Risk Factors For Vancomycin-resistant Enterococcus Colonization Research Articles

Extending outbreak investigation with machine learning and graph theory: Benefits of new tools with application to a nosocomial outbreak of a multidrug-resistant organism.

From January 1, 2018, until July 31, 2020, our hospital network experienced an outbreak of vancomycin-resistant enterococci (VRE). The goal of our study was to improve existing processes by applying machine-learning and graph-theoretical methods to a nosocomial outbreak investigation. We assembled medical records generated during the first 2 years of the outbreak period (January 2018 through December 2019). We identified risk factors for VRE colonization using standard statistical methods, and we extended these with a decision-tree machine-learning approach. We then elicited possible transmission pathways by detecting commonalities between VRE cases using a graph theoretical network analysis approach. We compared 560 VRE patients to 86,684 controls. Logistic models revealed predictors of VRE colonization as age (aOR, 1.4 (per 10 years), with 95% confidence interval [CI], 1.3-1.5; P < .001), ICU admission during stay (aOR, 1.5; 95% CI, 1.2-1.9; P < .001), Charlson comorbidity score (aOR, 1.1; 95% CI, 1.1-1.2; P < .001), the number of different prescribed antibiotics (aOR, 1.6; 95% CI, 1.5-1.7; P < .001), and the number of rooms the patient stayed in during their hospitalization(s) (aOR, 1.1; 95% CI, 1.1-1.2; P < .001). The decision-tree machine-learning method confirmed these findings. Graph network analysis established 3 main pathways by which the VRE cases were connected: healthcare personnel, medical devices, and patient rooms. We identified risk factors for being a VRE carrier, along with 3 important links with VRE (healthcare personnel, medical devices, patient rooms). Data science is likely to provide a better understanding of outbreaks, but interpretations require data maturity, and potential confounding factors must be considered.

Prevalence, risk factors, and molecular analysis of vancomycin-resistant Enterococci colonization in a referral neonatal intensive care unit: a prospective study in northern Iran

Vancomycin-resistant enterococcus (VRE) is an emerging drug-resistant organism responsible for increasing nosocomial infections. Few data are available on the epidemiology of VRE colonization or infection in neonates, and is of recent interest. This study analyzes the prevalence of neonatal VRE colonization in a neonatal intensive care unit (NICU), and describes risk factors and molecular phenotypes associated with VRE colonization. We performed a prospective epidemiological study on neonates admitted to an NICU. We compared neonates with VRE isolates detected in rectal swab cultures to those without. Association of VRE colonization with risk factors was tested by using univariate and multivariate methods. During a period of 18 months, amongst 180 neonates enrolled in the study, 76 (42.2%) were colonized by VRE. VRE isolates were resistant to amikacin in 68%, gentamicin in 26%, and ampicillin in 17.1% of cases. Molecular analysis showed the vanA gene in all isolates. Two VRE-positive patients developed infection during the observation time. No deaths occurred during this period. Prematurity (P=0.023), low birth weight (P=0.019), history of admission in other hospitals (P=0.00), and antibiotic therapy for more than seven days (P=0.01) were identified as risk factors for VRE colonization. Newborn susceptibility to early colonization with VRE in NICUs is increased in preterm and low birth weight newborns. All VRE colonization in the NICU was related to the acquisition of the vanA gene. Adherence to infection control policies and antimicrobial stewardship strategies are of the highest importance.

Multidrug Resistant Organisms (MDRO) in Rehabilitation: Prevalence and Risk Factors for MRGN and VRE

