultures are the most conventional and economical microbiological method of detection. Chromogenic assays that rapidly detect 3GC-hydrolysing enzymes (including ESBL) on clinical specimens or early cultures are available. For detection of CRE in the rectal swab, various chromogenic media (ChromID carba, ChromID OXA-48, HardyChrom and SuperCarba) and MacConkey agar with carbapenem disk (meropenem and imipenem) can be used. The turnaround time ranges from 2 to 24 h for various assays. The sensitivity for the detection of MDR organisms is higher (90%–98%) and specificity is variable (45%–100%). An enrichment step is also recommended for CRE.[46] Molecular assays allowing the detection of ESBL-encoding genes on clinical samples provide an edge over the conventional techniques. Real-time polymerase chain reaction has been used to detect A. baumannii within 3 h and demonstrated a high sensitivity (100%) and specificity (91.2%) compared with conventional culture.[47] The concordance rate with culture is generally high (99.5%) with a positive concordance rate of 85.7%.[48] Automated platforms such as Verigene, Unyvero and Accelerate Pheno system are available in the market. Although they offer higher sensitivity and specificity, the cost of these assays is higher.[49] Automated systems such a Biofire offers detection of microorganism and its associated resistant genes simultaneously, thus allowing more targeted treatment.[50]

 ~ Cost Top

The cost of active surveillance is a major challenge, especially for developing nations. These nations lack basic infrastructure and have logistic issues. In a study by Sloma et al., various strategies were compared. Screening of all patients at admissions was done, and cohorts of carriers were identified; then, antibiotic was proposed. This strategy was compared to hand hygiene (HH) improvement to 80%. The former led to better outcomes but at higher expense.[51] In a dynamic model of ESBL-E dissemination in a 10-bed ICU with an assumed baseline 15%-acquisition rate, improving HH compliance before and after each contact with patients from 60% to 80% was more effective and cost-saving than routine carriage screening and CP isolation. In Netherlands the estimated cost of Search and Destroy policy for MRSA was €215,559 a year, which nearly equals to €5.54 per admission. The daily isolation costs for MRSA-suspected and -positive hospitalised patients were €95.59 and €436.62, respectively.[52]

In another cost–benefit analysis study of carbapenemase-producing Enterobacteriaceae (CPE) colonisation, conventional culture-based screening was the cheapest method to screen approximately 7000 rectal samples (total cost approximately $22,000) in comparison to chromogenic agar ($37,000). Molecular testing is very expensive ($224,000 to screen all samples) and cumbersome in comparison to agar-based media.[53] The cost-effectiveness of the surveillance cultures increases if done in the endemic areas where the rates of invasive infection are higher.[54]

Recent publications suggest that the risk factors for MRSA colonisation at the time of hospital admission may be identified within a population and may reduce the number of required screening cultures at admission by 50%.[55] A similar risk factor-based method has been proposed for CRE also.[56] This strategy can reduce the cost of ASC. The reasoning of which patients to screen for any organism should be determined by local epidemiological data.

 ~ Ethical Considerations of Active Surveillance Cultures Top

Consent is required from the patient before performing ASC. It is a right of a rational individual to make an informed, uncoerced decision. Decisions made for the common good. Informed consent can be waived off in conditions where procedures involve no or minimal risk to the patient without violating the rights and welfare of the individual.[57] However, in an outbreak scenario, this consent might not be mandatory in the interest of the greater good.

 ~ Cons of Active Surveillance Culture and Subsequent Ipc Precautions Taken Top

ASC has been debated for performance to positively predict patients at risk of ESBL-E infections. Incorrect method of rectal swabbing procedures leads to high-frequency of false-negative ASC samples – up to 25%.[58] The efficacy of ASC and CP to control the dissemination of ESBL-E in hospitals is still questionable. There is a continuous influx of ESBL-E into the hospital system.[59] Carriage prevalence at ICU admission varies in different countries, which is 10%–15% in Europe and up to 40% in certain Asian countries.

In a non-outbreak setting such as wards, studies conducted revealed that standard precautions can contain the spread of ESBL-producing E. coli better than CPs.[60] Further, the cross-transmission of ESBL-E cross-transmission is low or occurs rarely when standard precautions are followed.[61] In the European multi-ICU MOSAR trial, increased HH compliance and daily chlorhexidine body-washing offer more benefit than universal screening for carriage of MDROs and CP.[62],[63]

Not all studies on ASC demonstrate an efficacy. Certain organism might be more malleable to eradication compared to others. In a quasi-experimental study in a paediatric ICU for 35 months, active surveillance decreased the incidence of CR Klebsiella pneumoniae while it remained unchanged for CR A. baumannii and actually increased for CR P. aeruginosa. In another study in an ICU in Greece, the CR K. pneumoniae and CR P. aeruginosa decreased while CR A. baumannii infections increased.[15]

Even in situ ations where efficacy is previously established like MRSA transmission, there are studies showing no superiority of ASC and CP combined over standard precautions in acquisition rate of MRSA.[64]

ASC screening programs are labour and resource-intensive for microbiology. The Medicare-like incentives/disincentives in the USA does not cover nosocomial infections. Further, the broad institution of ASCs for MRSA could quadruple the number of patients placed under CPs. Consequently, the freedom of a substantial number of patients would be limited by restricting them to the confines of their rooms, to protect other patients from potential exposure to MRSA. Unintended consequences of CP such as social isolation can lead to feelings of depression, less frequent examinations with HCW and an increased number of non-infectious AEs.

 ~ Conclusion Top

There are many unresolved questions such as whom to screen, when to screen and how to screen. The frequency of ASC and when to declare 'colonisation-free' status is still unanswered. Lacunae in knowledge whether administration of empirical antibiotics should be done on the basis of ASC. Regimens for the decolonisation of Gram-negative bacteria and the role of selective oral and/or digestive decontamination are variable. Further, the responsibility of the hospital on the discharge of colonised patients back into the community is unanswered. The specific plan for the performance of ASCs and management of colonisation and/or infection of patients should be stated in an institutional infection control policy. Such a policy would require approval from a group of representative institutional administrative and clinical leaders. Ethical accountability should be ensured. Equally important, fiscal and human resources must be made available for implementation of an effective infection control program.

To conclude, an ASC program for colonised patients may be beneficial depending on the targeted population, level of endemicity, the species of pathogen and the combination of multifaceted strategies. Multimodal infection control and prevention strategies are crucial for implementation in resource-limited settings. After discovering the culprit, it is a challenge to control MDR-GNB by containment or eradication and prevent cross-transmission. An ASC program should consider both the local epidemiology and cost-effectiveness based on the available resources in endemic MDR-GNB areas in the Asia-Pacific region.

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Conflicts of interest

There are no conflicts of interest.

 ~ References Top

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2004 - Indian Journal of Medical Microbiology
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