1. Chapter 4: Reporting and Submitting VISA/VRSA in Texas
Texas department of state health services
Infectious disease control unit
Stephanie titus, mph
June, 2014
Slide 1:
Hello and welcome to Chapter 4: Reporting and submitting VISA and VRSA, Vancomycin-intermediate Staphylococcus aureus and Vancomycin-resistant Staphylococcus aureus, in Texas.
My name is Stephanie Titus.

2. Three Steps for Reporting and Submitting VISA/VRSA in Texas
Step 1: Identify vancomycin resistance of S. aureus isolate
Step 2: Notify local or regional health department
Step 3: Submit an isolate to Dshs laboratory
Slide 2:
In this webinar, we are going to cover the three steps for reporting and submitting VISA and VRSA in Texas.
Step one is to identify the vancomycin resistance of your Staphylococcus aureus isolate.
Step two is to notify your local or regional health department.
And step three is to submit an isolate to the DSHS laboratory.

3. Step 1: Initial testing of S. aureus culture for Vancomycin resistance
Vancomycin-intermediate S. aureus
Defined as an MIC 4-8 μg/ml by CDC
Vancomycin-resistant S. aureus
Defined as an MIC >16 μg/ml by CDC
Texas Administrative Code requires any S. aureus isolate with MIC >2 μg/ml be submitted. DSHS has chosen a more inclusive case definition for surveillance purposes.
Slide 3:
The first step is to test the Staphylococcus aureus isolate for vancomycin resistance.
According to the CDC, VISA is defined by an MIC between 4 and 8; VRSA is defined by an MIC greater than 16.
The Texas Administrative Code requires providers to submit any Staphylococcus aureus isolate with an MIC greater than 2 to the DSHS laboratory.
The Texas Department of State Health Services has chosen a more inclusive case definition for surveillance purposes.
(TAC Title 25, Part 1, Chapter 97, Subchapter A, Rule §97.3)

4. Step 2: Notify local or regional health department
If a VISA/VRSA isolate has been identified by a practitioner, it must be immediately reported to local or regional health department by phone
Local contacts can be found here
Slide 4:
The second step is to notify your local or regional health department immediately by phone of any confirmed or suspected VISA/VRSA isolate.
If you do not know the contact information of your closest health department, please follow the link.

5. Step 2: Notify local or regional health department
Once the local or regional health department has been informed by phone, practitioners must complete two forms to submit to the health department along with supporting documents (H&P, discharge summary).
1. VISA/VRSA Case Report Form
Form is found at the bottom of linked webpage
2. Initial Provider Disease Report Form (EPI-2)
Slide 5:
Next, practitioners should complete two forms and send them to the health department along with supporting documents, such as the patient’s history and physical and discharge summary.
The two forms are the VISA/VRSA Case Report Form and the Initial Provider Disease Report Form (also known as the EPI-2 form).
Links to these forms are given below.

6. VISA/VRSA Case Report Form
Slide 6:
The VISA/VRSA Case Report Form can be found by following the hyperlink.
There are many investigation forms on this website. Scroll down to find the VISA/VRSA Case Report Form at the bottom, as shown here.
Click on the “PDF” link to download the form.
Form Number EF

7. Initial Provider Disease Report Form (EPI-2)
Slide 7:
The Initial Provider Disease Report Form, or EPI-2 Form, can be downloaded by following the hyperlink.
The website will look like this.
Click on the “EPI-2” link to download the form.

8. Step 2: Notify local or regional health department
The forms can be sent your local or regional health department by mail or fax.
Again, local contacts can be found here
Slide 8:
You can submit these two forms to the health department by mail or fax.

9. Step 3: Submit an Isolate to DSHS Laboratory
Practitioners are required to submit VISA/VRSA isolates for confirmatory testing, if MIC >2 μg/ml.
Three things must be included for each VISA/VRSA isolate submitted to the DSHS laboratory:
1. Culture isolate
2. G2-B Form
3. Antibiogram / Lab report
Include MIC, if available
Slide 9:
The health department will give you permission to send an isolate to the DSHS laboratory. In contrast to CRE and MDR-A, you are always required to submit an isolate for VISA and VRSA if the MIC is greater than 2.
There are three things that should be included when submitting to the lab:
First, the culture isolate.
Second, the G2-B form.
And finally, the antibiogram or lab report. The MIC should be included if available.

10. Step 3: Submit an Isolate to DSHS Laboratory
Culture Isolate Requirements:
If the specimen is currently at room temperature
Submit pure isolate on any media in a petri dish or slant
Slants are preferred as they are more durable for shipping
Send specimens following Category B shipping guidelines at room temperature to the DSHS Laboratory
If the specimen has been frozen
Should be in trypticase soy broth with 20% glycerol
Should have been stored at -20C or -70C
Send following Category B shipping guidelines with dry ice, overnight to the DSHS Laboratory to ensure it is received frozen
Limiting to one freeze-thaw cycle is optimal for specimen integrity
Slide 10:
When submitting an isolate to the DSHS laboratory, there are several requirements for quality assurance.
If the isolate is currently at room temperature, you can send the isolate on whatever media it is growing on.
Isolates can be sent in a petri dish or on a slant. The laboratory prefers slants as they are generally more durable when shipping.
The isolate should be sent following Category B shipping guidelines at room temperature. For more information on Category B shipping guidelines, please click the link.
If the isolate has been frozen, it should have been frozen in trypticase soy broth with 20% glycerol and stored at either -20 or -70 degrees Celsius.
The isolate should be sent following Category B shipping guidelines for frozen specimens. This means it should be sent on dry ice, overnight to the DSHS laboratory to ensure it is received frozen.
For more information on how to appropriately package a frozen specimen, please follow the link.
Limiting your sample to one freeze-thaw cycle is optimal for specimen integrity.
Please note that you should not send a specimen on a Friday or adjacent to a holiday as we cannot ensure the specimen will be received in a timely manner.