After a first large-scale study on multi-drug resistant organisms (MDRO) in rehabilitation facilities in 2014, the Rhine-Main network on MDRO carried out another investigation in 2019. With regard to the recently published KRINKO recommendations on multidrug resistant enterococci, now vancomycin -resistant enterococci (VRE) and multi-drug resistant gram-negative pathogens (3MRGN and 4MRGN, i. e. gramnegative organisms resistant against 3 resp. 4 groups of antiinfectiva) were investigated. A total of 16 hospitals took part, including one clinic for early neurological rehabilitation (ENR). Patient participation was voluntary. Rectal swabs were analyzed in a medical-microbiological laboratory (certified according to DIN ISO 15189) using standard methods (including MALDI-TOF-MS and VITEK 2 resistance testing according to EUCAST). By using the standardized questionnaire of the Europe-wide HALT examination (healthcare associated infections in long-term care facilities), patient characteristics (age, gender, hospital, surgical and MDRO medical history, Medical devices, current antibiotic therapy etc.) were collected. 928 patients took part in the study, 895 from general rehabilitation facilities (GR) and 33 from early neurological rehabilitation (ENR). 65% of GR patients (ENR 100%) had been hospitalized in the previous 6 months, 29% (ENR 100%) of the patients had been admitted directly from a hospital, 22% (ENR 64%) had received antibiotic therapy in the last 3 months. Medical devices were rarely used in GR patients with 1% overall, but often in the ENR with 61% urinary catheters and 36% vascular catheters. 2.2% (ENR 33.3%) of GR patients were colonized with VRE and 6.7% (ENR 18.2%) with 3MRGN; one patient exhibited a 4MRGN (ENR 0). Compared to our previous study, there were no significant changes in the patient characteristics. The VRE prevalence was low at 3.3%, the prevalence of 3MRGN was higher compared to 2014 (7.1% vs. 3.6%). Risk factors for VRE and 3MRGN colonization (significant increased odds ratio) were: history of hospital treatment and an increased need for care due to restricted mobility, incontinence and disorientation. In addition, previous antibiotic treatment and skin barrier injuries due to Medical devices or wounds were detected as further risk factors for VRE colonization.

2457. Data Science for Outbreak Investigation: Identifying Risk Factors, Tracing Contacts, and Eliciting Transmission Pathways in a Vancomycin-Resistant Enterococci (VRE) Outbreak

BackgroundIn 2018 we experienced a nosocomial outbreak due to vancomycin-resistant enterococci (VRE) in our hospital network. Our goals were to characterize risk factors for VRE acquisition, elicit potential hot spots of transmission, and delineate an optimized approach to tracing contacts.MethodsWe assembled diverse datasets of variable quality and covering different aspects of care from electronic medical records generated during the outbreak period (1/2018–9/2018). Patients who tested VRE-positive during this period were compared with controls with up to 3 negative screenings. First, we identified risk factors for VRE colonization by means of uni- and multivariate analyses. Next, we elicited transmission pathways by detecting commonalities between VRE cases, and determined whether patients with characteristics and connections similar to VRE cases were missed by our current contact tracing strategy.ResultsWe compared 221 VRE patients to 33,624 controls. Independent predictors of VRE colonization were ICU admission (OR 4.9, with 95% confidence interval [3.7–6.5], P < 0.001)], number of records in the database (a proxy for severity-of-illness, OR 1.1 [1.1–1.1], P < 0.001), length of hospital stay (OR 2.7 [2.0–3.5], P < 0.001), age (OR 1.3 [1.2–1.4], P < 0.001), and weeks of antibiotics (OR 1.2 [1.1–1.3], P < 0.001). By using complex network analysis, we were able to establish three main pathways by which the 221 VRE cases are connected: healthcare personnel, medical devices, and patient rooms. This multi-dimensional network extends beyond our current contact tracing strategy, which captures inpatients based on geographical proximity (cf. figure).ConclusionIn this outbreak investigation based on a large electronic healthcare data collection, we found three main risk factors for being a VRE carrier (ICU admission, length of hospital stay, antibiotic exposure), along with three important links between VRE cases (healthcare personnel, medical devices, patient rooms). Data science is likely to provide a better understanding of outbreaks, but interpretations should take data maturity, the scope of included sources, and potential confounding factors into account. Disclosures All authors: No reported disclosures.

Factors associated with vancomycin-resistant enterococci colonization in a pediatric intensive care unit of Paraguay: A cross-sectional study on hospital charts.

