A new imperative for the Australian infection control community: improving detection of device-related outbreaks

Abstract

In late 2004, the authors became aware of international reports of increased bloodstream infections (BSI) associated with the use of mechanical valve access devices (MVAD). MVADs were already used in Australian and New Zealand hospitals; however, none of the state-wide standardised systems of BSI surveillance monitoring, nor the Therapeutic Goods Administration (TGA) had identified the potential for similar increases in Australian BSI rates temporally associated with MVADs. After describing this serious problem at relevant 2005 infection prevention meetings in Australia and New Zealand, several concerned infection control professionals (ICPs) who had identified potentially similar BSI increases approached the authors for advice and assistance to further investigate the issue. The authors convened a face-to-face meeting of self-identified ICPs whose BSI rates had changed subsequent to introducing MVADs. At the November 2005 meeting, participants considered the implications of the local increases. Meeting participants were brought together as an Advisory Panel and described their local circumstances in detail for peer review. The Panel concluded that one New Zealand and at least three other large Australian hospitals were experiencing MVAD-BSI increases identical to those reported in the US the year previously. Panelists were aggrieved by the failure of existing Australian and New Zealand surveillance and regulatory mechanisms to detect and raise general awareness of these MVAD-related BSI increases and proposed the development of a formal, rapid response alert system to advise ICPs of subsequent device-related outbreaks. This paper describes the process, findings and outcomes of the first meeting, including an overview of several local increases in BSI temporally associated with use of MVADs. It also recommends the introduction of a system to ensure the provision of timely and important advice to ICPs in the event of unexpected negative consequences associated with implementation of new equipment and/or devices. Failure to introduce this or a similar model represents an ongoing deficiency in proactive infection prevention in Australia and New Zealand.