Vancomycin-resistant Enterococci Colonization Research Articles

The local hospital milieu and healthcare-associated vancomycin-resistant enterococcus acquisition

Vancomycin-resistant enterococcus (VRE) causes 4% of all healthcare-associated infections in the USA. The process by which the local hospital milieu contributes to VRE acquisition is not fully understood. To determine the importance of specific factors within the local hospital environment for healthcare-associated VRE acquisition. This retrospective cohort study included patients admitted to six intensive care units at an academic medical centre from January 2012 to December 2016 with negative rectal VRE cultures on admission. VRE acquisition was defined as a positive surveillance swab performed at any time after the initial negative swab during the index hospitalization. The exposures of interest were VRE colonization pressure, VRE importation pressure, and use of vancomycin. Multivariable Cox proportional hazards modelling was performed, with patients followed until VRE acquisition, death, or for up to 30 days. Of 8485 patients who were initially VRE negative, 161 patients acquired VRE. On univariate analysis, patients with VRE acquisition were more likely to have received vancomycin, to have had a neighbouring patient who received vancomycin, to have high VRE importation pressure, or to have high VRE colonization pressure. On multivariable analysis, only high VRE colonization pressure was an independent predictor of VRE acquisition (adjusted hazard ratio: 1.79; 95% confidence interval: 1.19-2.70). VRE colonization pressure was the most important risk factor for healthcare-associated VRE acquisition, regardless of VRE importation pressure. Interventions seeking to reduce VRE acquisition should focus on minimizing transmission between patients with known VRE and the local hospital environment.

Gut colonization with vancomycin-resistant Enterococcus and risk for subsequent enteric infection

BackgroundGut colonization with vancomycin-resistant Enterococcus (VRE) is associated with poor outcomes. This study evaluated the impact of VRE colonization on subsequent acquisition of enteric pathogens.MethodsWe performed a retrospective cohort study of adults admitted to an ICU from 2012 to 2017 who were screened for VRE colonization and subsequently underwent stool testing with a gastrointestinal pathogen PCR panel (GI PCR) with or without PCR testing for Clostridium difficile. Our primary outcome was the presence of any enteric pathogen. Cox proportional hazards modeling was used to adjust for factors associated with enteric infection.ResultsOf 761 patients who underwent VRE screening and subsequent GI PCR, 131 (17%) were colonized with VRE. Patients with VRE colonization were less likely to test positive on GI PCR compared to patients without VRE (9.2% vs 18%, p = 0.01); specifically for E. coli species (p = 0.03) and viral (p = 0.04) enteric infections. In 716 patients who underwent C. difficile testing, there was a trend towards more C. difficile infections in patients colonized with VRE (15% vs 10%, p = 0.11). On multivariable analysis, patients with VRE had a decreased risk of a positive GI PCR (aHR 0.47, 95% CI 0.25–0.88, p = 0.02) but not C. difficile infection, effects which persisted during 5 years of follow-up. Among positive tests, there was a greater proportion of C. difficile with VRE (57% vs 28%, p < 0.01).ConclusionsVRE colonization was associated with a decreased risk of subsequent non-C. difficile enteric infection. VRE domination of the gut microbiome may protect against acquisition of common enteric pathogens.

Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection.

Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30days for death or culture-proven bacterial infection. Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.

Environmental Panels as a Proxy for Nursing Facility Patients With Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus Colonization.

Most nursing facilities (NFs) lack methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) surveillance programs due to limited resources and high costs. We investigated the utility of environmental screening of high-touch surfaces in patient rooms as a way to circumvent these challenges. We compared MRSA and VRE culture data from high-touch surfaces in patients' rooms (14450 samples from 6 NFs) and ranked each site's performance in predicting patient colonization (7413 samples). The best-performing sites were included in a MRSA- and a VRE-specific panel that functioned as a proxy for patient colonization. Molecular typing was performed to confirm available concordant patient-environment pairs. We identified and validated a MRSA panel that consisted of the bed controls, nurse call button, bed rail, and TV remote control. The VRE panel included the toilet seat, bed controls, bed rail, TV remote control, and top of the side table. Panel colonization data tracked patient colonization. Negative predictive values were 89%-92% for MRSA and 82%-84% for VRE. Molecular typing confirmed a strong clonal type relationship in available concordant patient-environment pairs (98% for MRSA, 91% for VRE), pointing to common epidemiological patterns for environmental and patient isolates. Environmental panels used as a proxy for patient colonization and incorporated into facility surveillance protocols can guide decolonization strategies, improve awareness of MRSA and VRE burden, and inform efforts to reduce transmission. Targeted environmental screening may be a viable surveillance strategy for MRSA and VRE detection in NFs.