Vancomycin-resistant enterococci (VRE) infections have become widespread and a challenge in hospitalized patients. The threat of infection by intractable enterococci and the possibility that vancomycin resistance could involve pneumococci or staphylococci advocate for careful surveillance of resistant strains. To determine the risk factors associated with VRE colonization in pediatric patients admitted to the Pediatric Intensive Care Unit (PICU) in the period between January 2012 and June 2013. We conducted a cross-sectional study analyzing the clinical histories of 140 patients admitted to the PICU (children from 1 month to 18 years) who underwent rectal swab cultures within 48 hours of admission. We calculated the odds ratios and confidence intervals of the risk factors for VRE colonization in the PICU, and then we used multiple logistic regression for the statistically significant variables. VRE colonization was present in 18.6% of patients. The following variables were identified as risk factors associated with VRE colonization: prior hospitalization in the past year (odds ratio: 10.8; 95% confidence interval: 2.43 to 47.8; p = 0.001); prior use of one broad-spectrum antibiotic (odds ratio: 5.05; 95% confidence interval: 2.04 to 12.5; p = 0.000); use of two or more broad-spectrum antibiotics in past year (odds ratio: 5.4; 95% confidence interval: 1.5 to 18.4; p = 0.009); prior hospitalization in a high-risk area (odds ratio: 4.91; 95% confidence interval: 1.83 to 13.2; p = 0.000); hospitalization for more than five days in a high-risk area (odds ratio: 5.64; 95% confidence interval: 2.18 to 14.6; p = 0.000); and use of immunosuppressant drugs (odds ratio: 4.84; 95% confidence interval: 1.92 to 11.9; p = 0.001). In a logistic multiple regression the use of two or more broad-spectrum antibiotics (odds ratio: 4.81; 95% confidence interval: 1.01 to 22.8; p = 0.047) and prior hospitalization in past year (odds ratio: 7.84; 95% confidence interval: 1.24 to 49.32; p = 0.028) were identified as independent factors statistically associated with VRE colonization. Pediatric patients admitted for intensive care with a history of prior hospitalization in the past year and exposure to two or more broad-spectrum antibiotics have a greater risk of colonization by vancomycin-resistant enterococci.

P3.27: Gastric Acid Suppression May Lead to an Increased Risk of Vancomycin-Resistant Enterococcus Colonization

Introduction: Gastric acid suppression therapy has been reported to change the gastrointestinal microbiome, resulting in increased gastrointestinal infections. This may be of increased importance in intestinal transplantation subjects as immunosuppressive agents are associated with peptic ulcers, leading to increased gastric acid suppression therapy. Also, immunosuppressive therapy leads to a higher risk of vancomycin-resistant enterococcus (VRE) colonization. However, the effect of gastric acid suppression therapy on vancomycin-resistant enterococcus (VRE) colonization has not been investigated. Methods: Subjects who had surveillance rectal swabs for VRE at a university hospital were investigated. Surveillance was performed on subjects with prior hospitalization within 3months, history of VRE colonization/infection, or positive VRE findings from an adjacent patient. Gastric acid suppression therapy was defined as use of proton pump inhibitor or histamine-receptor-2 antagonists. Results: Of 886 subjects who underwent VRE screening, 452 were included with 69 VRE positive and 383 VRE negative subjects. In univariable analysis, gastric acid suppression therapy, antibiotics use, male gender and prior hospitalization were significant risk factors for VRE colonization. Multivariable analysis showed that gastric acid suppression therapy (OR 2.873, 95% CI 1.473–5.605, P=0.002) and antibiotics use (OR 3.896, 95% CI 2.019–7.520, P<0.001) significantly increased VRE risk. Of antibiotics, carbapenems (OR 3.836, 95% CI 1.603–9.182, P=0.003) glycopeptides (OR 2.784, 95% CI 1.155–6.712, P=0.023), and cephalosporins (OR 2.210, 95% CI 1.213–4.025, P=0.010) were most significantly associated with VRE colonization. The unfavorable effect of gastric acid suppression therapy on VRE colonization was consistent, regardless of antibiotics type. Conclusion: Gastric acid suppression therapy significantly increased VRE colonization risk. Gastric acid suppression should be administered according to strict guidelines. Physicians should be made aware of the increased VRE risk, and should consider VRE surveillance in those under long-term gastric suppression therapy.

