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Swetha PS, Gupta K, Saha S, Panda SK, Behera B. Predictors for multidrug-resistant organisms (MDROs) carriage in haemodialysis patients. J Family Med Prim Care 2024; 13:486-491. [PMID: 38605748 PMCID: PMC11006063 DOI: 10.4103/jfmpc.jfmpc_708_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 04/13/2024] Open
Abstract
Introduction Infections in haemodialysis (HD) patients are an important cause of morbidity, hospitalization, and mortality. Patients undergoing HD are more prone to develop bacterial infections by multidrug-resistant organisms (MDROs). Objectives This study is aimed to detect MDROs colonization in HD patients and its associated risk factors and outcome. Methodology A total of 62 nasal swabs and 124 rectal swabs were collected from 62 patients coming to the haemodialysis unit from of March to May 2021 and were further screened for MRSA, VRE and CRE. Results Out of 62 patients, 22.59% showed the presence of methicillin-resistant staphylococcus aureus (MRSA) while VRE was present in four patients (4/62). CRE was found as 24.2% (15/62). Duration of dialysis was found as a significant risk factor-associated MRSA carriage, Whereas Charlson index and drug and medication were found as significant risk factor for VRE carriage. Discussion & Conclusion HD patients are particularly vulnerable to life threatening infections. Therefore, continuous epidemiological surveillance for these MDROs, including genotypic analysis and implementation of adequate decolonization strategies, is crucial and will reduce the possibility of autoinfection as well as disrupt transmission of multi-resistant isolates to others.
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Affiliation(s)
| | - Kavita Gupta
- Department of Microbiology, AIIMS, Bhubaneswar, Odisha, India
| | | | | | - Bijayini Behera
- Department of Microbiology, AIIMS, Bhubaneswar, Odisha, India
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Trautmannsberger I, Kolberg L, Meyer-Buehn M, Huebner J, Werner G, Weber R, Heselich V, Schroepf S, Muench HG, von Both U. Epidemiological and genetic characteristics of vancomycin-resistant Enterococcus faecium isolates in a University Children's Hospital in Germany: 2019 to 2020. Antimicrob Resist Infect Control 2022; 11:48. [PMID: 35279207 PMCID: PMC8917738 DOI: 10.1186/s13756-022-01081-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Vancomycin-resistant Enterococcus faecium (VREfm) strains are one of the most important pathogens causing nosocomial infections in Germany. Due to limited treatment options and an increased risk for acquisition in immunocompromised children, surveillance to monitor occurrence of VREfm in paediatric clinical facilities is of critical importance. Following an unusual accumulation of VREfm positive patients between April 2019 and August 2020 at Dr. von Hauner Children's Hospital in Munich, Germany, our study aimed to identify dynamics and routes of transmission, and analyse the affected population in view of previously described host risk factors for VREfm colonisation or infection. METHODS The hospital database was used to collect epidemiological and clinical data of VREfm cases. Descriptive statistical analyses were conducted to outline patient characteristics and depict possible differences between VREfm-colonised and -infected children. An outbreak investigation determining genetic relatedness among VREfm isolates was performed by core genome multilocus sequence typing (cgMLST). To examine potential transmission pathways, results of genome analysis were compared with epidemiological and clinical data of VREfm positive patients. RESULTS VREfm acquisition was documented in a total of 33 children (< 18 years). Seven VREfm-colonised patients (21.2%), especially those with a haemato-oncological disease (4/7; p = 0.011), showed signs of clinical infection. cgMLST analysis revealed seven distinct clusters, demonstrating a possible connection within each clonal lineage. Additional eight singletons were identified. Comparison with epidemiological and clinical data provided strong evidence for a link between several VREfm positive patients within the hospital. CONCLUSIONS A nosocomial spread-at least in part-was the most likely reason for the unusual accumulation of VREfm cases. The study highlights that there is a constant need to increase efforts in hygiene measures, infection control and antibiotic stewardship to combat VREfm transmission events within German paediatric hospitals. Continuous monitoring of adherence to respective policies might reduce the occurrence of clustered cases and prevent future outbreaks.
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Affiliation(s)
- Ilona Trautmannsberger
- Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr. 4, 80337, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Laura Kolberg
- Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Melanie Meyer-Buehn
- Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Johannes Huebner
- Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr. 4, 80337, Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Guido Werner
- Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - Robert Weber
- Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
- Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Valerie Heselich
- Division of Neonatology, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Schroepf
- Division of Neonatology, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Hans-Georg Muench
- Division of Neonatology, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr. 4, 80337, Munich, Germany.
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany.
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Belga S, Chiang D, Kabbani D, Abraldes JG, Cervera C. The direct and indirect effects of vancomycin-resistant enterococci colonization in liver transplant candidates and recipients. Expert Rev Anti Infect Ther 2019; 17:363-373. [PMID: 30977692 DOI: 10.1080/14787210.2019.1607297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Vancomycin-resistant enterococci (VRE) colonization and subsequent infection results in increased morbidity, mortality and use of health-care resources. The burden of VRE colonization in liver transplant candidates and recipients is significant. VRE colonization is a marker of gut dysbiosis and its impact on the microbiota-liver axis, may negatively affect graft function and result in negative outcomes pre- and post-transplantation. Areas covered: In this article we describe the epidemiology of VRE colonization, risk factors for VRE infection, health-care costs associated with VRE, with a focus on the impact of VRE colonization on liver transplant recipients' fecal microbiota, the therapeutic strategies for VRE decolonization and proposed pathophysiologic mechanisms of VRE colonization in liver transplant recipients. Expert opinion: VRE colonization results in a significant loss of bacterial microbiome diversity. This may have metabolic consequences, with low production of short-chain fatty acids which may, in turn, result in immune dysregulation. As antibiotics have failed to decolonize the gut, alternative strategies such as fecal microbiota transplantation (FMT), stimulation of intestinal antimicrobial peptides and phage therapy warrants future studies.
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Affiliation(s)
- Sara Belga
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Diana Chiang
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Dima Kabbani
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Juan G Abraldes
- b Department of Medicine, Division of Gastroenterology and Hepatology , University of Alberta , Edmonton , Alberta , Canada
| | - Carlos Cervera
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
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Hygienemaßnahmen zur Prävention der Infektion durch Enterokokken mit speziellen Antibiotikaresistenzen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1310-1361. [DOI: 10.1007/s00103-018-2811-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bilinski J, Grzesiowski P, Sorensen N, Madry K, Muszynski J, Robak K, Wroblewska M, Dzieciatkowski T, Dulny G, Dwilewicz-Trojaczek J, Wiktor-Jedrzejczak W, Basak GW. Fecal Microbiota Transplantation in Patients With Blood Disorders Inhibits Gut Colonization With Antibiotic-Resistant Bacteria: Results of a Prospective, Single-Center Study. Clin Infect Dis 2018; 65:364-370. [PMID: 28369341 DOI: 10.1093/cid/cix252] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/17/2017] [Indexed: 12/26/2022] Open
Abstract
Background Patients with blood disorders colonized with antibiotic-resistant bacteria (ARB) are prone to systemic infections that are difficult to treat. Reintroduction of commensal bacteria in a murine model of enterococcal colonization of the gut can lead to eradication of enterococci. We hypothesized that fecal microbiota transplantation (FMT) could be used to eradicate ARB in humans. Methods Participants colonized with ARB were treated with intraduodenal FMT according to a prospective protocol (NCT02461199). The primary endpoint was complete ARB decolonization at 1 month after FMT. Secondary endpoints included safety assessment and partial ARB decolonization. Microbiome sequencing was performed to investigate the influence of microbial composition of the transplanted material on the outcome of FMT. Results Twenty-five FMTs were performed in 20 participants (including 40% who had neutropenia) who were colonized by a median of 2 (range, 1-4) strains of ARB. The primary endpoint was reached in 15/25 (60%) of the FMTs and more frequently in cases in which there was no periprocedural use of antibiotics (79% vs 36%, P < .05). Among participants, 15/20 (75%) experienced complete ARB decolonization. There were no severe adverse events, and partial ARB decolonization was observed in 20/25 (80%) of the FMTs. The microbiota composition analysis revealed higher abundance of Barnesiella spp., Bacteroides, and Butyricimonas and greater bacterial richness in the fecal material, resulting in eradication of Klebsiella pneumoniae compared with nonresponders. Conclusions FMT in patients with blood disorders is safe and promotes eradication of ARB from the gastrointestinal tract. Clinical Trials Registration NCT02461199.