Clearance of carbapenem-resistant Enterobacteriaceae vs vancomycin-resistant enterococci carriage after faecal microbiota transplant: a prospective comparative study

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. 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. 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. 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.

Vancomycin-resistant enterococcus infection in the hematopoietic stem cell transplant recipient: an overview of epidemiology, management, and prevention.

Vancomycin-resistant enterococcus (VRE) is now one of the leading causes of nosocomial infections in the United States. Hematopoietic stem cell transplantation (HSCT) recipients are at increased risk of VRE colonization and infection. VRE has emerged as a major cause of bacteremia in this population, raising important clinical questions regarding the role and impact of VRE colonization and infection in HSCT outcomes as well as the optimal means of prevention and treatment. We review here the published literature and scientific advances addressing these thorny issues and provide a rational framework for their approach.

Factors Associated with Vancomycin-Resistant Enterococcus Colonization in Patients Transferred to Emergency Departments in Korea.

BackgroundVancomycin-resistant enterococci (VRE) infections have become a major healthcare-associated pathogen problem worldwide. Nosocomial VRE infections could be effectively controlled by screening patients at high risk of harboring VRE and thereby lowering the influx of VRE into healthcare centers. In this study, we evaluated factors associated with VRE colonization in patients transferred to emergency departments, to detect patients at risk for VRE carriage.MethodsThis study was conducted in the emergency department of a medical college-affiliated hospital in Korea. Every patient transferred to the emergency department and admitted to the hospital from January to December 2016 was screened for VRE using rectal cultures. In this cross-sectional study, the dependent variable was VRE colonization and the independent variables were demographic and clinical factors of the patients and factors related to the transferring hospital. Patients were divided into two groups, VRE and non-VRE, and previously collected patient data were analyzed. Then we performed logistic regression analyses of characteristics that differed significantly between groups.ResultsOut of 650 patients, 106 (16.3%) had positive VRE culture results. Significant variables in the logistic analysis were transfer from geriatric long-term care hospital (adjusted odds ration [aOR]: 8.017; 95% confidence interval [CI]: 1.378–46.651), hospital days (4–7 days; aOR: 7.246; 95% CI: 3.229–16.261), duration of antimicrobial exposure (1–3 days; aOR: 1.976; 95% CI: 1.137–3.436), and age (aOR: 1.025; 95% CI: 1.007–1.043).ConclusionVRE colonization in patients transferred to the emergency department is associated primarily with factors related to the transferred hospitals rather than demographic and clinical characteristics.

Risk factors for intestinal colonization with vancomycin resistant enterococci' A prospective study in a level III pediatric intensive care unit.

PURPOSE:Vancomycin-resistant enterococci (VRE) emerged as one of the major nosocomial pathogens across the globe. Gut colonization rate with VRE is higher in patients admitted to intensive care units (ICUs) due to the higher antibiotic pressure. VRE colonization increases the risk of developing infection up to 5–10 folds. The aim of this study was to determine the rates of VRE colonization among the patients admitted to pediatric ICU (PICU) and risk factors associated with it.MATERIALS AND METHODS:Rectal swabs were collected after 48 h of admission to PICU from 198 patients. The samples were inoculated onto bile esculin sodium azide agar with 6 mg/ml of vancomycin. Growth on this medium was identified by the standard biochemical test, and minimum inhibitory concentration of vancomycin and teicoplanin was detected by agar dilution method. Resistance genes for vancomycin were detected by polymerase chain reaction. Risk factors were assessed by logistic regression analysis.RESULTS:The rates of VRE colonization in patients admitted to PICU was 18.6%. The majority of the isolates were Enterococcus faecium (75.6%) followed by Enterococcus faecalis (24.4%). One patient acquired a VRE bloodstream infection (2.6%) among colonized patients, and none of the noncolonized patients acquired the infection. Consumption of vancomycin was found to be the only risk factor significantly associated with VRE colonization.CONCLUSION:Routine surveillance and isolation of patients found to be VRE colonized may not be possible in tertiary care hospitals; however, educating health-care workers, promoting handwashing with antiseptic soaps or solutions, and antibiotic Stewardship policy may help in the reduction of vancomycin resistance and VRE colonization.

