Blog | Friday, April 19, 2013

How strong is our first line of CRE detection?

I feel like I should expand on this recent post about why relying upon prompt laboratory detection of Carbapenem-resistant Enterobacteriaceae (CRE) carriers is unlikely to help contain spread (aside from during local outbreak responses). Why shouldn't screening be a pillar of our prevention efforts, particularly given the inspiring stories of local and regional CRE control that utilized screening to detect carriers? Leaving aside the question of how important screening was among multiple simultaneous interventions, these two reports are from academic tertiary care centers with robust on-site laboratory support and external funding to provide financial support for state-of-the-art screening approaches (such as rapid PCR detection of KPC producers).

The sad fact is that this level of clinical microbiology laboratory support is far from the norm. The trend over the past two decades has been toward consolidation and outsourcing of laboratory services, and reducing local resources available for diagnostic microbiology labs. I spoke about this trend, and some of the consequences, at the 5th Decennial conference a few years ago (you can view the slide set here). In the decade that has passed since we noted frequent errors in testing and reporting of blood culture results in a sample of 14 hospital laboratories, I doubt that much has improved. Yes, there are CAP proficiency surveys, but for several reasons these are not good indicators of actual laboratory performance. And while outsourcing microbiology to a regional lab may make short-term financial and technical sense for some hospitals, it also removes lab support further from the front line of patient care and infection prevention, prolongs turnaround times, and comes with a host of pre- and post-analytic problems.

If current fiscal and political trends continue, with additional cuts to public health infrastructure and CDC's budget, it is difficult to imagine that we can do much in the short term to shore up our surveillance capabilities to respond to the CRE threat.

Meanwhile, thank goodness we're spending almost $500 million to stockpile a ridiculous amount of a new drug to treat smallpox. I wonder how we might expand our national CRE surveillance and response if each of our state public health departments could focus $10 million on the effort. My head hurts.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.