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Affiliation(s)
- Jaroslaw Bilinski
- Department of Hematology, Oncology, and Internal Diseases, Medical University of Warsaw
| | | | | | - Krzysztof Madry
- Department of Hematology, Oncology, and Internal Diseases, Medical University of Warsaw
| | | | - Katarzyna Robak
- Department of Hematology, Oncology, and Internal Diseases, Medical University of Warsaw
| | - Marta Wroblewska
- Department of Microbiology, Central Clinical Hospital.,Department of Dental Microbiology
| | | | - Grazyna Dulny
- Department of Epidemiology, Central Clinical Hospital, Medical University of Warsaw, Poland
| | | | | | - Grzegorz W Basak
- Department of Hematology, Oncology, and Internal Diseases, Medical University of Warsaw
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Dinh A, Fessi H, Duran C, Batista R, Michelon H, Bouchand F, Lepeule R, Vittecoq D, Escaut L, Sobhani I, Lawrence C, Chast F, Ronco P, Davido B. Clearance of carbapenem-resistant Enterobacteriaceae vs vancomycin-resistant enterococci carriage after faecal microbiota transplant: a prospective comparative study. J Hosp Infect 2018; 99:481-486. [PMID: 29477634 DOI: 10.1016/j.jhin.2018.02.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/16/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE) carriage are increasing worldwide. Faecal microbiota transplantation (FMT) appears to be an attractive option for decolonization. This study aimed to evaluate CRE vs VRE clearance by FMT among carriers. METHODS A multi-centre trial was undertaken on patients with CRE or VRE digestive tract colonization who received FMT between January 2015 and April 2017. Adult patients with CRE or VRE colonization, confirmed by three consecutive rectal swabs at weekly intervals, including one in the week prior to FMT, were included in the study. Patients with immunosuppression or concomitant antibiotic prescription at the time of FMT were excluded. Successful decolonization was determined by at least two consecutive negative rectal swabs [polymerase chain reaction (PCR) and culture] on Days 7, 14, 21 and 28, and monthly for three months following FMT. RESULTS Seventeen patients were included, with a median age of 73 years [interquartile range (IQR) 64.3-79.0]. Median duration of carriage of CRE or VRE before FMT was 62.5 days (IQR 57.0-77.5). One week after FMT, three of eight patients were free of CRE colonization and three of nine patients were free of VRE colonization. After three months, four of eight patients were free of CRE colonization and seven of eight patients were free of VRE colonization. Qualitative PCR results were concordant with culture. Six patients received antibiotics during follow-up, three in each group. No adverse events were reported. CONCLUSION CRE and VRE clearance rates were not significantly different in this study, possibly due to the small sample size, but a trend was observed. These data should be confirmed by larger cohorts and randomized trials.
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Affiliation(s)
- A Dinh
- Infectious Diseases Unit, Raymond Poincaré Teaching Hospital, APHP, Versailles Saint-Quentin University, Garches, France.
| | - H Fessi
- Nephrology Unit, Tenon Teaching Hospital, APHP, Pierre et Marie Curie University, Paris, France
| | - C Duran
- Infectious Diseases Unit, Raymond Poincaré Teaching Hospital, APHP, Versailles Saint-Quentin University, Garches, France
| | - R Batista
- Pharmacy Department, Cochin Teaching Hospital, APHP, Paris Descartes University, Paris, France
| | - H Michelon
- Pharmacy Department, Raymond Poincaré Teaching Hospital, APHP, Versailles Saint-Quentin University, Garches, France
| | - F Bouchand
- Pharmacy Department, Raymond Poincaré Teaching Hospital, APHP, Versailles Saint-Quentin University, Garches, France
| | - R Lepeule
- Antimicrobial Stewardship Unit, Henri Mondor Teaching Hospital, APHP, Paris-Est Créteil-Est University, Créteil, France
| | - D Vittecoq
- Infectious Diseases Unit, Bicêtre Teaching Hospital, APHP, Paris-Sud University, Kremlin-Bicêtre, France
| | - L Escaut
- Infectious Diseases Unit, Bicêtre Teaching Hospital, APHP, Paris-Sud University, Kremlin-Bicêtre, France
| | - I Sobhani
- Gastro-enterology Department, Henri Mondor Teaching Hospital, APHP, Paris-Est Créteil-Est University, Créteil, France
| | - C Lawrence
- Microbiology Laboratory, Raymond Poincaré Teaching Hospital, APHP, Versailles Saint-Quentin University, Garches, France
| | - F Chast
- Pharmacy Department, Cochin Teaching Hospital, APHP, Paris Descartes University, Paris, France
| | - P Ronco
- Nephrology Unit, Tenon Teaching Hospital, APHP, Pierre et Marie Curie University, Paris, France
| | - B Davido
- Infectious Diseases Unit, Raymond Poincaré Teaching Hospital, APHP, Versailles Saint-Quentin University, Garches, France
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Flokas ME, Karageorgos SA, Detsis M, Alevizakos M, Mylonakis E. Vancomycin-resistant enterococci colonisation, risk factors and risk for infection among hospitalised paediatric patients: a systematic review and meta-analysis. Int J Antimicrob Agents 2017; 49:565-572. [PMID: 28336313 DOI: 10.1016/j.ijantimicag.2017.01.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/20/2016] [Accepted: 01/06/2017] [Indexed: 10/19/2022]
Abstract
The objective of this study was to estimate the rate and significance of colonisation with vancomycin-resistant enterococci (VRE) among hospitalised children. The PubMed and EMBASE databases were systematically searched (last accessed on 29 May 2016) to identify studies evaluating VRE colonisation of the gastrointestinal tract of hospitalised children in non-outbreak periods. Of 945 non-duplicate citations, 19 studies enrolling 20 234 children were included. The overall and paediatric intensive care unit (PICU) rate of VRE colonisation were both 5% [95% confidence interval (CI) 3-8% overall and 95% CI 2-9% in the PICU] but was 23% in haematology/oncology units (95% CI 18-29%). Studies that were exclusively performed in haematology/oncology units reported significantly higher rates compared with all other studies in the univariate and multivariate analyses (P = 0.001). Previous vancomycin [risk ratio (RR) = 4.34, 95% CI 2.77-6.82] or ceftazidime (RR = 4.15, 95% CI 2.69-6.40) use was a risk factor for VRE colonisation. Importantly, VRE colonisation increased the risk of subsequent VRE infection (RR = 8.75, 95% CI 3.19-23.97). In conclusion, a high rate of VRE colonisation was found among hospitalised children in institutions that performed targeted screening. Importantly, colonised children were almost 9 times more likely to develop subsequent VRE infection. Judicious use of specific antibiotics along with intensification of infection control measures should be considered in high-prevalence institutions. Also, the high incidence of VRE colonisation among children with haematological/oncological diseases identifies a high-risk population.
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Affiliation(s)
- Myrto Eleni Flokas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Spyridon A Karageorgos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Marios Detsis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA.
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Alevizakos M, Gaitanidis A, Nasioudis D, Tori K, Flokas ME, Mylonakis E. Colonization With Vancomycin-Resistant Enterococci and Risk for Bloodstream Infection Among Patients With Malignancy: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2016; 4:ofw246. [PMID: 28480243 PMCID: PMC5414102 DOI: 10.1093/ofid/ofw246] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/14/2016] [Indexed: 11/13/2022] Open
Abstract
Background Vancomycin-resistant enterococci (VRE) cause severe infections among patients with malignancy, and these infections are usually preceded by gastrointestinal colonization. Methods We searched the PubMed and EMBASE databases (up to May 26, 2016) to identify studies that reported data on VRE gastrointestinal colonization among patients with solid or hematologic malignancy. Results Thirty-four studies, reporting data on 8391 patients with malignancy, were included in our analysis. The pooled prevalence of VRE colonization in this population was 20% (95% confidence interval [CI], 14%–26%). Among patients with hematologic malignancy, 24% (95% CI, 16%–34%) were colonized with VRE, whereas no studies reported data solely on patients with solid malignancy. Patients with acute leukemia were at higher risk for VRE colonization (risk ratio [RR] = 1.95; 95% CI, 1.17–3.26). Vancomycin use or hospitalization within 3 months were associated with increased colonization risk (RR = 1.92, 95% CI = 1.06–3.45 and RR = 4.68, 95% CI = 1.66–13.21, respectively). Among the different geographic regions, VRE colonization rate was 21% in North America (95% CI, 13%–31%), 20% in Europe (95% CI, 9%–34%), 23% in Asia (95% CI, 13%–38%), and 4% in Oceania (95% CI, 2%–6%). More importantly, colonized patients were 24.15 (95% CI, 10.27–56.79) times more likely to develop a bloodstream infection due to VRE than noncolonized patients. Conclusions A substantial VRE colonization burden exists among patients with malignancy, and colonization greatly increases the risk for subsequent VRE bloodstream infection. Adherence to antimicrobial stewardship is needed, and a re-evaluation of the use of vancomycin as empiric therapy in this patient population may be warranted.
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Affiliation(s)
- Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Apostolos Gaitanidis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Dimitrios Nasioudis
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York
| | - Katerina Tori
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Myrto Eleni Flokas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence
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Singh N, Léger MM, Campbell J, Short B, Campos JM. Control of Vancomycin-Resistant Enterococci in the Neonatal Intensive Care Unit. Infect Control Hosp Epidemiol 2016; 26:646-9. [PMID: 16092746 DOI: 10.1086/502595] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AbstractBackground and Objective:Multidrug-resistant organisms (MDROs), such as vancomycin-resistant enterococci (VRE), cause serious infections, especially among high-risk patients in NICUs. When VRE was introduced and transmitted in our NICU despite recommended infection control practices, we instituted active surveillance cultures to determine their efficacy in detecting and controlling spread of VRE among high-risk infants.Methods:Active surveillance cultures, other infection control measures, and a mandatory in-service education module on preventing MDRO transmission were implemented. Cultures were performed on NICU admission and then weekly during their stay. Molecular DNA fingerprinting of VRE isolates facilitated targeting efforts to eliminate clonal spread of VRE. Repetitive sequence PCR (rep-PCR)-based DNA fingerprinting was used to compare isolates recovered from patients with VRE infection or colonization. Environmental VRE cultures were performed around VRE-colonized or -infected patients. DNA fingerprints were prepared from the products of rep-PCR amplification and analyzed using software to determine strain genetic relatedness.Results:Active surveillance cultures identified 65 patients with VRE colonization or infection among 1,820 admitted to the NICU. Rep-PCR performed on 60 VRE isolates identified 3 clusters. Cluster 1 included isolates from 21 patients and 4 isolates from the environment of the index patient. Clusters 2 and 3 included isolates from 23 and 3 patients, respectively. Similarity coefficients among the members of each cluster were 95% or greater.Conclusions:Control of transmission of multi-clonal VRE strains was achieved. Active surveillance cultures, together with implementation of other infection control measures, combined with rep-PCR DNA fingerprinting were instrumental in controlling VRE transmission in our NICU. (Infect Control Hosp Epidemiol 2005;26:646-649)
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Affiliation(s)
- Nalini Singh
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC 20010, USA.