Vancomycin-resistant Enterococcus (VRE) outbreak in a neonatal intensive care unit and special care nursery at a tertiary-care hospital in Australia-A retrospective case-control study.

We investigated the risk factors and origins of the first known occurrence of VRE colonization in the neonatal intensive care unit (NICU) at the Canberra Hospital. A retrospective case-control study. A 21-bed neonatal intensive care unit (NICU) and a 15-bed special care nursey (SCN) in a tertiary-care adult and pediatric hospital in Australia. All patients admitted to the NICU and SCN over the outbreak period: January-May 2017. Of these, 14 were colonized with vancomycin-resistant Enterococcus (VRE) and 77 were noncolonized. Demographic and clinical variables of cases and controls were compared to evaluate potential risk factors for VRE colonization. Whole-genome sequencing of the VRE isolates was used to determine the origin of the outbreak strain. Swift implementation of wide-ranging infection control measures brought the outbreak under control. Multivariate logistic regression revealed a strong association between early gestational age and VRE colonization (odds ratio [OR], 3.68; 95% confidence interval [CI], 1.94-7.00). Whole-genome sequencing showed the isolates to be highly clonal Enterococcus faecium ST1421 harboring a vanA gene and to be closely related to other ST1421 previously sequenced from the Canberra Hospital and the Australian Capital Territory. The colonization of NICU patients was with a highly successful clone endemic to the Canberra Hospital likely introduced into the NICU environment from other wards, with subsequent cross-contamination spreading among the neonate patients. Use of routine surveillance screening may have identified colonization at an earlier stage and have now been implemented on a 6-monthly schedule.

Gastric Acid Suppression May Lead to an Increased Risk of Vancomycin-Resistant Enterococcus Colonization: Presidential Poster Award

Introduction: Gastric acid suppression therapy has been reported to change the gastrointestinal microbiome, resulting in increased gastrointestinal infections. However, the effect of gastric acid suppression therapy on vancomycin-resistant enterococcus (VRE) colonization has not been investigated. Methods: Subjects who had surveillance rectal swabs for VRE at a university hospital were investigated. Surveillance was performed on subjects with prior hospitalization within 3months, history of VRE colonization/infection, or positive VRE findings from an adjacent patient. Gastric acid suppression therapy was defined as use of proton pump inhibitor or histamine-receptor-2 antagonists. Results: Of 886 subjects who underwent VRE screening, 452 were included with 69 VRE positive and 383 VRE negative subjects. In univariable analysis, gastric acid suppression therapy, antibiotics use, male gender and prior hospitalization were significant risk factors for VRE colonization. Multivariable analysis showed that gastric acid suppression therapy (OR 2.873, 95% CI 1.473-5.605, P=0.002) and antibiotics use (OR 3.896, 95% CI 2.019-7.520, P<0.001) significantly increased VRE risk. Of antibiotics, carbapenems (OR 3.836, 95% CI 1.603-9.182, P=0.003) glycopeptides (OR 2.784, 95% CI 1.155-6.712, P=0.023), and cephalosporins (OR 2.210, 95% CI 1.213-4.025, P=0.010) were most significantly associated with VRE colonization. The unfavorable effect of gastric acid suppression therapy on VRE colonization was consistent, regardless of antibiotics type. Conclusion: Gastric acid suppression therapy significantly increased VRE colonization risk. Gastric acid suppression should be administered according to strict guidelines. Physicians should be made aware of the increased VRE risk, and should consider VRE surveillance in those under long-term gastric suppression therapy.1112_A Figure 1. Characteristics of the study subjects1112_B Figure 2. Antibiotics use in the study subjects1112_C Figure 3. Multivariable analysis of VRE risk factors

Similarities and Differences in Risk Factors for Vancomycin-resistant Enterococcus Colonization between an Acute Hospital and its affiliated Intermediate- and Long-term care facilities