Vancomycin-resistant enterococci isolates colonizing and infecting haematology patients: clonality, and virulence and resistance profile

Vancomycin-resistant enterococci (VRE) are an important agent of colonization and infection in haematology patients. However, the role of virulence on VRE colonization and infection is controversial. To characterize the lineage, virulence and resistance profile of VRE infection and colonization isolates; as well as their impact on outcome of haematology patients using a regression logistic model. Eighty-six isolates (80 Enterococcus faecium and six E.faecalis) from 76 patients were evaluated. Polymerase chain reaction for resistance and virulence genes, and pulsed-field gel electrophoresis and whole genome sequencing of the major clusters, were performed. Bivariate and multivariate analyses were carried out to evaluate the role of virulence genes on outcome. All isolates harboured the vanA gene. Regarding the virulence genes, 96.5% of isolates were positive for esp, 69.8% for gelE and asa1 genes. VRE infection isolates were more virulent than colonization isolates and harboured more often the gelE gene (P=0.008). Infections caused by VRE carrying asa1 gene resulted more frequently in death (P=0.004), but only the predominant clone remained as protector in the multivariate model. The E.faecium strains were assigned to seven STs (ST78, ST412, ST478, ST792, ST896, ST987, ST963) that belonged to CC17. The E.faecalis sequenced belonged to ST9 (CC9). E.faecium was predominant, and infection isolates were more virulent than colonization isolates and harboured more often the gene gelE. Infections caused by VRE carrying the asa1 gene appeared to be associated with a fatal outcome.

Impact of Fecal Microbiota Transplantation on Digestive Tract Colonization due to Carbapenem-resistant Enterobacteriacae and Vancomycin-resistant Enterococci

BackgroundFecal Microbiota Transplantation (FMT) has proved to be an efficient therapy for recurrent C. difficile infection. Its indication is currently discussed for the decolonization of Multidrug-resistant organisms (MDRO) on the basis of mice experiments. Two recent publications suggest that it could be an efficient strategy for patients colonized with digestive MDRO colonization but few data are available for Carbapenem-Resistant Enterobacteria (CRE) and Vancomycin-Resistant Enterococcus (VRE) colonization.MethodsWe performed a FMT among patients colonized by CRE or VRE documented by at least 3 nonconsecutive positive swabs (including one in the week prior to the FMT).Procedure: 2 days prior to the FMT, patients received a proton pump inhibitor and a naso-duodenal tube was inserted to perform a bowel lavage with X-prep. FMT was performed with frozen feces from 4 donors previously screened for potential diseases using 5 syringes of 50 cc of feces diluted with saline. Patients were discharged after 24h and benefited of outpatient control swabs (PCR + culture) on day 7, 14, 21, 28 and each month during 3 months in order to assess the decolonization. The study is registered at ClinicalTrials.gov (NCT03029078).ResultsSeventeen individuals were included. Mean age was 69 ± 12.7 (SD) years.Eight patients were positive for CRE (KPC, OXA48 or NDM-1) and 9 for VRE.All suffered from severe underlying condition (hemodialysis, dementia, cirrhosis) or chronic wounds. Median functional autonomy scale was evaluated using the French Iso-Resources Groups (GIR)=4/6 IQR[3–6] supporting they were dependent persons.At 1-month follow-up, 3/8 patients were free from CRE and 5/9 from VRE. At 3-month follow-up, 3/8 patients were still free from CRE whereas 7/8 were free from VRE, considering one death from cirrhosis.Moreover, one of them received antibiotics during a week for a hospital-acquired infection a long time after FMT. No adverse events were reported.ConclusionFMT seems to be an attractive option to eradicate colonization of MDRO, especially for VRE. Limited data are available in the literature to determine response factors. Meanwhile its efficacy is moderate; it provides an alternative solution to quarantine for fragile and frequently hospitalized patients. More data and a controlled trial are required.Disclosures All authors: No reported disclosures.

Risk Factors and Outcomes of Vancomycin-Resistant Enterococcus Colonization in Patients on Peritoneal Dialysis: A Single-Center Study in Hong Kong.