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Huh JY, Lee WG, Jin HY. Molecular Characterization of Vancomycin-Resistant Enterococci from Clinical and Surveillance Specimens. Infect Control Hosp Epidemiol 2016; 27:1076-80. [PMID: 17006815 DOI: 10.1086/507961] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 11/03/2005] [Indexed: 11/03/2022]
Abstract
Objective:To compare the molecular characteristics of infection-derived (ID) isolates and intestinal colonization–derived (ICD) isolates of vancomycin-resistant enterococci (VRE) recovered from hospitalized patients.Design.A 12-month prospective cohort study.Setting.A 1,000-bed teaching facility.Methods.From January through December 2004, a total of 30 pairs ofvanA-containing enterococcal isolates were collected from patients admitted to a teaching hospital in South Korea. Each pair comprised an ID and an ICD VRE isolate from the same patient. All VRE isolates were investigated on the basis ofSmaI-restricted pulsed-field gel electrophoresis (PFGE) pattern, Tn1546type, and presence of theespgene, including A and C repeat number variation.Results.Members of 19 pairs (63%) of VRE isolates were genetically indistinguishable from each other. The 11 patients for whom the molecular characteristics of the ID isolates differed from those of the ICD isolates had longer durations of hospitalization and intensive care unit (ICU) stay, compared with the other 19 patients.Conclusions.These findings suggest the longer durations of hospitalization and ICU stay may be possible risk factors for colonization with multiple clones of VRE.
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Affiliation(s)
- Ji Young Huh
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Weber SG, Huang SS, Oriola S, Huskins WC, Noskin GA, Harriman K, Olmsted RN, Bonten M, Lundstrom T, Climo MW, Roghmann MC, Murphy CL, Karchmer TB. Legislative Mandates for Use of Active Surveillance Cultures to Screen for Methicillin-ResistantStaphylococcus aureusand Vancomycin-Resistant Enterococci: Position Statement From the Joint SHEA and APIC Task Force. Infect Control Hosp Epidemiol 2015; 28:249-60. [PMID: 17326014 DOI: 10.1086/512261] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 01/05/2007] [Indexed: 01/14/2023]
Abstract
Legislation aimed at controlling antimicrobial-resistant pathogens through the use of active surveillance cultures to screen hospitalized patients has been introduced in at least 2 US states. In response to the proposed legislation, the Society for Healthcare Epidemiology of America (SHEA) and the Association of Professionals in Infection Control and Epidemiology (APIC) have developed this joint position statement. Both organizations are dedicated to combating healthcare-associated infections with a wide array of methods, including the use of active surveillance cultures in appropriate circumstances. This position statement reviews the proposed legislation and the rationale for use of active surveillance cultures, examines the scientific evidence supporting the use of this strategy, and discusses a number of unresolved issues surrounding legislation mandating use of active surveillance cultures. The following 5 consensus points are offered. (1) Although reducing the burden of antimicrobial-resistant pathogens, including methicillin-resistantStaphylococcus aureus(MRSA) and vancomycin-resistant enterococci (VRE), is of preeminent importance, APIC and SHEA do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE, or other antimicrobial-resistant pathogens. (2) SHEA and APIC support the continued development, validation, and application of efficacious and cost-effective strategies for the prevention of infections caused by MRSA, VRE, and other antimicrobial-resistant and antimicrobial-susceptible pathogens. (3) APIC and SHEA welcome efforts by healthcare consumers, together with private, local, state, and federal policy makers, to focus attention on and formulate solutions for the growing problem of antimicrobial resistance and healthcare-associated infections. (4) SHEA and APIC support ongoing additional research to determine and optimize the appropriateness, utility, feasibility, and cost-effectiveness of using active surveillance cultures to screen both lower-risk and high-risk populations. (5) APIC and SHEA support stronger collaboration between state and local public health authorities and institutional infection prevention and control experts.
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Affiliation(s)
- Stephen G Weber
- Section of Infectious Diseases, University of Chicago, Chicago, IL 60637, USA.
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Olivier CN, Blake RK, Steed LL, Salgado CD. Risk of Vancomycin-ResistantEnterococcus(VRE) Bloodstream Infection Among Patients Colonized With VRE. Infect Control Hosp Epidemiol 2015; 29:404-9. [DOI: 10.1086/587647] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background.Colonization with vancomycin-resistantEnterococcus(VRE) is a risk factor for subsequent VRE bloodstream infection (BSI); however, risk factors for BSI among colonized patients have not been adequately described. We sought to determine the proportion of VRE-colonized patients who subsequently develop VRE BSI and to identify risk factors for VRE BSI among these patients.Methods.Records of 768 patients colonized with VRE from January 2002 through June 2005 were reviewed. The proportion of patients who developed VRE BSI was calculated, and the characteristics of these patients were compared, in a 2 : 1 ratio, with those of patients who did not develop VRE BSI. To identify risk factors for VRE BSI and for death, we used univariate logistic regression analysis and then multivariate logistic regression analysis. Using pulsed-field gel electrophoresis (PFGE), we compared the isolate recovered when the patient was colonized and the isolate recovered when the patient developed VRE BSI.Results.Of the 768 patients colonized with VRE, 31 (4.0%) developed VRE BSI. Multivariate analysis identified the following idependent risk factors for developing VRE BSI: infection of an additional body site other than blood (adjusted odds ratio [aOR], 3.9;P= .04), admission to the hospital from a long-term care facility (aOR, 12.6;P= .04), and receipt of vancomycin (aOR, 10.6;P< .001). The independent risk factors for death among patients colonized with VRE were immunosuppression (aOR, 12.9;P= .001 ) and VRE BSI (aOR, 9.1;P= .002). Of the 31 patients who developed VRE BSI, 23 (74%) had a pair of isolates representing VRE colonization and VRE BSI. For 19 (83%) of these 23 patients, the isolate representing BSI was genetically related to the isolate representing VRE colonization: 12 pairs of isolates (52%) had identical banding patterns, 5 had closely related patterns, and 2 had possibly related patterns.Conclusion.Of the 768 patients colonized with VRE, 31 (4.0%) usually developed VRE BSI due to a related strain. Independent risk factors for BSI among colonized patients were admission from a long-term care facility, infection of an additional body site, and exposure to vancomycin. Independent risk factors for death were immunosuppression and VRE BSI.
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Averbuch D, Orasch C, Cordonnier C, Livermore DM, Mikulska M, Viscoli C, Gyssens IC, Kern WV, Klyasova G, Marchetti O, Engelhard D, Akova M. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia. Haematologica 2014; 98:1826-35. [PMID: 24323983 DOI: 10.3324/haematol.2013.091025] [Citation(s) in RCA: 381] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Owing to increasing resistance and the limited arsenal of new antibiotics, especially against Gram-negative pathogens, carefully designed antibiotic regimens are obligatory for febrile neutropenic patients, along with effective infection control. The Expert Group of the 4(th) European Conference on Infections in Leukemia has developed guidelines for initial empirical therapy in febrile neutropenic patients, based on: i) the local resistance epidemiology; and ii) the patient's risk factors for resistant bacteria and for a complicated clinical course. An 'escalation' approach, avoiding empirical carbapenems and combinations, should be employed in patients without particular risk factors. A 'de-escalation' approach, with initial broad-spectrum antibiotics or combinations, should be used only in those patients with: i) known prior colonization or infection with resistant pathogens; or ii) complicated presentation; or iii) in centers where resistant pathogens are prevalent at the onset of febrile neutropenia. In the latter case, infection control and antibiotic stewardship also need urgent review. Modification of the initial regimen at 72-96 h should be based on the patient's clinical course and the microbiological results. Discontinuation of antibiotics after 72 h or later should be considered in neutropenic patients with fever of unknown origin who are hemodynamically stable since presentation and afebrile for at least 48 h, irrespective of neutrophil count and expected duration of neutropenia. This strategy aims to minimize the collateral damage associated with antibiotic overuse, and the further selection of resistance.
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Fecal carriage of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus in healthy children. Antimicrob Agents Chemother 2013; 58:1261-2. [PMID: 24277049 DOI: 10.1128/aac.02466-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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16
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Karki S, Land G, Aitchison S, Kennon J, Johnson PDR, Ballard SA, Leder K, Cheng AC. Long-term carriage of vancomycin-resistant enterococci in patients discharged from hospitals: a 12-year retrospective cohort study. J Clin Microbiol 2013; 51:3374-9. [PMID: 23926167 PMCID: PMC3811615 DOI: 10.1128/jcm.01501-13] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 08/01/2013] [Indexed: 11/20/2022] Open
Abstract
Contact precautions are recommended in hospitals to prevent the transmission of vancomycin-resistant enterococci (VRE); however, there is no clear policy for how long patients should be under contact precautions due to a lack of information on the duration of carriage of these organisms. We conducted a retrospective cohort study to understand the duration of carriage of VRE (by screening of a single stool culture) and associated factors among patients who had been identified with VRE infection and/or colonization since the year 2000 at our health facilities. Of the 345 eligible participants, 136 did not respond, 90 declined to participate, and 16 did not send in the required specimens. Of the 103 remaining participants, 13 were found to have current VRE fecal carriage. The proportion of colonized patients fell from 40% (2/5) in the first year to 23.3% (7/30) in year 4. None of the 40 patients who had VRE detected >4 years prior were found to be colonized at the time of the study. The longest duration of detected VRE positivity was 46.5 months. Univariate analysis revealed that recent exposure to any antibiotics (P = 0.016), multiple antibiotics (P = 0.001), amoxicillin-clavulanic acid (P = 0.021), piperacillin-tazobactam (P = 0.007), glycopeptides (P < 0.001), meropenem (P = 0.007), aminoglycosides (P = 0.021), or fluoroquinolones (P = 0.021), being the index case in a clinical specimen (P = 0.016), and recent hospitalization (P < 0.001) were significantly associated with continued carriage on follow-up. In the surviving outpatients, a significant proportion appeared to clear VRE carriage. Our results suggest that in the absence of recent risk factors, such as hospitalization or antibiotic use, patients with a remote history of colonization (>4 years) may no longer require contact isolation precautions.
