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Hotchkiss JR, Holley P, Crooke PS. Analyzing pathogen transmission in the dialysis unit: time for a (schedule) change? Clin J Am Soc Nephrol 2007; 2:1176-85. [PMID: 17962421 DOI: 10.2215/cjn.00130107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Infectious diseases and antimicrobial-resistant microorganisms are a growing problem for the dialysis population. The frequency of patient visits and intimate, prolonged physical contact with the inanimate environment during dialysis treatments make these facilities potentially efficient venues for nosocomial pathogen transmission. Isolation measures and infection control practices can be inconvenient and consume limited resources. Quantitative tools for analyzing the effects of different containment strategies can help to identify optimal strategies for further study. However, spatial and temporal considerations germane to the dialysis unit greatly complicate analyses relying on conventional mathematical approaches. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A stochastic, individual-based, Monte Carlo simulation tool that predicts the effects of various infection control strategies on pathogen dissemination through the dialysis unit in the face of diagnostic uncertainty was developed. The model was configured to emulate a medium-sized dialysis unit. The predicted consequences of various policies for scheduling patients who were suspected of being infectious were then explored, using literature-based estimates of pathogen transmissibility, prevalence, and diagnostic uncertainty. RESULTS Environmental decontamination was predicted to be of paramount importance in limiting pathogen dissemination. Temporal segregation (scheduling patients who were suspected of being infectious to dialysis shifts that are later in the day) was predicted to have the greatest effectiveness in reducing transmission, given adequate environmental decontamination between successive days. CONCLUSIONS Decontamination of the patient's environment (chair) can markedly attenuate pathogen dissemination. Temporal segregation could be a simple, low-cost, system-level intervention with significant potential to reduce nosocomial transmission in the dialysis unit.
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Affiliation(s)
- John R Hotchkiss
- Department of Critical Care Medicine, University of Pittsburgh, and Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15261, USA.
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102
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Lucet JC, Armand-Lefevre L, Laurichesse JJ, Macrez A, Papy E, Ruimy R, Deblangy C, Lozach A, Lolom I, Jarlier V, Andremont A, Leport C. Rapid control of an outbreak of vancomycin-resistant enterococci in a French university hospital. J Hosp Infect 2007; 67:42-8. [PMID: 17719129 DOI: 10.1016/j.jhin.2007.06.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 06/15/2007] [Indexed: 11/25/2022]
Abstract
Vancomycin-resistant enterococci (VRE) are emerging in French hospitals. A VRE outbreak occurred in our hospital, prompting efforts to eradicate the organism. The following interventions were implemented simultaneously to control the outbreak: (1) creation of a VRE control committee; (2) cohorting of VRE carriers in a dedicated ward; (3) extensive screening of contact patients; (4) use of a sensitive technique for detecting VRE in rectal samples; (5) intervention of a dedicated team to reduce consumption of selected antibiotics; (6) information for, and education of, all hospital staff; and (7) electronic tracking of in-hospital transfer and readmission of VRE carriers and contact patients. Over a four-week period following admission of the index case, 37 carriers of a single strain of vanA vancomycin-resistant Enterococcus faecium were identified across seven units. A single additional readmitted contact patient was identified later. Of the 39 VRE-positive patients, two had urinary tract infections and 37 were colonised. Of the 32 patients with known VRE stool concentrations, 23 had low and nine high concentrations. One low-concentration patient precipitated transmission in another unit. This aggressive, co-ordinated, multifaceted strategy was successful in halting a widespread VRE outbreak in our hospital.