11. Step 3: Submit an Isolate to DSHS Laboratory
Label the petri dish or slant with at least two unique patient identifiers, for example:
First and last name
Date of birth
Social security number
Medical record number
Slide 11:
When labeling your petri dish or slant, you must include a minimum of two unique patient identifiers.
For example, you could put the first and last name plus the date of birth, or the first and last name and the social security number or medical record number.
The more information on the label, the better.
Below is a sample label that would provide more than sufficient information when submitting an isolate.
Patient Name: ____________________________
Date of Birth: __/__/____ MRN: _____________
Social Security Number: ___-__-_____
Date of Collection: __/__/____
Time of Collection: __ : __ AM/PM

12. Step 3: Submit an Isolate to DSHS Laboratory
G2-B Form is used for Bacteriology submissions.
Slide 12:
Included with your isolate should be a G2-B form. It is used for all bacteriology submissions and it looks like this.

13. Step 3: Submit an Isolate to DSHS Laboratory
If you do not have a G2-B form, you can request them by . The instructions and link are available here.
Slide 13:
If you do not have a G2-B form, you can request one from the Laboratory Reporting Division of DSHS.
The instructions and link are available by following the link and scrolling down to the section shown below.

14. Step 3: Submit an Isolate to DSHS Laboratory
G2-B Forms are specific to each submitter
This section is completed by DSHS Laboratory Reporting Division
The submitter number in this section must match the submitter’s information
Slide 14:
G2-B forms are specific to each submitter.
The submitter information section should be completed in its entirety.
When you receive a G2-B form from the Laboratory Reporting Division, this section should already be filled out.
The submitter number in this section must match the facility or practitioner submitting the isolate.

15. Step 3: Submit an Isolate to DSHS Laboratory
When filling out the G2-B, practitioners must fill out as much information as possible. The critical information is indicated by the “**” in the boxes.
Full name, address, DOB, sex, date of collection, ICD diagnosis code, and the specimen source are absolutely required.
Slide 15:
When you are filling out the G2-B, you should include as much information as possible. The mandatory information is indicated by the “**” in the boxes.
The full name, address, date of birth, sex, date of collection, ICD diagnosis code, and the specimen source are absolutely required.
Please complete the form in blue or black ink with clearly legible handwriting.

16. Step 3: Submit an Isolate to DSHS Laboratory
If the submission of an isolate has been authorized and DSHS is covering the cost, check the “IDEAS” box under Section 9 – Payor Source on the G2-B.
Slide 16:
If you have been told to submit an isolate and DSHS will be covering the cost, check the “IDEAS” box under Section 9 – Payor Source.
By checking this box, you will not be responsible for the laboratory fees of submitting an isolate for confirmation.
If you do select the IDEAS box, do not provide additional payment information. This ensures that you will not be charged.
If IDEAS is selected, do not provide additional payment information.

17. Step 3: Submit an Isolate to DSHS Laboratory
Indicate on the G2-B Form that the sample is arriving for VISA/VRSA confirmation.
There are three possible ways to indicate this on the G2-B Form.
Slide 17:
You must also indicate on the G2-B form that the isolate is arriving for VISA/VRSA confirmation.
There are three ways to indicate this.

18. Step 3: Submit an Isolate to DSHS Laboratory
VISA/VRSA
Option #1:
Check the Organism suspected box
Write in “VISA” or “VRSA”
Slide 18:
The first way is to check the “Organism suspected” box below Pure Culture in the Bacteriology Section and write in “VISA” or “VRSA” next to it.

19. Step 3: Submit an Isolate to DSHS Laboratory
(VISA/VRSA)
Option #2:
Check Staphylococcus box
Write in next to it “(VISA)” or “(VRSA)”
Slide 19:
The second way is to check the “Staphylococcus” box in the Bacteriology Section and write in “(VISA)” or “(VRSA)”.

20. Step 3: Submit an Isolate to DSHS Laboratory
(VISA/VRSA)
Option #3:
Check Other box
Write in below it “VISA” or “VRSA”
Slide 20:
The third way is to the check the “Other” box under Bacteriology and to write in “VISA” or “VRSA”.

21. Step 3: Submit an Isolate to DSHS Laboratory
The isolate, G2-B form and antibiogram / lab report should be placed in the same box and sent to the DSHS Laboratory at their physical address:
Specimen Receiving Laboratory Services Section, MC 1947 Department of State Health Services 1100 W. 49th Street Austin, TX 
Do not send to a PO Box
Slide 21:
The isolate, G2-B form, and lab report should all be placed in the same box and sent to the DSHS laboratory at their physical address, not to a PO Box.
The physical address is below.

22. Summary of Reporting and Submitting VISA/VRSA in Texas
Step 1: Identify vancomycin resistance of S. aureus isolate
Step 2: Notify local or regional health department
Step 3: Submit an isolate to Dshs laboratory
Slide 22:
In summary, the three steps for reporting and submitting VISA and VRSA in Texas are as follows:
Step One: Identify the vancomycin resistance of your Staphylococcus aureus isolate.
Step Two: Notify the local or regional health department.
And Step Three: Is to submit an isolate to the DSHS laboratory.

23. Follow - Up
Once a practitioner has followed all three steps for reporting and submitting VISA/VRSA, they have completed their duties.
An epidemiologist may follow-up with submitters regarding the results and further actions that may be required.
Slide 23:
Once you have completed all three steps, your reporting duties are complete.
An epidemiologist may follow up with you regarding the results or any further actions that may be required.
Thank you for your attention. For information on submitting CRE and MDR-A, please see the links to Chapters Two and Three on the original navigation page.