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Affiliation(s)
- Surendra Karki
- Department of Epidemiology and Preventive Medicine, Infectious Disease Epidemiology Unit, Monash University, Melbourne, Australia
| | - Gillian Land
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
| | | | - Jacqueline Kennon
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
| | - Paul D. R. Johnson
- Austin Centre for Infection Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Microbiology and Immunology, University of Melbourne, Melbourne, Australia
| | - Susan A. Ballard
- Austin Centre for Infection Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Karin Leder
- Department of Epidemiology and Preventive Medicine, Infectious Disease Epidemiology Unit, Monash University, Melbourne, Australia
| | - Allen C. Cheng
- Department of Epidemiology and Preventive Medicine, Infectious Disease Epidemiology Unit, Monash University, Melbourne, Australia
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
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The value of chlorhexidine gluconate wipes and prepacked washcloths to prevent the spread of pathogens--a systematic review. Aust Crit Care 2013; 26:158-66. [PMID: 23827390 DOI: 10.1016/j.aucc.2013.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/15/2013] [Accepted: 05/27/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Use of chlorhexidine gluconate wipes and pre-packed washcloths has been described for preventing pathogen spread in healthcare settings. AIM To assess the impact of chlorhexidine washcloths/wipes in preventing the spread of pathogens. METHODS Extensive and structured literature search from studies in Google Academic, Cochrane Library, Web of Science, Pubmed and Cinahl from their inception until November 2012. FINDINGS Final analysis included 15 studies, 9 of which were randomised controlled trials. The most frequent setting was the intensive care unit. In intensive care units, a significant reduction of bloodstream infection was associated with intervention and 3 studies revealed a decrease in blood culture contamination. One study showed a decrease in staff and environmental contamination and no increase in chlorhexidine resistance with intervention. Positive blood cultures for multiple pathogens also declined with intervention. In a paediatric intensive care unit, intervention decreased bacteraemia and catheter-associated bloodstream infection. In hospital wards, intervention was associated to a 64% reduction of pathogen transmission. One study had no statistically significant results. Pre-surgical chlorhexidine use significantly decreased bacterial colonisation but had no impact on surgical site infections. Regarding maternal and perinatal setting, one study did not show reduction of early onset neonatal sepsis and pathogen transmission. Another study of vaginal and neonatal decolonisation with chlorhexidine wiping revealed significant reduction in colonisation. One study concluded that single and multiple umbilical cord cleansing reduced the likelihood for a positive swab in 25% and 29%, respectively. Neonatal wiping maintained low levels of skin colonisation for a 24h period, for multiple pathogens. CONCLUSION Current evidence supports the usefulness of chlorhexidine washcloths and wipes in an intensive care, hospital and pre-surgical setting. More studies are required to encourage its use for prevention of perinatal and neonatal transmission of pathogens.
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Vancomycin-resistant Enterococcus in pediatric oncology patients: balancing infection prevention and family-centered care. J Pediatr Hematol Oncol 2013; 35:227-31. [PMID: 22627579 DOI: 10.1097/mph.0b013e318257a6ca] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In February 2007, we experienced an abrupt 8-fold increase in vancomycin-resistant Enterococcus (VRE)-positive pediatric hematology/oncology patients in isolation per day, peaking at 12 patients in isolation per day in June 2007. We enforced and expanded infection prevention practices and initiated a rigorous 6-month clearance process. After noting an eventual decrease, we modified clearance to a 3-month process, maintaining <1 patient/day in isolation by June 2009, subjectively improving family and staff satisfaction after this 2-year process. VRE infection was relatively uncommon (7.8%), although continued VRE colonization portended an overall poorer prognosis.
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Hong SK, Kim TS, Park KU, Kim JS, Kim EC. Active Surveillance for Multidrug-resistant Organisms. ANNALS OF CLINICAL MICROBIOLOGY 2013. [DOI: 10.5145/acm.2013.16.2.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Kuk Hong
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Taek Soo Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyoung Un Park
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae-Seok Kim
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Eui-Chong Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
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Polyclonal outbreak of vancomycin-resistant Enterococcus faecium in a pediatric oncology department. J Pediatr Hematol Oncol 2012; 34:511-6. [PMID: 22627577 DOI: 10.1097/mph.0b013e318257a5d3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present a polyclonal outbreak of vancomycin-resistant enterococci (VRE) colonization in a pediatric oncology department and the role of a bundle of actions. After the occurrence of VRE bloodstream infections in 2 patients, an active surveillance of VRE colonization was started. Enhanced infection control measures and closure of the department to new admissions for the first 3 months were implemented. Among 32 patients screened for VRE, 21 were found colonized. Daily prevalence of VRE colonization among hospitalized patients ranged from 40% to 75%, but no new VRE infections occurred. Monthly incidence of VRE colonization decreased from 2.5 to 0.6 cases per 100 occupied bed-days at the end of this outbreak by the implementation of the above-mentioned measures. All VRE isolates tested were Enterococcus faecium carrying VanA gene. Pulsed field gel electrophoresis showed a polyclonal outbreak. A case-control study did not show any particular risk factors for colonization. High use of glycopeptide was noted before study outbreak that was drastically decreased during the study but only temporarily. Control of VRE in pediatric oncology departments with high colonization rates is challenging and requires a multifaceted strategy. Polyclonal spread of VRE found in this study suggests a possible effect of prior antimicrobial overuse and the critical need for antimicrobial stewardship especially in the era of multidrug-resistant bacteria.
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An evaluation of the ability of the probiotic strain Lactobacillus rhamnosus GG to eliminate the gastrointestinal carrier state of vancomycin-resistant enterococci in colonized children. J Clin Gastroenterol 2011; 45:872-7. [PMID: 21814146 DOI: 10.1097/mcg.0b013e318227439f] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
GOALS To evaluate the efficacy of Lactobacillus rhamnosus GG (LGG) supplementation in eliminating the gastrointestinal carrier state of vancomycin-resistant enterococci (VRE) in colonized children, and to evaluate the affect of the probiotic on Lactobacillus spp. counts in the gastrointestinal tract. STUDY A randomized, single-blind, placebo-controlled study. Children (0 to 18 y old) hospitalized at the wards of the children's hospital who were diagnosed with gastrointestinal carrier state of VRE were randomized to group receiving 3 billion colony forming unit of LGG/day or placebo for 21 consecutive days. A total of 61 children completed the study (32 in the treatment group and 29 in the control group). Rectal swabs for VRE and Lactobacillus spp. were collected at baseline, during supplementation at weekly intervals and 1 month after supplementation. Antibiotic supply was controlled throughout the duration of the analysis. RESULTS A significant difference in the number of children colonized with VRE between the groups was observed at 3 weeks (P = 0.002). The VRE carrier state was lost by 20 of 32 participants in the treatment group and 7 of 29 in the control group. We also observed increased gastrointestinal counts of Lactobacillus spp. in children receiving LGG. A statistically significant difference in the occurrence of bacteria was observed from week 1 onwards, whereas in the aspect of growth intensity from week 2 onwards. CONCLUSIONS LGG supplementation temporarily eliminates the VRE carrier state and increases gastrointestinal counts of Lactobacillus spp. in children versus placebo.
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Weber B, Saliken J, Jadavji T, Gray RR, Moore R. A near-fatal case of sepsis with an antibiotic-resistant organism complicating a routine transrectal prostate biopsy in a health care worker. Can Urol Assoc J 2011; 2:543-5. [PMID: 18953456 DOI: 10.5489/cuaj.926] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 58-year-old physician with an elevated prostate specific antigen developed severe septic shock following a repeat transrectal prostate biopsy despite standard preoperative prophylactic protocol. This case highlights the significance of harbouring antibiotic-resistant bacteria and the risk of previous quinolone exposure. We believe this case may herald a rare but potentially serious consequence of increasingly common antibiotic resistance and that high-risk patients should be studied to determine their likelihood of carrying antibiotic-resistant flora in their genitourinary/gastrointestinal tract.