Background: Vancomycin-resistant Enterococci (VRE) infections in acute hospitals (AHs) are increasing, but little is known in intermediate- and long-term care facilities (ILTCs). Patients often transfer between AHs and ILTCs. We sought to compare risk factors for VRE colonization between an AH and ILTCs in a healthcare network. Methods & Materials: Two cross-sectional studies were conducted in a 1600-bed tertiary-care AH and its six affiliated ILTCs in June-July 2014 and June-July 2015. Rectal swabs or stool were cultured for VRE. Clinical data were obtained from medical records and associations with colonization made. To control for confounding, multivariable logistic regression models were constructed. Results: Of 3469 patients screened, 11.4% were colonized with VRE. VRE prevalence was higher in the AH(16.9%) than ILTCs(4.4%)(OR 2.75, 95%CI 1.96-3.86, P < 0.001). After adjusting for age, gender, screening year, and co-morbidities, risk factors for VRE colonization in the AH included length of stay(LOS) >14 days(OR 1.67, 95%CI 1.27-2.21, P < 0.001), number of beds in hospital room(OR 1.08 95%CI 1.02-1.15, P = 0.009), presence of wounds(OR 1.82 95%CI 1.39-2.39, P < 0.001), as well as prior admission to the AH(OR 1.42, 95%CI 1.07-1.88, P = 0.014), prior VRE carriage(OR 4.92 95%CI 2.74-8.83, P < 0.001), and prior antibiotics exposure in the preceding 12 months(OR 4.51, 95%CI 2.15-9.44, P < 0.001). For ILTCs, prior admission to AHs(OR 6.73, 95%CI 1.58-28.71, P = 0.010) and prior antibiotics exposure(OR 5.53, 95%CI 1.66-18.40, P = 0.005), presence of indwelling urinary catheter(OR 1.97, 95%CI 1.14-3.40, P = 0.014), and LOS >14 days(OR 0.47, 95%CI 0.26-0.83, P = 0.010) were associated with VRE colonization. Conclusion: Antibiotics exposure and hospitalization in an AH in the preceding 12 months were common risk factors for VRE colonization in the AH and ILTCs. Prior VRE carriage and LOS >14 days increased the risk of colonization in the AH. Presence of indwelling urinary catheter increased but LOS >14 days decreased the risk in ILTCs. Pre-emptive contact precautions and targeted screening could be implemented for these high-risk patients at AHs and ILTCs.

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.

Risk factors for enterococcal infection and colonization by vancomycin-resistant enterococci in critically ill patients.

Vancomycin-Resistant Enterococci (VRE) are important causes of Intensive Care Unit (ICU) infections. Our goal was to identify the prevalence and risk factors for VRE colonization upon ICU admission and during ICU stay, as well as, their impact in enterococcal infection including vancomycin-susceptible cases (VSE). A prospective study regarding patients admitted in ICU (n = 497) was conducted during a 24-month period. Rectal swabs were collected upon admission and during hospitalization and inoculated onto selective medium. Enterococci were phenotypically characterized. van genes were investigated by PCR and clones were identified by Pulsed-Field Gel Electrophoresis and Multilocus Sequence Typing. Epidemiologic data were collected from the ICU database. Risk factors for VRE carriage upon ICU admission (71/497) were: duration of previous hospitalization, glycopeptide administration, chronic heart failure, malignancy, insulin-dependent diabetes mellitus, and previous enterococcal infection (VRE and/or VSE). Risk factors for VRE colonization during ICU stay (36/250) were: quinolone administration, chronic obstructive pulmonary disease, chronic renal failure, and number of VRE-positive patients in nearby beds. Risk factors for enterococcal infection during ICU stay (15/284), including VRE and VSE cases, were: administration of third- or fourth-generation cephalosporins, cortisone use before ICU admission and VRE colonization, whereas, enteral nutrition was a protective factor. Previous VRE colonization and antibiotic usage are essential parameters for enterococcal infection (by VRE or VSE) during ICU stay. Previous enterococcal infection, co-morbidities and antibiotic usage are associated with VRE colonization upon ICU admission, whereas, patient to patient transmission, co-morbidities and antibiotic usage constitute risk factors for VRE colonization during ICU hospitalization.