Vancomycin-resistant Enterococcus (VRE) colonization is common among patients with chronic kidney disease. However, data concerning VRE colonization among patients receiving peritoneal dialysis (PD) is lacking. The aim of this study is to evaluate the risk factors and various clinical outcomes for VRE colonization among PD patients. This is a retrospective cohort study of 166 PD patients who were hospitalized between 1 August 2013 and 31 July 2014. They were screened for VRE colonization status during a major VRE outbreak in Hong Kong in 2013 and were then categorized into 2 groups: VRE-positive and VRE-negative. The primary outcome was all-cause mortality while the secondary outcomes included VRE infection, PD-related peritonitis, and length of hospitalization. Twenty-eight patients (16.9%) belonged to the VRE-positive group. Multivariate analysis showed that previous contact with VRE-positive patients (odds ratio [OR]: 417.86; 95% confidence interval [CI]: 17.21 - 10,147.26, p < 0.01), vancomycin use in previous 3 months (OR: 130.32; 95% CI: 5.35 - 3,176.30, p < 0.01), and old age (OR: 1.13; 95% CI: 1.02 - 1.24, p = 0.02) were the independent risk factors for VRE colonization. Patients in the VRE-positive group had significantly longer length of hospitalization, but there was no significant difference in all-cause mortality and peritonitis-free survival. Vancomycin-resistant Enterococcus colonization is important among hospitalized PD patients. Cautious use of antibiotics and infection control measures are necessary to prevent VRE spreading, especially in high-risk patients.

Decrease in Vancomycin-Resistant Enterococcus Colonization After Extensive Renovation of a Unit Dedicated to the Treatment of Hematologic Malignancies and Hematopoietic Stem-Cell Transplantation.

OBJECTIVE While a direct relation between hospital construction and concomitant infection rates has been clearly established, few data are available regarding the environmental decontamination effects of renovation in which surfaces are replaced and regarding subsequent infection incidence. DESIGN Retrospective clinical study with vancomycin-resistant Enterococcus (VRE) molecular strain typing and environmental cultures. SETTING A regional referral center for acute leukemia and hematopoietic stem-cell transplantation. PATIENTS Overall, 536 consecutive hospital admissions for newly diagnosed acute leukemia or a first autologous or allogeneic stem-cell transplantation were reviewed. INTERVENTION During 2009-2010, our unit underwent complete remodeling including replacement of all surfaces. We assessed the effects of this construction on the incidence of hospital-acquired VRE colonization before, during, and after the renovation. RESULTS We observed a sharp decrease in VRE colonization rates (hazard ratio, <0.23; 95% confidence interval, 0.18-0.44; P<.0001) during the first year after the renovation, with a return to near baseline rates thereafter. The known risk factors for VRE colonization appeared to be stable over the study interval. Environmental cultures outside of patient rooms revealed several contaminated areas that are commonly touched by unit personnel. Multilocus sequence typing of VRE isolates that were cryopreserved over the study interval showed that dominant strains prior to construction disappeared and were replaced by other strains after the renovation. CONCLUSIONS Unit reconstruction interrupted endemic transmission of VRE, which resumed with novel strains upon reopening. Contamination of environmental surfaces and shared equipment may play an important role in endemic transmission of VRE. Infect Control Hosp Epidemiol 2017;38:1055-1061.

Intestinal Colonization of Vancomycin-Resistant Enterococci Isolates among Patients in an Iranian Hospital

Vancomycin-resistant enterococci (VRE) remain as one of the important cause of nosocomial infections. Reports of the VRE carriers are increasing worldwide. In this study, a total of 220 patients was screened for vancomycin-resistant enterococci colonization, of which 36 (16.3) were VRE carriers. Among the VRE isolates, 17 were vanA positive. The distribution of VRE carriers in different wards that pose high risks for healthcare infection to hospitalized patients emphasizes applying suitable infection control strategies to prevent the dissemination of the organism. This is the first report from Iran in which a vanA-containing enterococci were isolated from intestinal colonization of patients. Strict measures are required to control the further spread of VRE strains in the Iranian patients.

Effect of meteorological factors and geographic location on methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci colonization in the US.

BackgroundLittle is known about the effect of meteorological conditions and geographical location on bacterial colonization rates particularly of antibiotic-resistant Gram-positive bacteria. We aimed to evaluate the effect of season, meteorological factors, and geographic location on methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) colonization.MethodsThe prospective cohort included all adults admitted to 20 geographically-dispersed ICUs across the US from September 1, 2011 to October 4, 2012. Nasal and perianal swabs were collected at admission and tested for MRSA and VRE colonization respectively. Poisson regression models using monthly aggregated colonization counts as the outcome and mean temperature, relative humidity, total precipitation, season, and/or latitude as predictors were constructed for each pathogen.ResultsA total of 24,704 ICU-admitted patients were tested for MRSA and 24,468 for VRE. On admission, 10% of patients were colonized with MRSA and 12% with VRE. For MRSA and VRE, a 10% increase in relative humidity was associated with approximately a 9% increase in prevalence rate. Southerly latitudes in the US were associated with higher MRSA colonization, while northerly latitudes were associated with higher VRE colonization. In contrast to MRSA, the association between VRE colonization and latitude was observed only after adjusting for relative humidity, which demonstrates how this effect is highly driven by this meteorological factor.ConclusionsTo our knowledge, we are the first to study the effect of meteorological factors and geographical location/latitude on MRSA and VRE colonization in adults. Increasing humidity was associated with greater MRSA and VRE colonization. Southerly latitudes in the US were associated with greater MRSA and less VRE. The effect of these factors on MRSA and VRE rates has the potential not only to inform patient management and treatment, but also infection prevention interventions.