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Affiliation(s)
- Bryce Weber
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ont., the
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Yoon YK, Lee SE, Lee J, Kim HJ, Kim JY, Park DW, Sohn JW, Kim MJ. Risk factors for prolonged carriage of vancomycin-resistant Enterococcus faecium among patients in intensive care units: a case-control study. J Antimicrob Chemother 2011; 66:1831-8. [PMID: 21652622 DOI: 10.1093/jac/dkr204] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES The aim of this study was to identify the risk factors for prolonged carriage of vancomycin-resistant Enterococcus faecium (VREF) in intensive care units (ICUs). METHODS A retrospective case-control study was performed in the ICUs of a university hospital in Korea from September 2006 to July 2009. VREF carriage was identified through weekly active surveillance rectal cultures. Clinical characteristics and the risk factors for VREF acquisition were compared between cases with prolonged VREF carriage (≥ 5 weeks, n = 58) and controls with shorter VREF carriage (<3 weeks, n = 36) in a multivariate logistic regression model. The effect of vancomycin consumption on vancomycin-resistant enterococci (VRE) colonization pressure was investigated using time-series analysis with an autoregressive error model. RESULTS Out of a total of 6327 rectal swab cultures examined, 1915 (30.3%) specimens from 266 patients were positive for VREF. The weekly VRE colonization pressure ranged from 0.77% to 42.42%. Vancomycin use after VREF acquisition significantly increased VREF carriage (adjusted odds ratio = 4.09; 95% confidence interval = 1.32-12.65). The case group had higher in-hospital mortality than the control group [21 (36.2%) versus 4 (11.1%), P = 0.007]. Increment of VRE colonization pressure was significantly associated with vancomycin consumption of 1week before (i.e. time t - 1) (P = 0.0028) and moderately associated with that of the corresponding week (i.e. time t) (P = 0.0595). CONCLUSIONS Vancomycin use in patients with VREF colonization might prolong the duration of carriage. Restriction of vancomycin use should be strengthened in these patients through infection control measures.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Korea University Medical Center, Seoul, Korea
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Haas EJ, Zaoutis TE, Prasad P, Li M, Coffin SE. Risk Factors and Outcomes for Vancomycin-Resistant Enterococcus Bloodstream Infection in Children. Infect Control Hosp Epidemiol 2010; 31:1038-1042. [PMID: 20807035 DOI: 10.1086/655464] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background and objective. Enterococcal bloodstream infections (BSIs) cause morbidity and mortality in children. This study aims to describe the epidemiological characteristics of enterococcal BSI, to determine the risk factors for vancomycin-resistant Enterococcus (VRE) BSI, and to compare outcomes of VRE BSI and vancomycin-susceptible Enterococcus (VSE) BSI in this population. Methods. A retrospective cohort study at a 418-bed tertiary care children's hospital in Philadelphia, Pennsylvania, examined the epidemiological characteristics of children hospitalized with enterococcal BSI during the period from 2001 through 2006. A nested case-control study compared patients with VRE BSI with control patients with VSE BSI. Analysis included regression modeling to identify independent risk factors for VRE BSI. Results. We identified 339 patients with enterococcal BSI during the study period, including 39 patients with VRE infection. Fifty-three patients (16%) died before hospital discharge. Risk factors for VRE included long-term receipt of mechanical ventilation (adjusted odds ratio [OR], 5.40 [95% confidence interval {CI}, 1.28-6.48]), receipt of immunosuppressive medications during the preceding 30 days (adjusted OR, 2.88 [95% CI, 1.40-20.78]), use of vancomycin during the 2 weeks before onset of bacteremia (adjusted OR per day of vancomycin use, 1.25 [95% CI, 1.14-1.38]), and older age (adjusted OR, 1.08 [95% CI, 1.03-1.14]). VRE BSI was not associated with an increased length of stay after onset of bacteremia (0.77 days [95% CI, 0.55-1.07 days]). Mortality was higher for VRE BSI, but the difference was not statistically significant (adjusted OR, 1.94 [95% CI, 0.78-4.8]). Conclusion. Most enterococcal BSI in children was caused by VSE. Risk factors for VRE BSI included receipt of vancomycin, long-term receipt of mechanical ventilation, immunosuppression, and older age. Differences in length of stay and mortality were not detected.
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Affiliation(s)
- Eric J Haas
- From the Division of Infectious Diseases (E.J.H., T.E.Z., P.P., S.E.C.) and the Center for Clinical Effectiveness (T.E.Z., S.E.C.), the Children's Hospital of Philadelphia, and the Department of Pediatrics (T.E.Z., S.E.C.), the Center for Clinical Epidemiology and Biostatistics (T.E.Z., S.E.C.), and the Department of Biostatistics (M.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. (Present affiliation: Division of Maternal and Child Health, Ministry of Health, Southern District, Beersheva, Israel [E.J.H].)
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25
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Nolan SM, Gerber JS, Zaoutis T, Prasad P, Rettig S, Gross K, McGowan KL, Reilly AF, Coffin SE. Outbreak of vancomycin-resistant enterococcus colonization among pediatric oncology patients. Infect Control Hosp Epidemiol 2009; 30:338-45. [PMID: 19239375 DOI: 10.1086/596202] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To detect the burden of vancomycin-resistant Enterococcus (VRE) colonization among pediatric oncology patients and to determine risk factors for VRE acquisition. DESIGN Retrospective case-control study. SETTING The Children's Hospital of Philadelphia. PATIENTS Pediatric oncology patients hospitalized from June 2006 through December 2007. METHODS Prevalence surveys revealed an increased VRE burden among pediatric oncology patients. For the case-control study, the 16 case patients were pediatric oncology patients who had 1 stool sample negative for VRE at screening before having a stool sample positive for VRE at screening; the 62 control patients had 2 consecutive screenings in which stool samples were negative for VRE. Case and control patients were matched on the duration of the interval between screens. Analyses were performed to determine the association between multiple exposures and VRE acquisition. RESULTS The prevalence survey revealed that 5 (9.6%) of 52 patients had unsuspected VRE colonization at the time of hospitalization. Multivariate analysis identified a lack of empirical contact precautions (odds ratio [OR], 17.16 [95% confidence interval {CI}, 1.49-198.21]; P= .02) and the presence of a gastrointestinal device (OR, 4.03 [95% CI, 1.04-15.56]; P= .04) as significant risk factors for acquisition of VRE. Observations in the interventional radiology department revealed that staff could not access the portions of the electronic medical record in which isolation precautions were documented. Simple interventions that granted access and that trained interventional radiology staff to review the need for precautions, coupled with enhanced infection control practices, interrupted ongoing transmission and reduced the proportion of VRE screens that were positive to 15 (1.2%) of 1,270. CONCLUSIONS Inadequate communication with regard to infection control precautions can increase the risk of transmission of epidemiologically important organisms, particularly when patients receive care at multiple clinic locations. Adherence to infection control practices across the spectrum of care may limit the spread of resistant organisms.
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Affiliation(s)
- Sheila M Nolan
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Mazuski JE. Vancomycin-resistant enterococcus: risk factors, surveillance, infections, and treatment. Surg Infect (Larchmt) 2009; 9:567-71. [PMID: 19216668 DOI: 10.1089/sur.2008.9955] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of vancomycin has continued to expand because of the increasing number of patients infected or colonized with methicillin-resistant Staphylococcus aureus, causing an increase in the prevalence of vancomycin-resistant Enterococcus (VRE). METHODS Review of the pertinent English language literature. RESULTS Vancomycin-resistant Enterococcus spp. are being identified more often in nosocomial infections of surgical patients. The biology of resistance, modes of transmission, patient risk factors, and current treatment strategies are discussed. CONCLUSIONS The reservoir of resistance in enterococci looms as a major threat for genetic transfer and the emergence of increasing numbers of vancomycin-resistant S. aureus.
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Affiliation(s)
- John E Mazuski
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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Kosack A, Riedel E, Kiehn TE, Small TN, Wexler LH, Dunkel IJ. Vancomycin-resistant enterococcus in pediatric oncology patients: An analysis of potential consequences of colonization and infection. Pediatr Blood Cancer 2009; 52:300-2. [PMID: 18837434 DOI: 10.1002/pbc.21793] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A retrospective analysis of 57 pediatric oncology patients with a baseline positive vancomycin-resistant enterococcus (VRE) culture who subsequently received chemotherapy and/or radiation therapy was performed. The incidence of subsequent VRE infection was calculated using a competing risk analysis accounting for death from non-VRE causes as a competing risk. Ten patients had subsequent VRE infection. The cumulative incidence of subsequent infection was 14% (7-27%, 95% confidence interval) at 1 year and 16% (9-29%, 95% confidence interval) at 2 years. None of the hypothesized risk factors appeared to differ between patients who developed a subsequent infection and those who did not.
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Affiliation(s)
- Amanda Kosack
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Chlebicki MP, Kurup A. Vancomycin-resistant Enterococcus – A Review From a Singapore Perspective. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n10p861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Vancomycin-resistant enterococcus (VRE) can cause serious infections in vulnerable, immunocompromised patients.
Materials and Methods: In this article, we summarise current data on epidemiology, detection, treatment and prevention of VRE. Results: VRE was first isolated in Singapore in 1994 and until 2004 was only sporadically encountered in our public hospitals. After 2 outbreaks in 2004 and in 2005, VRE has become established in our healthcare institutions. Multiple studies have shown that VRE spreads mainly via contaminated hands, cloths and portable equipment carried by healthcare workers.
Conclusions: Only a comprehensive programme (consisting of active surveillance, isolation of colonised/infected patients, strict adherence to proper infection control practices and anti-microbial stewardship) can limit the spread of these organisms. In addition to monitoring the compliance with traditional infection control measures, new strategies that merit consideration include pre-emptive isolation of patients in high-risk units and molecular techniques for the detection of VRE.
Keywords: Antibiotic resistance, Infection control, Outbreaks, Surveillance
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Verma N, Clarke RW, Bolton-Maggs PHB, van Saene HKF. Gut overgrowth of vancomycin-resistant enterococci (VRE) results in linezolid-resistant mutation in a child with severe congenital neutropenia: a case report. J Pediatr Hematol Oncol 2007; 29:557-60. [PMID: 17762497 DOI: 10.1097/mph.0b013e3180f61b81] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A child with severe congenital neutropenia was monitored with microbiologic surveillance cultures for 3 years. He had recurrent bacterial infections and carriage of vancomycin-resistant enterococci. Resistance to linezolid emerged in the colonizing vancomycin-resistant enterococci after each course of this antibiotic when enterococci were present in overgrowth in the gut before treatment. The child was successfully treated for his congenital neutropenia by unrelated donor stem cell transplantation.