Risk factors for vancomycin-resistant Enterococcus colonization in hematologic patients

Vancomycin-resistant Enterococci (VRE) is one of the most important hospital pathogens. The aim of the study was to evaluate VRE colonization in patients hospitalized at the Hematology Intensive Care Unit, as well as the associated risk factors. A prospective cohort study involved 70 patients hospitalized at the Intensive Care Unit (ICU), Clinic for Hematology, Clinical Center of Serbia, Belgrade, during 3 months. Baseline demographic data, data about antibiotic usage and other risk factors for VRE colonization during the present and previous hospitalizations (within 6 months) were recorded for each patient using the questionnaire. Feces or rectal swab was collected for culture from patients on admission and at discharge in case when VRE was not isolated on admission. Enterococci were isolated by standard microbiological methods. Isolate sensitivity was tested by disk-diffusion test using 30 microg/mL (BBL) Vancomycin plates according to the Clinical and Laboratory Standards Institute (CLSI) standard. Analysing results showed that 7% of the patients had been already colonized with VRE upon ICU admission. The rate of VRE colonization during present hospitalization was 41.5%. Univariate logistic regression demonstrated the statistically significant differences in diagnosis, length of present stay, use of aminoglycosides and piperacillin/tazobactam in present hospitalization, duration of use of carbapenem and piperacillin/tazobactam in present hospitalization between the VRE-colonized and non-colonized patients. Acute myeloid leukemia (AML), use of carbapenem in previous hospitalization and duration of use of piperacillin/tazobactam in present hospitalization were independent risk factors for VRE-colonized patients according to multivariate logistic regression. VRE colonization rate was high among the patients admitted to hematology ICU. Rational use of antibiotics and active surveillance may be helpful preventive measures against the development of bacterial resistance to antimicrobial agents.

Risk Factors and Clinical Outcomes for Vancomycin-Resistant Enterococcus Colonization on Intensive Care Unit Admission

The purpose of this study was to identify vancomycin-resistant enterococcus (VRE) colonization rate in patients admitted to the intensive care unit (ICU), associated risk factors and clinical outcomes for VRE colonization. Of the 7,703 patients admitted to the ICUs between January, 2008 and December, 2010, medical records of 554 VRE colonized and 503 uncolonized patients were reviewed retrospectively. To analyzed the impact of colonization on patients' clinical outcomes, 199 VRE colonized patients were matched with 199 uncolonized patients using a propensity score matching method. During the study period, 567 (7.2%) of the 7,703 patients were colonized with VRE. Multivariate analysis identified the following independent risk factors for VRE colonization: use of antibiotics (odds ratio [OR]=3.33), having bedsores (OR=2.92), having invasive devices (OR=2.29), methicillin-resistant Staphylococcus aureus co-colonization (OR=1.84), and previous hospitalization (OR=1.74). VRE colonized patients were more likely to have infectious diseases than uncolonized patients. VRE colonization was associated with prolonged hospitalization and higher mortality. Strict infection control program including preemptive isolation for high-risk group may be helpful. Further research needs to be done to investigate the effects of active surveillance program on the incidence of colonization or infection with VRE in the ICU.

Successful prevention of the transmission of vancomycin-resistant enterococci in a Brazilian public teaching hospital