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Affiliation(s)
- J-C Lucet
- Infection Control Unit, Bichat-Claude Bernard Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
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103
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de Bruin MA, Riley LW. Does vancomycin prescribing intervention affect vancomycin-resistant enterococcus infection and colonization in hospitals? A systematic review. BMC Infect Dis 2007; 7:24. [PMID: 17425800 PMCID: PMC1863420 DOI: 10.1186/1471-2334-7-24] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 04/10/2007] [Indexed: 11/30/2022] Open
Abstract
Background Vancomycin resistant enterococcus (VRE) is a major cause of nosocomial infections in the United States and may be associated with greater morbidity, mortality, and healthcare costs than vancomycin-susceptible enterococcus. Current guidelines for the control of VRE include prudent use of vancomycin. While vancomycin exposure appears to be a risk factor for VRE acquisition in individual patients, the effect of vancomycin usage at the population level is not known. We conducted a systematic review to determine the impact of reducing vancomycin use through prescribing interventions on the prevalence and incidence of VRE colonization and infection in hospitals within the United States. Methods To identify relevant studies, we searched three electronic databases, and hand searched selected journals. Thirteen studies from 12 articles met our inclusion criteria. Data were extracted and summarized for study setting, design, patient characteristics, types of intervention(s), and outcome measures. The relative risk, 95% confidence interval, and p-value associated with change in VRE acquisition pre- and post-vancomycin prescription interventions were calculated and compared. Heterogeneity in study results was formally explored by stratified analysis. Results No randomized clinical trials on this topic were found. Each of the 13 included studies used a quasi-experimental design of low hierarchy. Seven of the 13 studies reported statistically significant reductions in VRE acquisition following interventions, three studies reported no significant change, and three studies reported increases in VRE acquisition, one of which reported statistical significance. Results ranged from a reduction of 82.5% to an increase of 475%. Studies of specific wards, which included sicker patients, were more likely to report positive results than studies of an entire hospital including general inpatients (Fisher's exact test 0.029). The type of intervention, endemicity status, type of study design, and the duration of intervention were not found to significantly modify the results. Among the six studies that implemented vancomycin reduction strategies as the sole intervention, two of six (33%) found a significant reduction in VRE colonization and/or infection. In contrast, among studies implementing additional VRE control measures, five of seven (71%) reported a significant reduction. Conclusion It was not possible to conclusively determine a potential role for vancomycin usage reductions in controlling VRE colonization and infection in hospitals in the United States. The effectiveness of such interventions and their sustainability remains poorly defined because of the heterogeneity and quality of studies. Future research using high-quality study designs and implementing vancomycin as the sole intervention are needed to answer this question.
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Affiliation(s)
- Monique A de Bruin
- Department of Medicine, Stanford University School of Medicine, Medicine Residency Office S101 (m/c 5109), Stanford, CA 94305, USA
| | - Lee W Riley
- Divisions of Infectious Diseases and Epidemiology, School of Public Health, University of California, Berkeley 140 Warren Hall, Berkeley, CA, 94720, USA
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Vonberg RP, Chaberny IF, Kola A, Mattner F, Borgmann S, Dettenkofer M, Jonas D, Fahr AM, Klare I, Werner G, Weist K, Wendt C, Gastmeier P. Prävention und Kontrolle der Ausbreitung von Vancomycin-resistenten Enterokokken. Anaesthesist 2007; 56:151-7. [PMID: 17171367 DOI: 10.1007/s00101-006-1123-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The incidence of vancomycin-resistant enterococci (VRE), especially E. faecium, is increasing in several German hospitals and some facilities have experienced VRE outbreaks. The German National Nosocomial Infection Surveillance System has also noticed a sharp increase in the incidence of nosocomial VRE infections per 10,000 patients from 0.5 in 2003 to 11.0 in 2005 accompanied by a rise in VRE-associated mortality. However, the reasons of this increase remain unknown. As VRE may cause severe nosocomial infections, transmission must be restricted. This article provides the guidelines as defined by the workshop of the German Society for Hygiene and Microbiology for the prevention of VRE transmission in both, endemic and epidemic, settings. The following topics are discussed: indication for VRE screening, microbiological diagnostics, general infection control measures (isolation precautions and use of protective clothing) and additional hygiene measures in the nosocomial VRE outbreak setting.