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Affiliation(s)
- Nitin Verma
- Department of Haematology and Oncology, Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool
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Weber SG, Huang SS, Oriola S, Huskins WC, Noskin GA, Harriman K, Olmsted RN, Bonten M, Lundstrom T, Climo MW, Roghmann MC, Murphy CL, Karchmer TB. Legislative mandates for use of active surveillance cultures to screen for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci: Position statement from the Joint SHEA and APIC Task Force. Am J Infect Control 2007; 35:73-85. [PMID: 17327185 DOI: 10.1016/j.ajic.2007.01.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Legislation aimed at controlling antimicrobial-resistant pathogens through the use of active surveillance cultures to screen hospitalized patients has been introduced in at least 2 US states. In response to the proposed legislation, the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology, Inc., (APIC) have developed this joint position statement. Both organizations are dedicated to combating health care-associated infections with a wide array of methods, including the use of active surveillance cultures in appropriate circumstances. This position statement reviews the proposed legislation and the rationale for use of active surveillance cultures, examines the scientific evidence supporting the use of this strategy, and discusses a number of unresolved issues surrounding legislation mandating use of active surveillance cultures. The following 5 consensus points are offered. (1) Although reducing the burden of antimicrobial-resistant pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), is of preeminent importance, the APIC and the SHEA do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE, or other antimicrobial-resistant pathogens. (2) The SHEA and the APIC support the continued development, validation, and application of efficacious and cost-effective strategies for the prevention of infections caused by MRSA, VRE, and other antimicrobial-resistant and antimicrobial-susceptible pathogens. (3) The APIC and the SHEA welcome efforts by health care consumers, together with private, local, state, and federal policy makers, to focus attention on and formulate solutions for the growing problem of antimicrobial resistance and health care-associated infections. (4) The SHEA and the APIC support ongoing additional research to determine and optimize the appropriateness, utility, feasibility, and cost-effectiveness of using active surveillance cultures to screen both lower-risk and high-risk populations. (5) The APIC and the SHEA support stronger collaboration between state and local public health authorities and institutional infection prevention and control experts.
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Affiliation(s)
- Stephen G Weber
- Section of Infectious Diseases, University of Chicago Hospitals, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Abstract
From relative obscurity, enterococci have become a leading cause of nosocomial infection. This has been attributed, in part, to the growth in susceptible host populations, increased use of intravascular devices, prolonged hospital stay, and widespread antibiotics use. Furthermore, the facility with which enterococci acquire resistance characteristics coupled with their capacity to survive in the environment renders them uniquely suited as nosocomial opportunists and have resulted in global dissemination of resistant strains. Debate continues as to whether most serious infections arise from a person's indigenous flora or dissemination of virulent clones. Enterococci are normal inhabitants of the human gastrointestinal tract. Classically associated with endocarditis and wound and urinary tract infections, increasingly they are a cause of nosocomial bacteremia. The rise in incidence of serious enterococcal infection has been particularly evident in neonatal, paediatric intensive care, and haematology/oncology units. Spread of resistant phenotypes has posed a difficult therapeutic challenge. We have been rescued, albeit perhaps only temporarily, by the addition of newer agents, such as linezolid, to the therapeutic armamentarium. However, there is no room for complacency. Linezolid resistance already has been reported. Efforts must continue to focus on prevention of the emergence and dissemination of resistance through policies of rational antibiotic use, infection control and education.
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Affiliation(s)
- Karina M Butler
- Pediatric Infectious Diseases, Our Lady's Children's Hospital Crumlin & The Children's University Hospital, Dublin, Ireland.
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Brown DFJ, Brown NM, Cookson BD, Duckworth G, Farrington M, French GL, King L, Lewis D, Livermore DM, Macrae B, Scott GM, Williams D, Woodford N. National Glycopeptide-Resistant Enterococcal Bacteraemia Surveillance Working Group Report to the Department of Health — August 2004. J Hosp Infect 2006; 62 Suppl 1:S1-27. [PMID: 16338028 DOI: 10.1016/j.jhin.2005.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Accepted: 04/22/2005] [Indexed: 10/25/2022]
Affiliation(s)
- D F J Brown
- Clinical Microbiology and Public Health Laboratory, Health Protection Agency, Addenbrooke's Hospital, Cambridge CB2 2QW, UK.
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Cookson BD, Macrae MB, Barrett SP, Brown DFJ, Chadwick C, French GL, Hateley P, Hosein IK, Wade JJ. Guidelines for the control of glycopeptide-resistant enterococci in hospitals. J Hosp Infect 2006; 62:6-21. [PMID: 16310890 DOI: 10.1016/j.jhin.2005.02.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Accepted: 02/18/2005] [Indexed: 11/26/2022]
Abstract
The increase since the mid 1980s in glycopeptide resistant enterococci (GRE) raised concerns about the limited options for antimicrobial therapy, the implications for ever-increasing numbers of immunocompromised hospitalised patients, and fuelled fears, now realised, for the transfer of glycopeptide resistance to more pathogenic bacteria, such as Staphylococcus aureus. These issues underlined the need for guidelines for the emergence and control of GRE in the hospital setting. This Hospital Infection Society (HIS) and Infection Control Nurses Association (ICNA) working party report reviews the literature relating to GRE prevention and control. It provides guidance on microbiological investigation, treatment and management, including antimicrobial prescribing and infection control measures. Evidence identified to support recommendations has been categorized. A risk assessment approach is recommended and areas for research and development identified.
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Affiliation(s)
- B D Cookson
- Laboratory of Healthcare Associated Infection, Specialist and Reference Microbiology Division, Health Protection Agency, London, UK
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34
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Mascini EM, Bonten MJM. Vancomycin-resistant enterococci: consequences for therapy and infection control. Clin Microbiol Infect 2005; 11 Suppl 4:43-56. [PMID: 15953021 DOI: 10.1111/j.1469-0691.2005.01164.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vancomycin-resistant enterococci (VRE) have emerged as important nosocomial pathogens, initially in the USA, but now also in Europe, where hospital outbreaks are being reported with increasing frequency, although the incidence of VRE infections remains extremely low in most European countries. The recently demonstrated in-human transmission of vancomycin resistance from VRE to methicillin-resistant Staphylococcus aureus (MRSA) in two American patients underscores the potential danger of a coexisting reservoir of both pathogens. As MRSA is already endemic in many European hospital settings, prevention of endemicity with VRE seems relevant, but should be balanced against the costs associated with the implementation of effective strategies. The presence of a large community reservoir of VRE in Europe could hamper the feasibility of infection control strategies. Although the prevalence of colonisation amongst healthy subjects has apparently decreased after the ban on avoparcin use in the agricultural industry, a large proportion of admitted patients are still potential sources of VRE transmission. With no risk profile available to identify these carriers, effective screening, followed by barrier precautions for carriers, seems to be impossible. Recent studies, however, have suggested that hospital outbreaks are almost exclusively caused by specific genogroups of VRE that can be characterised phenotypically and genotypically (e.g., co-resistance to ampicillin and the presence of the variant esp gene). Based on our own experience, we propose that VRE infection control programmes should be restricted to patients colonised with these VRE strains. If such a strain is cultured from a clinical sample, surveillance amongst contact patients is recommended and barrier precautions should be implemented in the case of documented spread.
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Affiliation(s)
- E M Mascini
- Eijkman-Winkler Institute for Medical Microbiology, Infectious Diseases and Inflammation, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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35
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Koch S, Hufnagel M, Huebner J. Treatment and prevention of enterococcal infections--alternative and experimental approaches. Expert Opin Biol Ther 2005; 4:1519-31. [PMID: 15335318 DOI: 10.1517/14712598.4.9.1519] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Enterococci are one of the leading types of organisms isolated from infections of hospitalised patients and the third most common cause of nosocomial bloodstream infections. They contribute significantly to patient mortality and morbidity, as well as healthcare costs. The emergence of resistance against virtually all clinically available antibiotics and the ability to transfer these resistance determinants to other pathogens demonstrates the urgency for an improved understanding of enterococcal virulence mechanisms, and the development of alternative treatment and prevention options. This article reviews new antimicrobials, vaccine targets, bacteriophage therapy, as well as treatments targeting virulence factors and biofilm, for their potential to treat and/or prevent enterococcal infections. Although clinical isolates often cause serious infections, so-called 'non-pathogenic' strains are used as therapeutics in the form of probiotics. Understanding the differences between true pathogens and beneficial commensals may help to evaluate future treatment and prophylactic options.
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Affiliation(s)
- Stefanie Koch
- Department of Medicine, Channing Laboratory, Brigham and Women's Hospital, 181 Longwood Ave, Boston, MA 02115, USA
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36
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Kline RM, Baorto EP. Treatment of pediatric febrile neutropenia in the era of vancomycin-resistant microbes. Pediatr Blood Cancer 2005; 44:207-14. [PMID: 15515043 DOI: 10.1002/pbc.20224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE The increasing frequency of Gm(+) infections in febrile neutropenic (FN) patients has resulted in increased use of vancomycin (VN). Likely as a result, VN-resistant Enterococcus (VRE) has become a significant concern in FN patients. We sought to understand how the emergence of VN resistant microbes has changed the antibiotic management of pediatric FN. METHODS A questionnaire was distributed by e-mail to responsible investigators of the Children's Oncology Group. RESULTS One hundred and thirty responses were analyzed. Forty-four percent initially used monotherapy, with 82% of those using ceftazidime. Twenty-seven used VN with another agent, generally ceftazidime. After the emergence of VRE and VN-resistant staphylococcus (VRS), monotherapy increased to 58%. Ceftazidime continued to be most frequently used. There was a 57% reduction in the use of VN with 88% of centers not currently using VN in their initial treatment of FN. Forty-seven percent of the centers that continue to use VN have VRE, while 90% that have discontinued its use have VRE/VRS. CONCLUSIONS Ours is the first study to survey current practices in the treatment of pediatric FN and to document changes in practice patterns due to emerging antibiotic resistance patterns. We demonstrate increased use of monotherapy for FN, and a 57% decrease in the use of VN. Local considerations influence antibiotic choices with a significant difference in VRE prevalence between those centers that continue to use VN as compared to those that have discontinued it.
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Affiliation(s)
- Ronald M Kline
- Children's Center for Cancer and Blood Diseases, Las Vegas, Nevada, USA.