Vancomycin-resistant enterococci (VRE) can colonize or cause infections in high-risk patients and contaminate the environment. Our objective was to describe the epidemiological investigation of an outbreak of VRE, the interventions made, and their impact on its control. We conducted a retrospective, descriptive, non-comparative study by reviewing the charts of patients with a VRE-positive culture in the University Hospital of Campinas State University, comprising 380 beds, 40 of which were in intensive care units (ICUs), who were admitted from February 2008-January 2009. Interventions were divided into educational activity, reviewing the workflow processes, engineering measures, and administrative procedures. There were 150 patients, 139 (92.7%) colonized and 11 (7.3%) infected. Seventy-three percent were cared for in non-ICUs (p = 0.028). Infection was more frequent in patients with a central-line (p = 0.043), mechanical ventilation (p = 0.013), urinary catheter (p = 0.049), or surgical drain (p = 0.049). Vancomycin, metronidazole, ciprofloxacin, and third-generation cephalosporin were previously used by 47 (31.3%), 31 (20.7%), 24 (16%), and 24 (16%) patients, respectively. Death was more frequent in infected (73%) than in colonized (17%) patients (p < 0.001). After the interventions, the attack rate fell from 1.49 to 0.33 (p < 0.001). Classical risk factors for VRE colonization or infection, e.g., being cared for in an ICU and previous use of vancomycin, were not found in this study. The conjunction of an educational program, strict adhesion to contact precautions, and reinforcement of environmental cleaning were able to prevent the dissemination of VRE.

Implications for vancomycin-resistant Enterococcus colonization associated with Clostridium difficile infections

Vancomycin-resistant Enterococcus (VRE) colonization of the gastrointestinal tract shares similar risk factors with Clostridium difficile infection. We sought to elucidate the prevalence and risk factors of VRE colonization associated with C difficile infection. All adult inpatients with C difficile infection from July 2006 to October 2006 were prospectively evaluated. All C difficile toxin-positive stool samples were screened for detection of VRE. Risk factors for VRE colonization were compared in patients with C difficile infection with and without VRE colonization. Of the 158 cases of C difficile infection evaluated, 88 (55.7%) involved VRE colonization. Independent risk factors for VRE colonization were admission from long-term care facilities (P = .013), dementia (P = .017), and hospitalization in the previous 2 months (P = .014). No statistically significant difference between C difficile infection cases with and without VRE colonization in terms of previous receipt (within 1 month) of antibiotics, including metronidazole and vancomycin, was found on multivariate analysis. C difficile infection cases with VRE colonization had a higher prevalence of coinfection with methicillin-resistant Staphylococcus aureus (P = .002) and Acinetobacter spp (P = .006). VRE colonization was associated with >50% of C difficile infection cases and with a higher rate of coinfection with multidrug-resistant pathogens. Given the high rate of C difficile infection associated with VRE colonization, active surveillance of VRE in patients with C difficile infection is reasonable in high-risk settings.

Epidemiology of vancomycin-resistant enterococci in children with acute lymphoblastic leukemia at two referral centers in Tehran, Iran: a descriptive study

Risk factors for colonization with vancomycin-resistant enterococci (VRE) vary by population and locale. The objective of this study was to determine the prevalence of and risk factors for VRE colonization in children with acute lymphoblastic leukemia (ALL) in Tehran. Stools were collected from children with ALL at the Ali Asghar Children's Hospital and the Mahak Pediatric Oncology Center between March 2007 and October 2008. Demographic features and potential risk factors for VRE colonization, including duration of ALL, presence of severe neutropenia in the preceding month, receipt of antibiotics in the preceding 3 months, concurrent medical problems, days of hospitalization, and the need for intensive care since the time of diagnosis of ALL, were recorded. VRE was identified from stools in 33 of 130 children with ALL (25%). No clear risk factors were identified for VRE colonization in the current study, but there was a trend towards an increased prevalence in children admitted to the intensive care unit since their ALL diagnosis (p=0.07). The VanA genotype was found in 28 of the 33 stools (85%), with all other enterococci being VanB. The prevalence of VRE colonization in children with ALL in Tehran is high. Modifiable risk factors have not been identified. The implementation of routine surveillance for colonization and an increased emphasis on adherence to standard infection control precautions may prevent spread.