Weekly screening supports terminating nosocomial transmissions of vancomycin-resistant enterococci on an oncologic ward \u2013 a retrospective analysis

BackgroundTo investigate the impact of weekly screening within the bundle of infection control measures to terminate vancomycin-resistant enterococci (VRE) transmissions on an oncologic ward.MethodsA cluster of 12 VRE colonisation and five infections was detected on an oncologic ward between January and April 2015. Subsequently, the VRE point prevalence was detected and, as part of a the bundle of infection control strategies to terminate the VRE cluster, we isolated affected patients, performed hand hygiene training among staff on ward, increased observations by infection control specialists, intensified surface disinfection, used personal protective equipment and initiated an admission screening in May 2015. After a further nosocomial VRE infection in August 2015, a weekly screening strategy of all oncology patients on the respective ward was established while admission screening was continued. Whole genome sequencing (WGS)-based typing was applied to determine the clonal relationship of isolated strains.ResultsInitially, 12 of 29 patients were VRE colonised; of these 10 were hospital-acquired. During May to August, on average 7 of 40 patients were detected to be VRE colonised per week during the admission screening, showing no significant decline compared to the initial situation. WGS-based typing revealed five different clusters of which three were due to vanB- and two vanA-positive enterococci. After an additional weekly screening was established, the number of colonised patients significantly declined to 1/53 and no further nosocomial cases were detected.ConclusionsWeekly screening helped to differentiate between nosocomial and community-acquired VRE cases resulting in earlier infection control strategies on epidemic situations for a successful termination of nosocomial VRE transmissions.

Vancomycin-resistant enterococci colonisation, risk factors and risk for infection among hospitalised paediatric patients: a systematic review and meta-analysis.

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.

Prediction of Bloodstream Infection Due to Vancomycin-Resistant Enterococcus in Patients Undergoing Leukemia Induction or Hematopoietic Stem-Cell Transplantation.

Bloodstream infection (BSI) to due vancomycin-resistant Enterococcus (VRE) is an important complication of hematologic malignancy. Determining when to use empiric anti-VRE antibiotic therapy in this population remains a clinical challenge. A single-center cohort representing 664 admissions for induction or hematopoietic stem-cell transplant (HSCT) from 2006 to 2014 was selected. We derived a prediction score using risk factors for VRE BSI and evaluated the model's predictive performance by calculating it for each of 16232 BSI at-risk inpatient days. VRE BSI incidence was 6.5% of admissions (2.7 VRE BSI per 1000 BSI at-risk days). Adjusted 1-year mortality and length of stay were significantly higher in patients with VRE BSI. VRE colonization (adjusted odds ratio [aOR] = 8.4; 95% confidence interval [CI] = 3.4-20.6; P < .0001), renal insufficiency (aOR = 2.4; 95% CI = 1.0-5.8; P = .046), aminoglycoside use (aOR = 4.7; 95% CI = 2.2-9.8; P < .0001), and antianaerobic antibiotic use (aOR = 2.8; 95% CI = 1.3-5.8; P = .007) correlated most closely with VRE BSI. A prediction model with optimal performance included these factors plus gastrointestinal disturbance, severe neutropenia, and prior beta-lactam antibiotic use. The score effectively risk-stratified patients (area under the receiver operating curve = 0.84; 95% CI = 0.79-0.89). At a threshold of ≥5 points, per day probability of VRE BSI was increased nearly 4-fold. This novel predictive score is based on risk factors reflecting a plausible pathophysiological model for VRE BSI in patients with hematological malignancy. Integrating VRE colonization status with risk factors for developing BSI is a promising method of guiding rational use of empiric anti-VRE antimicrobial therapy in patients with hematological malignancy. Validation of this novel predictive score is needed to confirm clinical utility.