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37
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Moretti ML, Bratfich OJ, Stucchi RB, Levi C, Levin AS, Duboc GM, Vormittag E, Blum-Menezes D. Clonal dissemination of VanA-type glycopeptide-resistant Enterococcus faecalis between hospitals of two cities located 100 km apart. Braz J Med Biol Res 2004; 37:1339-43. [PMID: 15334199 DOI: 10.1590/s0100-879x2004000900008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Nosocomial dissemination of glycopeptide-resistant enterococci represents a major problem in hospitals worldwide. In Brazil, the dissemination among hospitals in the city of São Paulo of polyclonal DNA profiles was previously described for vancomycin-resistant Enterococcus faecium. We describe here the dissemination of VanA phenotype E. faecalis between two hospitals located in different cities in the State of São Paulo. The index outbreak occurred in a tertiary care university hospital (HCUSP) in the city of São Paulo and three years later a cluster caused by the same strain was recognized in two patients hospitalized in a private tertiary care hospital (CMC) located 100 km away in the interior of the state. From May to July 1999, 10 strains of vancomycin-resistant E. faecalis were isolated from 10 patients hospitalized in the HCUSP. The DNA genotyping using pulsed-field gel electrophoresis (PFGE) showed that all isolates were originated from the same clone, suggesting nosocomial dissemination. From May to July 2002, three strains of vancomycin-resistant E. faecalis were isolated from two patients hospitalized in CMC and both patients were colonized by the vancomycin-resistant Enterococcus in skin lesions. All isolates from CMC and HCUSP were highly resistant to vancomycin and teicoplanin. The three strains from CMC had minimum inhibitory concentration >256 micro g/ml for vancomycin, and 64 (CMC 1 and CMC 2) and 96 micro g/ml (CMC 3) for teicoplanin, characterizing a profile of VanA resistance to glycopeptides. All strains had the presence of the transposon Tn1546 detected by PCR and were closely related when typed by PFGE. The dissemination of the E. faecalis VanA phenotype among hospitals located in different cities is of great concern because E. faecalis commonly colonizes the gastrointestinal tract of patients and healthy persons for periods varying from weeks to years, which, together with the persistence of vancomycin-resistant Enterococcus in hospital rooms after standard cleaning procedures, increases the risk of the dissemination and reservoir of the bacteria.
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Affiliation(s)
- M L Moretti
- Laboratório de Epidemiologia Molecular e Moléstias Infecciosas, Divisão de Moléstias Infecciosas, Faculdade de Ciências Médicas, Universidade Estadual de CampinasCampinas, SP, Brasil.
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38
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Smith DL, Dushoff J, Perencevich EN, Harris AD, Levin SA. Persistent colonization and the spread of antibiotic resistance in nosocomial pathogens: resistance is a regional problem. Proc Natl Acad Sci U S A 2004; 101:3709-14. [PMID: 14985511 PMCID: PMC373527 DOI: 10.1073/pnas.0400456101] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Infections with antibiotic-resistant bacteria (ARB) in hospitalized patients are becoming increasingly frequent despite extensive infection-control efforts. Infections with ARB are most common in the intensive care units of tertiary-care hospitals, but the underlying cause of the increases may be a steady increase in the number of asymptomatic carriers entering hospitals. Carriers may shed ARB for years but remain undetected, transmitting ARB to others as they move among hospitals, long-term care facilities, and the community. We apply structured population models to explore the dynamics of ARB, addressing the following questions: (i) What is the relationship between the proportion of carriers admitted to a hospital, transmission, and the risk of infection with ARB? (ii) How do frequently hospitalized patients contribute to epidemics of ARB? (iii) How do transmission in the community, long-term care facilities, and hospitals interact to determine the proportion of the population that is carrying ARB? We offer an explanation for why ARB epidemics have fast and slow phases and why resistance may continue to increase despite infection-control efforts. To successfully manage ARB at tertiary-care hospitals, regional coordination of infection control may be necessary, including tracking asymptomatic carriers through health-care systems.
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Affiliation(s)
- David L Smith
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892-2220, USA.
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39
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Mascini EM, Jalink KP, Kamp-Hopmans TEM, Blok HEM, Verhoef J, Bonten MJM, Troelstra A. Acquisition and duration of vancomycin-resistant enterococcal carriage in relation to strain type. J Clin Microbiol 2004; 41:5377-83. [PMID: 14662914 PMCID: PMC308960 DOI: 10.1128/jcm.41.12.5377-5383.2003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In May 2000, the first outbreak of vancomycin-resistant Enterococcus faecium (VREF) was detected in the University Medical Center Utrecht in the nephrology ward. The question arose why some VREF strains spread among hospitalized patients, whereas other strains do not. Thirty patients who were found to be colonized with VREF between May and November 2000 were included in the study. Molecular typing confirmed that 19 of them carried an identical epidemic strain which harbored the esp gene while 11 were colonized by nonepidemic strains that were all esp negative. Acquisition of the outbreak strain was significantly associated with diabetes mellitus, renal transplantation, and extensive use of antibiotics, especially cephalosporins, in the 2-month period before the first isolation of VREF. To establish the duration of colonization, prospective surveillance of VREF carriage for a 6-month period starting from the first isolation of VREF was realized for 20 patients. After 6 months, VREF was still recovered from 60% of carriers of the outbreak strain versus 20% of carriers of nonepidemic strains (P < 0.01). However, antibiotic use during the follow-up period was significantly higher by carriers of the outbreak strain than by carriers of nonepidemic strains. The fact that the outbreak strain was recovered for a longer period of time than nonepidemic strains may facilitate dissemination of the strain. The results support a careful restrictive antibiotic policy for wards at risk for spread of VREF and implementation of isolation precautions for patients who are colonized with esp-positive outbreak strains.
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Affiliation(s)
- E M Mascini
- Department of Hospital Hygiene and Infection Prevention, Eijkman-Winkler Centre for Microbiology, Infectious Diseases, and Inflammation, University Medical Center Utrecht, Utrecht, The Netherlands.
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40
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Pong A, Bradley JS. Clinical challenges of nosocomial infections caused by antibiotic-resistant pathogens in pediatrics. ACTA ACUST UNITED AC 2004; 15:21-9. [PMID: 15175992 DOI: 10.1053/j.spid.2004.01.005] [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: 11/11/2022]
Abstract
Antibiotic resistance in nosocomial infections is an ever-increasing problem as health care institutions provide care for children with more complicated medical and surgical problems. Several mechanisms of antibiotic resistance are reviewed for both gram-negative and gram-positive nosocomial pathogens. These adaptive resistance mechanisms allow organisms to survive in an environment of extensive antibiotic use and result in clinically significant infections. Mobile genetic elements have facilitated the rapid spread of antibiotic resistance within and among species. The clinical challenge faced by many practitioners is to understand these mechanisms of antibiotic resistance and to develop strategies for successfully treating infection caused by resistant pathogens. Nosocomial outbreaks caused by resistant organisms are described, and an approach to empiric therapy based on presumed pathogens, site of infection, and local resistance patterns is discussed.
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Affiliation(s)
- Alice Pong
- Division of Infectious Diseases, Children's Hospital and Health Center, San Diego, CA 92123, USA
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41
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Cetinkaya Y, Falk PS, Mayhall CG. Effect of gastrointestinal bleeding and oral medications on acquisition of vancomycin-resistant Enterococcus faecium in hospitalized patients. Clin Infect Dis 2002; 35:935-42. [PMID: 12355380 DOI: 10.1086/342580] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2001] [Revised: 05/14/2002] [Indexed: 11/03/2022] Open
Abstract
There has been minimal investigation of medications that affect gastrointestinal function as potential risk factors for the acquisition of vancomycin-resistant enterococci (VRE). We performed a retrospective case-control study, with control subjects matched to case patients by time and location of hospitalization. Strict exclusion criteria were applied to ensure that only case patients with a known time of acquisition of VRE were included. Control patients were patients with > or =1 culture negative for VRE. The risk factors identified were use of vancomycin (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7-6.0; P=.0003), presence of central venous lines (OR, 2.2; 95% CI, 1.04-4.6; P=.04), and use of antacids (OR, 2.9; 95% CI, 1.5-5.6; P=.002). Two protective factors included gastrointestinal bleeding (OR, 0.26; 95% CI, 0.08-0.79; P=.02) and use of Vicodin (Knoll Labs; hydrocodone and acetaminophen; OR, 0.93; 95% CI, 0.90-0.97; P=.0003). Changes in gastrointestinal function, whether due to bleeding or to the effects of oral medications, may affect whether patients become colonized with VRE.
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Affiliation(s)
- Yesim Cetinkaya
- Department of Healthcare Epidemiology, University of Texas Medical Branch Hospitals and Clinics, University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
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42
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Loeffler AM, Drew RH, Perfect JR, Grethe NI, Stephens JW, Gray SL, Talbot GH. Safety and efficacy of quinupristin/dalfopristin for treatment of invasive Gram-positive infections in pediatric patients. Pediatr Infect Dis J 2002; 21:950-6. [PMID: 12394819 DOI: 10.1097/00006454-200210000-00013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotic-resistant Gram-positive pathogens are an increasingly common cause of serious pediatric infections. Although quinupristin/dalfopristin demonstrates favorable activity against resistant Gram-positive pathogens (including many vancomycin-resistant and methicillin-resistant staphylococci), published experience in the pediatric patient population is limited. METHODS We retrospectively analyzed data from the global quinupristin/dalfopristin Emergency-Use Program, which enrolled patients with serious Gram-positive infections who had no further therapy options because of resistance to, failure on or intolerance to standard antibiotic treatments. Our subset included safety and efficacy data from pediatric patients (age <18 years). There were no restrictions on underlying diseases, severity of illness or prior/concomitant antimicrobial use. RESULTS Between May 1995 and October 1999, 127 pediatric patients with 131 infections were enrolled. Microbiologic confirmation of etiology was available in 124 patients. All patients had 1 or more concomitant conditions, including malignancy and solid organ or bone marrow transplantation. The most frequent causative pathogens were vancomycin-resistant (80%), spp. (7%), methicillin-resistant (6%) and (4%). All but 21 patients received intravenous quinupristin/dalfopristin 7.5 mg/kg every 8 h. The favorable clinical response rate of quinupristin/dalfopristin was 86 of 124 (69%); the favorable microbiologic response rate was 97 of 124 (78%). Eleven patients (8%) had nonvenous adverse events classified as possibly or probably related to quinupristin/dalfopristin. CONCLUSIONS Quinupristin/dalfopristin demonstrated favorable response rates and was reasonably well-tolerated in pediatric patients with serious Gram-positive infections unable to receive alternative therapy. In our opinion quinupristin/dalfopristin is a therapeutic option for the management of such infections.