Absence of vancomycin-resistant enterococci (VRE) despite the presence of risk factors: a survey of rectal carriage of VRE*

The resistant organisms from patients and healthcare workers (HCWs) first colonized the gastrointestinal tract before causing infections in patients. In this study, presence of risk factors for vancomycin-resistant enterococci (VRE) colonization and the prevalence of rectal carriage of VRE among HCWs and hospitalized patients in the absence of an outbreak were investigated. Design: Cross-sectional study. Setting: A 600-bed training and research hospital. Materials and methods: A total of 508 intensive-care unit (ICU) patients and HCWs in these units were included. Risk factors such as previous antibiotic use, especially vancomycin and cephalosporin, the presence of invasive devices like catheters, and co-morbid diseases were investigated. Rectal smear cultures were obtained from each participant to detect VRE colonization. Results: Risk factors for VRE colonization were identified among both patients and HCWs with a significant ratio. Except for one patient, who had been transferred from another hospital, no VRE colonization was detected in patients or HCWs. Conclusion: The result was attributed to factors such as low inter-institutional transfer, HCWs' being free of VRE colonization (transmission is less likely), strict infection control strategy of the hospital, isolation of newly transferred patients suspected of having VRE colonization, isolation of VRE colonization identified patients, use of indwelling catheters only when indicated and their early removal, and low prevalence of predisposing co-morbid diseases and malignity. We want to underline that a strict hospital infection control program can prevent colonization, even in the presence of risk factors.

Factors Associated With Acquisition of Vancomycin-Resistant Enterococci (VRE) in Roommate Contacts of Patients Colonized or Infected with VRE in a Tertiary Care Hospital

Most nosocomial acquistion of vancomycin-resistant enterococci (VRE) is due to cross-transmission. We sought to identify risk factors for acquisition of VRE by roommates of patients colonized or infected with VRE. Retrospective cohort study. A 472-bed tertiary care teaching hospital. All patients who shared a room with a patient colonized or infected with VRE at our hospital between January 1, 1999 and December 31, 2006 were identified. These roommates of VRE-positive patients were screened by rectal swab culture on days 2, 5, and 7 after the last exposure to the index patient. Chart reviews were performed to identify risk factors for VRE colonization in these roommates. Eighty-eight roommates of patients colonized or infected with VRE were identified. Of the 38 roommates with complete follow-up, 8 (21%) became colonized with VRE. These 8 roommates were older (median, 87.5 vs 62.5 years of age; P = .001), had longer duration of room exposure (median, 8.5 vs 4 days; P = .002), and were more likely to have a urinary catheter (odds ratio [OR], 16 [95% confidence interval {CI}, 1.7-152]; P = .005), an elevated serum creatinine level (OR, 17 [95% CI, 1.4-196]; P = .02), low serum albumin level (OR, 9.9 [95% CI, 1.3-113]; P = .01), and recent third-generation cephalosporin use (OR, 8.3 [95% CI, 1.5-47]; P = .02). Roommates of patients identified as colonized or infected with VRE are at substantial risk of becoming colonized, with the degree of risk increasing in older and more frail patients. VRE control programs should pay particular attention to such patients.

An Outbreak of Vancomycin-ResistantEnterococcus faeciumin an Acute Care Pediatric Hospital: Lessons from Environmental Screening and a Case-Control Study

The present study describes a vancomycin-resistant enterococci (VRE) outbreak investigation and a case-control study to identify risk factors for VRE acquisition in a tertiary care pediatric hospital. To report an outbreak investigation and a case-control study to identify risk factors for VRE colonization or infection in hospitalized children. Screening for VRE cases was performed by culture or polymerase chain reaction. A case-control study of VRE-colonized patients was undertaken. Environmental screening was performed using standard culture and susceptibility methods, with pulsed-field gel electrophoresis to determine relationships between VRE isolates. Statistical analysis was performed using SAS version 9.0 (SAS Institute Inc, USA). Thirty-four VRE-positive cases were identified on 10 wards between February 28, 2005, and May 27, 2005. Pulsed-field gel electrophoresis analysis confirmed a single outbreak strain that was also isolated from a video game found on one affected ward. Multivariate analysis identified cephalosporin use as the major risk factor for VRE colonization. In the present study outbreak, VRE colonization was significantly associated with cephalosporin use. Because shared recreational items and environmental surfaces may be colonized by VRE, they warrant particular attention in housekeeping protocols, particularly in pediatric institutions.