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Affiliation(s)
- R-P Vonberg
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Medizinische Hochschule, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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105
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Salgado CD, Ison MG. Should clinicians worry about vancomycin-resistant Enterococcus bloodstream infections? Bone Marrow Transplant 2007; 38:771-4. [PMID: 17133239 DOI: 10.1038/sj.bmt.1705532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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106
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Daptomycin in the treatment of vancomycin-resistant Enterococcus faecium bacteremia in neutropenic patients. J Infect 2006; 54:567-71. [PMID: 17188750 DOI: 10.1016/j.jinf.2006.11.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Revised: 10/30/2006] [Accepted: 11/03/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Vancomycin resistant enterococcal (VRE) blood stream infection (BSI) in neutropenic patients is associated with poor outcome. We report our experience in treating VRE BSI in febrile, neutropenic patients with daptomycin, a recently licensed lipopeptide with bactericidal activity against VRE. PATIENTS AND METHODS Patients with fever, neutropenia and VRE BSI were treated with more than one dose of daptomycin (either 6 mg/kg/day or 4 mg/kg/day) in an open label, emergency-use trial. Patients were then assessed for clinical and microbiological cures and survival. MIC's of isolates to daptomycin were determined. RESULTS Nine febrile, neutropenic patients with VRE BSI received daptomycin. Four of 9 courses (44%) had clinical and/or microbiologic cure. Two of the 5 who failed cure died within 3 days of initiation of daptomycin. Five subjects survived to 30 days after the onset of BSI. CONCLUSIONS Use of daptomycin in neutropenic patients with VRE BSI deserves further study as a treatment for VRE BSI in neutropenic patients.
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Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2006; 44:159-77. [PMID: 17173212 DOI: 10.1086/510393] [Citation(s) in RCA: 2313] [Impact Index Per Article: 128.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 10/04/2006] [Indexed: 12/31/2022] Open
Affiliation(s)
- Timothy H Dellit
- Harborview Medical Center and the University of Washington, Seattle, USA
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108
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Abele-Horn M, Vogel U, Klare I, Konstabel C, Trabold R, Kurihara R, Witte W, Kreth W, Schlegel PG, Claus H. Molecular epidemiology of hospital-acquired vancomycin-resistant enterococci. J Clin Microbiol 2006; 44:4009-13. [PMID: 17005748 PMCID: PMC1698368 DOI: 10.1128/jcm.00195-06] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 03/25/2006] [Accepted: 08/26/2006] [Indexed: 11/20/2022] Open
Abstract
Vancomycin-resistant Enterococcus faecium strains are a significant cause of nosocomial infections in predisposed patients. Multiple-locus variable-number tandem repeat analysis (MLVA) has been validated recently by use of a global strain collection. In this report, we applied MLVA together with multilocus sequence typing (MLST) and pulsed-field gel electrophoresis (PFGE) to type 14 isolates from three clusters of patients colonized or infected with vancomycin-resistant Enterococcus faecium and another 10 epidemiologically unrelated isolates from the same hospital. The clusters could be distinguished by all three typing methods, which proved to be concordant. PFGE patterns provided the highest resolution. We observed seven sequence types (ST), six MLVA types (MT), and nine distinct ST/MT combinations. The combination of MLST and MLVA may be an alternative to PFGE in hospital epidemiology, providing the benefits of high accuracy, reproducibility, and portability.