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43
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Donskey CJ, Hoyen CK, Das SM, Helfand MS, Hecker MT. Recurrence of vancomycin-resistant Enterococcus stool colonization during antibiotic therapy. Infect Control Hosp Epidemiol 2002; 23:436-40. [PMID: 12186208 DOI: 10.1086/502081] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To test the hypothesis that antibiotic therapy may promote recurrence of vancomycin-resistant Enterococcus (VRE) stool colonization in patients who have previously had three consecutive negative stool cultures obtained at least 1 week apart. DESIGN One-year prospective cohort study examining the effect of antibiotic therapy on recurrence and density of VRE stool colonization in patients who have cleared colonization. Pulsed-field gel electrophoresis (PFGE) was performed to determine whether recurrent VRE strains were the same clone as the previous colonizing strain. SETTING A Department of Veterans Affairs medical center including an acute care hospital and nursing home. PATIENTS All patients with at least one stool culture positive for VRE who subsequently had three consecutive negative stool cultures obtained at least 1 week apart. RESULTS Of the 16 patients who cleared VRE colonization, 13 received antibiotic therapy during the study period. Eight (62%) of the 13 patients who received antibiotics developed recurrent high-density VRE stool colonization (range, 4.9 to 9.1 log10 colony-forming units per gram) during a course of therapy. Five patients had VRE strains available for PFGE analysis; recurrent strains were unrelated to the prior strain in 3 patients, closely related in 1 patient, and indistinguishable in 1 patient. CONCLUSIONS Antibiotic therapy may be associated with recurrent high-density VRE stool colonization in many patients who have previously had three consecutive negative stool cultures. These patients should be screened for recurrent stool colonization when antibiotic therapy is administered.
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Affiliation(s)
- Curtis J Donskey
- Infectious Diseases Section, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio 44106, USA
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44
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Carmeli Y, Eliopoulos GM, Samore MH. Antecedent treatment with different antibiotic agents as a risk factor for vancomycin-resistant Enterococcus. Emerg Infect Dis 2002; 8:802-7. [PMID: 12141965 PMCID: PMC2732508 DOI: 10.3201/eid0808.010418] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We conducted a matched case-control study to compare the effect of antecedent treatment with various antibiotics on subsequent isolation of vancomycin-resistant Enterococcus (VRE); 880 in-patients; 233 VRE cases, and 647 matched controls were included. After being matched for hospital location, calendar time, and duration of hospitalization, the following variables predicted VRE positivity: main admitting diagnosis; a coexisting condition (e.g., diabetes mellitus, organ transplant, or hepatobiliary disease); and infection or colonization with methicillin-resistant Staphylococcus aureus or Clostridium difficile within the past year (independent of vancomycin treatment). After controlling for these variables, we examined the effect of various antibiotics. Intravenous treatment with third-generation cephalosporins, metronidazole, and fluoroquinolones was positively associated with VRE. In our institution, when we adjusted the data for temporo-spatial factors, patient characteristics, and hospital events, treatment with third-generation cephalosporins, metronidazole, and fluoroquinolones was identified as a risk factor for VRE. Vancomycin was not a risk factor for isolation of VRE.
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Affiliation(s)
- Yehuda Carmeli
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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45
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Harbarth S, Cosgrove S, Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci. Antimicrob Agents Chemother 2002; 46:1619-28. [PMID: 12019066 PMCID: PMC127216 DOI: 10.1128/aac.46.6.1619-1628.2002] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Stephan Harbarth
- Division of Infectious Diseases, Children's Hospital, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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46
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Byers KE, Anglim AM, Anneski CJ, Farr BM. Duration of colonization with vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol 2002; 23:207-11. [PMID: 12002235 DOI: 10.1086/502036] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the duration of colonization with vancomycin-resistant Enterococcus (VRE) and the adequacy of 3 consecutive negative cultures to determine clearance. DESIGN Retrospective cohort study. SETTING A university hospital. POPULATION Patients identified by perirectal cultures as VRE carriers who had follow-up cultures. METHODS Follow-up perirectal cultures were collected in inpatient and outpatient settings, at least 1 week apart, when patients were not receiving antibiotics with activity against VRE. The likelihood of culture positivity was analyzed given prior culture results and time from the initial positive culture. RESULTS A total of 116 patients colonized with VRE had 423 follow-up cultures, a mean of 204 days (range, 4 to 709 days) after their initial isolate. The first follow-up culture, collected a mean of 125 days after the initial positive isolate, was negative in 64%. After 1 negative follow-up culture, the next one was negative in 92% of the patients. After 2 negative cultures, 95% remained culture-negative. After 3 sequential negative cultures, 35 (95%) of 37 patients remained culture-negative. As the interval between the initial and the follow-up isolates increased, the probability that a subsequent culture would be positive decreased (P < .001, chi square for trend). Prolonged hospitalization, intensive care, and antibiotic use each decreased the likelihood of clearing VRE. CONCLUSION These data support the Centers for Disease Control and Prevention criterion of 3 sequential negative cultures, at least 1 week apart, to remove patients from VRE isolation. Nevertheless, this may reflect a decrease in the quantity of VRE to an undetectable level and these patients should be observed for relapse, especially when re-treated with antibiotics.
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Affiliation(s)
- Karin E Byers
- University of Virginia Health System, Charlottesville 22908, USA
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Elizaga ML, Weinstein RA, Hayden MK. Patients in long-term care facilities: a reservoir for vancomycin-resistant enterococci. Clin Infect Dis 2002; 34:441-6. [PMID: 11797169 DOI: 10.1086/338461] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2001] [Revised: 09/06/2001] [Indexed: 11/03/2022] Open
Abstract
A prospective cohort study with culture surveys and chart reviews was conducted to determine the prevalence of rectal colonization with vancomycin-resistant enterococci (VRE) and to identify risk factors for colonization among 100 residents of 20 different long-term care facilities (LTCFs) who were admitted to 2 medical wards of an academic acute care hospital. On admission to the hospital, 45 (45%) of these 100 patients were determined to be harboring VRE. Prior use of antibiotics and the presence of a decubitus ulcer were identified as risk factors. Fourteen other LTCF residents-33% of those at risk-acquired VRE in the hospital. Antecubital skin colonization with VRE was detected in 28% of patients. Hospital ward surveillance revealed a 60% mean point prevalence of VRE colonization among patients in LTCFs, compared with 21% for other patients (P<.001). Patients in LTCFs in urban referral hospitals are a major reservoir for VRE, which can be transmitted to other inpatients in the hospital, in the LTCF, and in smaller community hospitals.
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Affiliation(s)
- Marnie L Elizaga
- Section of Infectious Diseases, Rush Medical College, and Division of Infectious Diseases, Cook County Hospital, Chicago, IL, USA
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Baden LR, Thiemke W, Skolnik A, Chambers R, Strymish J, Gold HS, Moellering RC, Eliopoulos GM. Prolonged colonization with vancomycin-resistant Enterococcus faecium in long-term care patients and the significance of "clearance". Clin Infect Dis 2001; 33:1654-60. [PMID: 11595985 DOI: 10.1086/323762] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2001] [Revised: 05/29/2001] [Indexed: 12/17/2022] Open
Abstract
Little is known about the persistence of colonization with vancomycin-resistant Enterococcus faecium (VRE) in the nononcologic, non-intensive care unit patient. We studied all patients who had VRE isolated on > or =2 occasions of > 1 year apart (Study A) and those who had been "cleared" of VRE colonization after 3 negative stool cultures (Study B). Twelve patients had stored VRE isolates recovered > 1 year apart (Study A), and 58% of paired isolates were genotypically related according to pulsed field gel electrophoresis patterns. In Study B, stool samples were obtained weekly from 21 "cleared" patients for 5 weeks, which revealed that 24% were VRE positive. For these culture-positive patients, 72% of the cultures failed to detect VRE. Recent antibiotic use was significantly more common in the culture-positive patients, as compared with culture-negative patients (P=.003). Colonization with VRE may persist for years, even if the results of intercurrent surveillance stool and index site cultures are negative. Cultures for detection of VRE in stool samples obtained from patients declared "cleared" are insensitive.
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Affiliation(s)
- L R Baden
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA.
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Abstract
Gastrointestinal disease is a significant cause of morbidity and mortality in the immunocompromised patient. This article focuses on the infectious gastrointestinal complications associated with the treatment of malignant disease and with solid organ transplantation but not HIV. Gastrointestinal defenses and the various mechanisms by which they are impaired are reviewed. The major pathogens and malignancies of this patient population and an approach to their diagnosis, treatment, and prevention are discussed.
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Affiliation(s)
- L R Baden
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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50
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Affiliation(s)
- D F Bratcher
- Children's Mercy Hospital, University of Missouri School of Medicine, Kansas City, USA
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