Detection of vancomycin-resistant enterococci (VRE) in stool specimens submitted for Clostridium difficile toxin testing.

The aim of this study was to determine the association between Clostridium difficile (C. difficile) and vancomycin-resistant Enterococcus (VRE) and efficacy of screening stools submitted for C. difficile toxin assay for prevalence of VRE. Between April 2012 and February 2014, 158 stool samples submitted for C. difficile toxin to the Marmara University Microbiology Laboratory, were included in the study. Stool samples were analyzed by enzyme immuno assay test; VIDAS (bioMerieux, France) for Toxin A&B. Samples were inoculated on chromID VRE (bioMerieux, France) and incubated 24 h at 37 °C. Manuel tests and API20 STREP (bioMerieux, France) test were used to identify the Enterococci species. After the species identification, vancomycin and teicoplanin MIC's were performed by E test and molecular resistance genes for vanA vs vanB were detected by polymerase chain reaction (PCR). Of the 158 stool samples, 88 were toxin positive. The prevalence of VRE was 17%(n:19) in toxin positives however, 11.4% in toxin negatives(n:70). All VRE isolates were identified as Enterococcus faecium. These results were evaluated according to Fischer's exact chi-square test and p value between VRE colonization and C. difficile toxin positivity was detected 0.047 (p < 0.05). PPV and NPV were 79% and 47% respectively. In our study, the presence of VRE in C. difficile toxin positives is statistically significant compared with toxin negatives (p < 0.05). Screening for VRE is both additional cost and work load for the laboratories. Therefore VRE screening among C. difficile toxin positive samples, will be cost effective for determination of high risk patients in the hospitals especially for developing countries.

Hypogammaglobulinemia and Poor Performance Status are Predisposing Factors for Vancomycin-Resistant Enterococcus Colonization in Patients with Hematological Malignancies.

Objective:Vancomycin-resistant enterococci (VRE) are common pathogens of hospital-acquired infection. Long hospitalization periods, use of broad-spectrum antibiotics, and immunosuppression are major risks for VRE colonization. We aimed to evaluate patients’ characteristics and factors that may contribute to VRE colonization.Materials and Methods:Data of 66 patients with colonization and 112 patients without colonization who were hospitalized in the hematology clinic were collected. Hematological malignancies, preexisting gastrointestinal complaints, the presence of hypogammaglobulinemia at the time of diagnosis, complications like neutropenic enterocolitis (NEC), and Eastern Cooperative Oncology Group (ECOG) and Karnofsky performance statuses were recorded.Results:Ages of the patients ranged between 19 and 95 years (mean: 55.99). Karnofsky and ECOG scores were statistically related to VRE colonization (p<0.000 and p<0.000), though only the Karnofsky score was significant based on logistic regression analysis. Almost all patients with acute leukemia (45 patients) had been on antibiotics (piperacillin-tazobactam, ceftazidime, and meropenem), while no patients with myelodysplastic syndrome, myeloma, or benign diseases and 2 patients with lymphoma and 1 with chronic myeloid leukemia were on antibiotics. Median time for colonization regardless of antibiotic use and diagnosis was 4.5 days (range: 3-11 days). In the VRE-colonized group, 40.9% of patients had NEC development, while in the non-colonized group, only 1.7% had NEC development. In the VRE-colonized group 46 patients (69.7%) and in the non-colonized group 27 patients (24.1%) had hypogammaglobulinemia at diagnosis; among these patients, 23 patients in the VRE-colonized group (50%) had a B-cell malignancy (lymphoma, myeloma, or chronic lymphocytic leukemia).Conclusion:Besides already anticipated diseases like leukemia, B-cell malignancies are also at high risk for colonization. This proclivity may be attributed to lack of gastrointestinal IgA due to hypogammaglobulinemia. Prolonged hospitalization (>7 days) may also be accepted as a risk factor, independent of diagnosis or antibiotic use. Performance status is also an important factor for colonization, which may be related to poorer hygiene and increased external help.

Infant Colonization With Methicillin-Resistant Staphylococcus aureus or Vancomycin-Resistant Enterococci Preceding Neonatal Intensive Care Unit Discharge.

Rates of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) were determined for 1320 infants within 7 days of neonatal intensive care unit discharge. Overall, 4% and 1% of the infants were colonized with MRSA or VRE, respectively. Predictors identified in fixed-effects models were surgery during hospitalization (for MRSA colonization) and prolonged antimicrobial treatment (for VRE colonization).