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109
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Bar K, Wisplinghoff H, Wenzel RP, Bearman GML, Edmond MB. Systemic inflammatory response syndrome in adult patients with nosocomial bloodstream infections due to enterococci. BMC Infect Dis 2006; 6:145. [PMID: 17002792 PMCID: PMC1592497 DOI: 10.1186/1471-2334-6-145] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 09/26/2006] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Enterococci are the third leading cause of nosocomial bloodstream infection (BSI). Vancomycin resistant enterococci are common and provide treatment challenges; however questions remain about VRE's pathogenicity and its direct clinical impact. This study analyzed the inflammatory response of Enterococcal BSI, contrasting infections from vancomycin-resistant and vancomycin-susceptible isolates. METHODS We performed a historical cohort study on 50 adults with enterococcal BSI to evaluate the associated systemic inflammatory response syndrome (SIRS) and mortality. We examined SIRS scores 2 days prior through 14 days after the first positive blood culture. Vancomycin resistant (n = 17) and susceptible infections (n = 33) were compared. Variables significant in univariate analysis were entered into a logistic regression model to determine the affect on mortality. RESULTS 60% of BSI were caused by E. faecalis and 34% by E. faecium. 34% of the isolates were vancomycin resistant. Mean APACHE II (A2) score on the day of BSI was 16. Appropriate antimicrobials were begun within 24 hours in 52%. Septic shock occurred in 62% and severe sepsis in an additional 18%. Incidence of organ failure was as follows: respiratory 42%, renal 48%, hematologic 44%, hepatic 26%. Crude mortality was 48%. Progression to septic shock was associated with death (OR 14.9, p < .001). There was no difference in A2 scores on days -2, -1 and 0 between the VRE and VSE groups. Maximal SIR (severe sepsis, septic shock or death) was seen on day 2 for VSE BSI vs. day 8 for VRE. No significant difference was noted in the incidence of organ failure, 7-day or overall mortality between the two groups. Univariate analysis revealed that AP2>18 at BSI onset, and respiratory, cardiovascular, renal, hematologic and hepatic failure were associated with death, but time to appropriate therapy >24 hours, age, and infection due to VRE were not. Multivariate analysis revealed that hematologic (OR 8.4, p = .025) and cardiovascular failure (OR 7.5, p = 032) independently predicted death. CONCLUSION In patients with enterococcal BSI, (1) the incidence of septic shock and organ failure is high, (2) patients with VRE BSI are not more acutely ill prior to infection than those with VSE BSI, and (3) the development of hematologic or cardiovascular failure independently predicts death.
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Affiliation(s)
- Katharine Bar
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Hilmar Wisplinghoff
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany
| | - Richard P Wenzel
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Gonzalo ML Bearman
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael B Edmond
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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110
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Abele-Horn M, Hommers L, Trabold R, Frosch M. Validation of VITEK 2 version 4.01 software for detection, identification, and classification of glycopeptide-resistant enterococci. J Clin Microbiol 2006; 44:71-6. [PMID: 16390951 PMCID: PMC1351969 DOI: 10.1128/jcm.44.1.71-76.2006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We evaluated the ability of the new VITEK 2 version 4.01 software to identify and detect glycopeptide-resistant enterococci compared to that of the reference broth microdilution method and to classify them into the vanA, vanB, vanC1, and vanC2 genotypes. Moreover, the accuracy of antimicrobial susceptibility testing with agents with improved potencies against glycopeptide-resistant enterococci was determined. A total of 121 enterococci were investigated. The new VITEK 2 software was able to identify 114 (94.2%) enterococcal strains correctly to the species level and to classify 119 (98.3%) enterococci correctly to the glycopeptide resistance genotype level. One Enterococcus casseliflavus strain and six Enterococcus faecium vanA strains with low-level resistance to vancomycin were identified with low discrimination, requiring additional tests. One of the vanA strains was misclassified as the vanB type, and one glycopeptide-susceptible E. facium wild type was misclassified as the vanA type. The overall essential agreements for antimicrobial susceptibility testing results were 94.2% for vancomycin, 95.9% for teicoplanin, 100% for quinupristin-dalfopristin and moxifloxacin, and 97.5% for linezolid. The rates of minor errors were 9% for teicoplanin and 5% for the other antibiotic agents. The identification and susceptibility data were produced within 4 h to 6 h 30 min and 8 h 15 min to 12 h 15 min. In conclusion, use of VITEK 2 version 4.01 software appears to be a reliable method for the identification and detection of glycopeptide-resistant enterococci as well as an improvement over the use of the former VITEK 2 database. However, a significant reduction in the detection time would be desirable.
