Division of Healthcare Quality Promotion (DHQP)

External Peer Review Clinical and Environmental Microbiology Branch

The proceedings were held on March 31 – April 1, 2009
Atlanta, Georgia
Executive Summary

PDF icon External Peer Review CEMB PDF (74 KB / 6 pages)
PDF icon Appendix A. CEMB Peer Review Panel Members PDF (15 KB /1 page)

Released:Oct. 19, 2009

Background & Purpose

The Centers for Disease Control and Prevention (CDC) National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID) convened an External Peer Review of the Division of Healthcare Quality Promotion (DHQP) Clinical and Environmental Microbiology Branch (CEMB). The proceedings were held on March 31 – April 1, 2009 in Building 19, Room 245/246 at the CDC Roybal Campus in Atlanta, Georgia. The list of peer review panel members is appended to the report as Appendix A.

In selecting panel members, representation was sought from various areas: the CCID Board of Scientific Counselors (BSC), the Healthcare Infection Control Practices Advisory Committee (HICPAC), clinical microbiology, environmental microbiology, infection control, those with links to the Clinical and Laboratory Standards Institute (CLSI), public health reference laboratories, and professional organizations such as the Society for Healthcare Epidemiology of America (SHEA).

Overview: Clinical and Environmental Microbiology Branch

Matt Arduino, MS, DrPH
Acting Branch Chief
Clinical and Environmental Microbiology Branch

The Clinical and Environmental Microbiology Branch is one of four branches within DHQP, which also includes the Prevention and Response Branch (PRB), the Surveillance Branch (SB), and the Immunization Safety Office (ISO; which was acquired in October 2008). DHQP is a division within the National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID).

The mission of DHQP is to protect patients; protect healthcare personnel; and promote safety, quality, and value in the healthcare delivery system by providing national leadership for key areas, including: healthcare outcomes, outbreaks in healthcare settings, emerging antimicrobial-resistant infections, efficacy of new interventions for patient safety, clinical microbiology laboratory quality, water quality in healthcare settings, cost-effectiveness of prevention interventions, promotion of implementation and evaluation of prevention interventions, and development of infection control guidelines and policies.

CEMB has three teams: the Bacterial Characterization Team (BacTI), led by Dr. Brandi Limbago; the Environmental and Applied Microbiology Team (EAMT), led by Dr. Judith Noble-Wang; and the Antimicrobial Resistance Team (ART), led by Dr. Jean Patel. CEMB provides support for outbreak investigations and surveillance activities; provides reference services (e.g., bacterial identification, typing, and antimicrobial susceptibility testing); develops and evaluates new laboratory methods; investigates novel resistance mechanisms; studies the role of biofilms on surfaces of medical devices and water distribution systems (including dialysis machines and systems); and conducts healthcare and bioterrorism preparedness research.

CEMB’s current staffing is 51, including 35 FTEs (with two vacancies), 14 non-FTEs, and 4 students.

Panel Charge and Deliberations

The panelists were asked to consider the following questions:

  • What is the external landscape? How do others outside of CDC see us? What is the most important thing we can do at CDC that others cannot? Where do we add value?
  • What work should we do at CDC? What should we do in collaboration with others and what should we not do?
  • What should be the process to select the priorities for the branch and determine the lifespan of a project?
Peer Group Report to CDC
Overview

The Peer Review Panel was impressed with the overall quality of the work performed by the CEMB, its impact on public health, and the ability of the CEMB to achieve the mission goals of the DHQP. The team leaders are to be commended for their ability to fulfill the core functions of the branch in an environment of uncertain funding.

Recommendations

The following are recommendations of the CEMB Peer Review Panel, with a suggested timeline for actions listed below:

  1. Maintain critical CEMB services not available from any other federal agencies, healthcare organizations or academic centers
  • Investigation of focal, multi-state and national outbreaks of healthcare-associated infections
    • Investigations have led to recall of thousands (or more) units of contaminated products and prevention of many healthcare-associated infections, resulting in significant improvement of patient safety and substantial savings to the healthcare system
      • Examples: outbreaks due to contaminated pre-filled heparin syringes, contaminated mouthwash, nasal spray, ophthalmic irrigation solution, and oxygen delivery systems
  • Surveillance of emerging multidrug-resistant pathogens or organisms with increased virulence such as community- and healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) including vancomycin intermediate, hetero-resistant, and vancomycin resistant Staphylocossus aureus (VISA, hVISA, and VRSA), and Clostridium difficile, plus pathogens with very limited susceptibility to current antimicrobial agents, such as Acinetobacter baumannii, and KPC–producing Gram-negative bacilli. Supporting evidence:
    • Establishing the nationwide spread of USA300 strains of MRSA and NAP-1 strains of C. difficile
    • Spread of KPC-producing Klebsiella, E. coli and other Gram-negative bacilli
    • Characterization of community-acquired and healthcare-associated MRSA strains, vancomycin-resistant S. aureus, C. difficile and KPC-producing Gram-negative bacilli
    • Expanding role of NHSN in national reporting of healthcare-associated infections, including multidrug-resistant organisms
  • National reference laboratory for identification of organisms of public health importance as well as new and unusual pathogens encountered in healthcare facilities. Supporting evidence:
    • Very important function, given the national decline in the level of expertise of clinical microbiology laboratories and the prospect of further declines attributable to the paucity of individuals entering the field
    • Reference laboratory for potential bioterrorism (BT) agents, serving the public health community at large and other federal agencies such as EPA and Department of Homeland Security
    • Special laboratory expertise in cultivating C. difficile, a support service required by hospital laboratories and federal agencies such as EPA
    • Development and/or evaluation of susceptibility testing methods for multidrug-resistant organisms including, but not limited to, VISA and VRSA and KPC-producing Gram-negative bacilli
  • Unique expertise in environmental microbiology. Supporting evidence:
    • Support for investigation of clusters and large outbreaks of infection due to contaminated products or solutions and pathogens with environmental reservoirs
    • Expanding knowledge of the role of the environment in transmission of healthcare-associated pathogens and strategies for improving the cleaning and disinfection of healthcare facilities
    • Development of new environmental culture methods for healthcare-associated pathogens such as C. difficile, and bioterrorism agents
    • Research on pathophysiology and prevention of infections involving biofilm formation on medical devices, in dialysis systems and in water distribution systems
  1. Endeavor to stabilize funding for CEMB activities through line-item budgeting
  • Seek line-item budget appropriation to support IT-based laboratory reporting throughout CDC laboratory system and with outside customers (state health departments and hospitals)
  • Request funding to support continued laboratory support of outbreak investigations
    • Emphasize in budget deliberations the impact of product recalls made as a result of investigation of multi-state and national outbreaks of infections
    • Consider publishing a review of outbreak investigations performed by CEMB during the last five years
  • Seek funding for continued activities designed to understand the evolution and impact of antimicrobial-resistant pathogens, and methods for prevention and treatment
  • Request budget appropriation to support studies of impact of environmental hospital infrastructure, including aspects of environment
  1. Increase the visibility of CEMB activities and achievements
  • Increase liaisons with other professional organizations such as ASM, APHL, SHEA, APIC, CLSI
  • Formalized relationships with federal agencies, such as FDA and EPA
  • Improve access of the infection control, infectious diseases and clinical microbiology communities to CDC experts
    • Currently, some individuals in the community have found it difficult to reach the appropriate laboratory or expert at CDC
  1. Develop criteria for prioritizing CEMB activities, including projects emanating from outbreak investigations. Research priorities should be reassessed on a regular basis based on:
  • Clinical and public health impact
  • Availability or lack of availability of comparable work elsewhere
  • Regulatory or interagency requirements (EPA or FDA contracts)
  1. Re-assess fragmentation of laboratory services across CDC to eliminate redundancies and lack of efficiency
    • Examples: expertise on VRE, pneumococci and food-borne organisms are located in several branches of CDC
Timeline

Short-term recommendations

  1. Shift responsibility for identifying non-foodborne gram-negative enteric rods to other CDC laboratory
  2. The panel was uncertain regarding the utility of continuing identification of unusual anaerobic organisms. Evaluating the availability of similar capabilities at alternative sources outside CDC
  3. Develop criteria for prioritizing CEMB activities
  4. Reassess priorities on a regular basis

Intermediate-term recommendations

  1. Pursue line-item funding for core CEMB functions, including outbreak investigations, environmental infection control research, and antimicrobial resistance surveillance and testing
  2. Partner with CMS to secure funding for research on hemodialysis-related infections, including those related to biofilm formation on dialysis catheters and hemodialysis machines and water systems
  3. Seek MOU and/or contract with FDA for post-marketing evaluation of commercially-available manual and automated identification and antimicrobial susceptibility testing systems
  • Important for assuring that currently available systems can detect emerging pathogens with unusual biochemical reactions or susceptibility patterns
  1. Form a steering committee to reassess integration of bacteriology laboratory functions across CDC, with a goal of eliminating any redundancies that may exist

Long-term recommendations

  1. Seek line-item budget allocations for improved IT capabilities for electronic laboratory reporting and NHSN national reporting systems
  2. Seek line-item budget allocations to Identify environmental issues relating hospital construction and renovation

Appendix A. CEMB Peer Review Panel Members

Melvin Weinstein, MD
(ID, Clin Micro, CLSI, IDSA, SHEA)
University of Medicine and Dentistry of New Jersey
New Brunswick, NJ

Robert Weinstein, MD
(ID, BSC, Infect Control, Hosp Epi, Envir, SHEA)
Stroger Hospital/Rush University Hospital
Chicago, IL

Patrick Luedtke, MD, MPH
(Publ Health Lab, APHL)
Public Health Laboratories
Salt Lake City UT

Betty A. Forbes, PhD., D(ABMM), F(AAM)
(Clin Micro, CLSI)
Virginia Commonwealth University Medical Center
Richmond, VA

John Boyce, MD
(ID, Infect Control, Hosp Epi, EIS Alumni)
Hospital of St. Raphael
New Haven, CT

Yvette S. McCarter, PhD
(Clin Micro, HICPAC)
University of Florida Health Science Center
Jacksonville, FL


Date last modified: Nov. 18, 2009
Content source: 
Division of Healthcare Quality Promotion (DHQP)
National Center for Preparedness, Detection, and Control of Infectious Diseases