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111
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Strausbaugh LJ, Siegel JD, Weinstein RA. Preventing Transmission of Multidrug-Resistant Bacteria in Health Care Settings: A Tale of Two Guidelines. Clin Infect Dis 2006; 42:828-35. [PMID: 16477561 DOI: 10.1086/500408] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Accepted: 12/08/2005] [Indexed: 12/29/2022] Open
Abstract
Two guidelines for the control of multidrug-resistant organisms in health care facilities have appeared during the past 3 years--one from the Society for Healthcare Epidemiology of America and one, in draft form, from the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention. These guidelines reflect universal concern in the infection-control community about today's unprecedented levels of activity of multidrug-resistant organisms and about inadequate or inconsistent application of potentially effective control measures. The 2 guidelines provide detailed reviews of pertinent issues and evidence-based, rated recommendations, which overlap considerably. Recommendations regarding indications for active surveillance cultures and the extent of their use constitute the major divergence. Although implementation of comprehensive control plans for multidrug-resistant organisms advocated by both guidelines will require health care facilities to confront difficult programmatic issues, aggressive and widespread adoption of control measures for multidrug-resistant organisms is urgently needed.
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Affiliation(s)
- Larry J Strausbaugh
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Oregon Health Sciences University, Portland, OR, USA.
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112
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Abstract
BACKGROUND Lack of progress in developing new antimicrobials, particularly new classes, as opposed to variants of existing agents, has contributed to the emergence of antibiotic-resistant pathogens. METHODS Data synthesis after review of pertinent English-language literature. RESULTS The development of new classes of antimicrobial agents is crucial, considering the increasing prevalence of nosocomial pathogens resistant to empiric as well as second- and third-line antibiotic choices. Tigecycline has recently been approved for the treatment of complicated skin and skin structure as well as intra-abdominal infections. Published data on the in vitro and in vivo properties of tigecycline, the first-in-class glycylcycline, are reviewed. CONCLUSION It is plausible that tigecycline could to some extent replace available broadspectrum agents for approved indications and thereby reduce the selective pressure for some currently prevalent multi-resistant pathogens in the hospital setting.
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Affiliation(s)
- Mark H Wilcox
- Infection Prevention & Control, Leeds General Infirmary & University of Leeds, Leeds, U.K.
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113
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Nadarajah K, Green GR, Naglak M. Clinical outcomes of penicillin skin testing. Ann Allergy Asthma Immunol 2006; 95:541-5. [PMID: 16400893 DOI: 10.1016/s1081-1206(10)61016-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Penicillin or cephalosporin allergy is a common problem with antibiotic drug prescribing in hospitalized patients. OBJECTIVES To study the various clinical outcomes of penicillin skin testing (PST) in a community teaching hospital and to determine the percentage of patients who have an antibiotic drug modification after PST. METHODS This study was a retrospective medical record review of all inpatients who underwent PST in 6.6 years. Information was collected on 101 patients using a detailed data collection form. Data were summarized using descriptive statistics, including frequencies and percentages. RESULTS Of the 101 patients who underwent PST, 92 had a negative result and 5 had a positive result; in 4 patients the test result was indeterminate. There was a 96% (67/70) reduction in the use of vancomycin and a 96% (23/24) reduction in the use of fluoroquinolones after PST in patients with negative results. Forty-nine percent of patients with negative PST results were administered a penicillin-based drug, and 48% were given a cephalosporin. Cultures were positive most commonly for Staphylococcus aureus and enterococcus. There were no serious adverse reactions to PST or to the use of penicillins or cephalosporins after a negative PST result. CONCLUSIONS Penicillin skin testing lowered the use of vancomycin and fluoroquinolones and increased the use of penicillin-based drugs and cephalosporins in patients with a history of beta-lactam drug allergies.
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Affiliation(s)
- Kamalini Nadarajah
- Department of Internal Medicine, Allergy and Immunology, Abington Memorial Hospital, Abington, Pennsylvania 19001, USA.
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Askarian M, Shiraly R, McLaws ML. Knowledge, attitudes, and practices of contact precautions among Iranian nurses. Am J Infect Control 2005; 33:486-8. [PMID: 16216666 DOI: 10.1016/j.ajic.2005.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Knowledge, attitudes, and contact precaution practices were surveyed in nurses at Shiraz University of Medical Sciences. METHODS Two hundred seventy nurses, midwives, and auxiliary nurses completed a questionnaire consisting of 8 knowledge items with corresponding attitudes and practices items. RESULTS Compliance with precaution practices was low, 19.5%, and little more than half, 51.8%, held positive attitudes toward the guidelines, whereas 65.5% could correctly answered all precaution knowledge items. Nurses with correct knowledge were 11.3 times more likely (P < .0001) to hold positive attitudes toward the guidelines and 14.2 times more likely (P < .0001) to comply with all 8 precaution practices, and compliers were 6.3 times more likely (P < .0001) to hold positive attitudes than noncompliers. CONCLUSION Although correct knowledge was associated with compliance and positive attitudes, the proportion of nurses who held positive attitudes also had good knowledge, and compliance with practices was not abundant. Better training coverage may result in compliance with precaution practices becoming the norm.
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Affiliation(s)
- Mehrdad Askarian
- Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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115
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DiazGranados CA, Zimmer SM, Klein M, Jernigan JA. Comparison of Mortality Associated with Vancomycin-Resistant and Vancomycin-Susceptible Enterococcal Bloodstream Infections: A Meta-analysis. Clin Infect Dis 2005; 41:327-33. [PMID: 16007529 DOI: 10.1086/430909] [Citation(s) in RCA: 323] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2004] [Accepted: 03/03/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Whether vancomycin resistance is independently associated with mortality among patients with enterococcal bloodstream infection (BSI) is controversial. To address this issue, we performed a systematic literature review with meta-analysis. METHODS Data sources were studies identified using the MEDLINE database (for articles from 1988 through March 2003), the Cochrane Library (for articles published up to March 2003), and bibliographies of identified articles. Inclusion criteria were that the study assessed mortality after enterococcal BSI, compared mortality after vancomycin-resistant enterococci (VRE) BSI with that after vancomycin-susceptible enterococci (VSE) BSI, and adjusted for severity of illness. Study exclusion criteria were as follows: no report of the adjusted measure of effect (adjusted odds ratio [OR], adjusted hazard ratio, or adjusted relative risk) of vancomycin resistance on mortality available and/or its adjusted 95% confidence interval (95% CI). Data in the tables, figures, or text were independently extracted by 2 of the authors. Individual weights were calculated using the 95% CI of the adjusted measures of effect performing both fixed-effect and random-effects models. RESULTS Nine studies were eligible (11 studies met the inclusion criteria, and 2 were excluded), with a total of 1614 enterococcal BSI episodes (683 VRE episodes and 931 VSE episodes). Patients with bacteremia caused by VRE were more likely to die than were those with VSE bacteremia (summary OR, 2.52; 95% CI, 1.9-3.4). CONCLUSIONS Vancomycin resistance is independently associated with increased mortality among patients with enterococcal bloodstream infection.
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Affiliation(s)
- Carlos A DiazGranados
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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116
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Hotchkiss JR, Strike DG, Simonson DA, Broccard AF, Crooke PS. An agent-based and spatially explicit model of pathogen dissemination in the intensive care unit*. Crit Care Med 2005; 33:168-76; discussion 253-4. [PMID: 15644665 DOI: 10.1097/01.ccm.0000150658.05831.d2] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop and disseminate a spatially explicit model of contact transmission of pathogens in the intensive care unit. DESIGN A model simulating the spread of a pathogen transmitted by direct contact (such as methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus) was constructed. The modulation of pathogen dissemination attending changes in clinically relevant pathogen- and institution-specific factors was then systematically examined. SETTING AND PATIENTS The model was configured as a hypothetical 24-bed intensive care unit. The model can be parameterized with different pathogen transmissibilities, durations of caregiver and/or patient contamination, and caregiver allocation and flow patterns. INTERVENTIONS Pathogen- and institution-specific factors examined included pathogen transmissibility, duration of caregiver contamination, regional cohorting of contaminated or infected patients, delayed detection and isolation of newly contaminated patients, reduction of the number of caregiver visits, and alteration of caregiver allocation among patients. MEASUREMENTS AND MAIN RESULTS The model predicts the probability that a given fraction of the population will become contaminated or infected with the pathogen of interest under specified spatial, initial prevalence, and dynamic conditions. Per-encounter pathogen acquisition risk and the duration of caregiver pathogen carriage most strongly affect dissemination. Regional cohorting and rapid detection and isolation of contaminated patients each markedly diminish the likelihood of dissemination even absent other interventions. Strategies reducing "crossover" between caregiver domains diminish the likelihood of more widespread dissemination. CONCLUSIONS Spatially explicit discrete element models, such as the model presented, may prove useful for analyzing the transmission of pathogens within the intensive care unit.
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Affiliation(s)
- John R Hotchkiss
- CRISMA Laboratory, Department of Critical Care, University of Pittsburgh, USA
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117
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Carlet J, Ben Ali A, Chalfine A. Epidemiology and control of antibiotic resistance in the intensive care unit. Curr Opin Infect Dis 2004; 17:309-16. [PMID: 15241074 DOI: 10.1097/01.qco.0000136927.29802.68] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Resistance to antibiotics is very high in the intensive care units of many countries, although there are several exceptions. Some infections are becoming extremely difficult to treat. The risk of cross-transmission of those strains is very high. This review focuses on recent data (2003 to the present) that may help understanding and dealing with this serious public health problem. RECENT FINDINGS Intensive care units can be considered as 'factories' for creating, disseminating and amplifying resistance to antibiotics, for many reasons: importation of resistant microorganisms at admission, selection of resistant strains with an extensive use of broad-spectrum antibiotics, cross-transmission of resistant strains via the hands or the environment. Some national programs can be considered as failures, as in the UK and the USA. Other countries have been able to maintain a low level of resistance (Scandinavian countries, Netherlands, Switzerland, Germany, Canada). There is clearly an 'inoculum effect' above which preventive measures become poorly efficient. Several preventive measures have been proposed including preventive isolation, systematic screening at admission, local, national or international antibiotic guidelines, antibiotic prescriptions advice by infectious-disease teams, antibiotic prevention with selective digestive decontamination, antibiotic strategies such as 'cycling', or rather, for some authors, the use of an 'à la carte' antibiotic strategy which could be considered as a 'patient-to-patient antibiotic rotation'. SUMMARY There is obviously an international concern regarding the level of resistance to antibiotics in the intensive-care-unit setting. A strong program including prevention of cross-transmission and better usage of antibiotics seems to be needed in order to be successful. We do not know if this kind of program will enable countries with a very high endemic level of resistance to decrease the level in future years.
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Affiliation(s)
- Jean Carlet
- Intensive Care Unit, Fondation Hôpital Saint-Joseph, 185, rue Raymond Losserand, 75014 Paris, France.
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Farr BM. For nosocomial vancomycin-resistant enterococcal infections: the ounce of prevention or the pound of cure? Clin Infect Dis 2004; 38:1116-8. [PMID: 15095216 DOI: 10.1086/382891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Accepted: 01/14/2004] [Indexed: 11/03/2022] Open
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