Vancomycin-resistant Enterococci Surveillance Research Articles

Evaluation of Antimicrobial Resistancein Clinical Isolates of Enterococcus spp. Obtained from Hospital Patients in Latvia.

Background and Objective: Enterococci are typically found in a healthy human gastrointestinal tract but can cause severe infections in immunocompromised patients. Such infections are treated with antibiotics. This study addresses the rising concern of antimicrobial resistance (AMR) in Enterococci, focusing on the prevalence of vancomycin-resistant enterococcus (VRE) strains. Materials and Methods: The pilot study involved 140 Enterococci isolates collected between 2021 and 2022 from two multidisciplinary hospitals (with and without local therapeutic drug monitoring protocol of vancomycin) in Latvia. Microbiological assays and whole genome sequencing were used. AMR gene prevalence with resistance profiles were determined and the genetic relationship and outbreak evaluation were made by applying core genome multi-locus sequence typing (cgMLST). Results: The acquired genes and mutations were responsible for resistance against 10 antimicrobial classes, including 25.0% of isolates expressing resistance to vancomycin, predominantly of the vanB type. Genetic diversity among E. faecalis and E. faecium isolates was observed and seven potential outbreak clusters were identified, three of them containing sequence types ST6, ST78 and ST80. The prevalence of vancomycin resistance was highest in the hospital without a therapeutic drug-monitoring protocol and in E. faecium. Notably, a case of linezolid resistance due to a mutation was documented. Conclusions: The study illustrates the concerning prevalence of multidrug-resistant Enterococci in Latvian hospitals, showcasing the rather widespread occurrence of vancomycin-resistant strains. This highlights the urgency of implementing efficient infection control mechanisms and the need for continuous VRE surveillance in Latvia to define the scope and pattern of the problem, influencing clinical decision making and planning further preventative measures.

Implementation of contact precautions for multidrug-resistant organisms in the post-COVID-19 pandemic era: An updated national Emerging Infections Network (EIN) survey.

To understand how healthcare facilities employ contact precautions for patients with multidrug-resistant organisms (MDROs) in the post-coronavirus disease 2019 (COVID-19) era and explore changes since 2014. Cross-sectional survey. Emerging Infections Network (EIN) physicians involved in infection prevention or hospital epidemiology. In September 2022, we sent via email an 8-question survey on contact precautions and adjunctive measures to reduce MDRO transmission in inpatient facilities. We also asked about changes since the COVID-19 pandemic. We used descriptive statistics to summarize data and compared results to a similar survey administered in 2014. Of 708 EIN members, 283 (40%) responded to the survey and 201 reported working in infection prevention. A majority of facilities (66% and 69%) routinely use contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) respectively, compared to 93% and 92% in 2014. Nearly all (>90%) use contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter baumannii. More variability was reported for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing gram-negative organisms. Compared to 2014, fewer hospitals perform active surveillance for MRSA and VRE. Overall, 90% of facilities used chlorhexidine gluconate bathing in all or select inpatients, and 53% used ultraviolet light or hydrogen peroxide vapor disinfection at discharge. Many respondents (44%) reported changes to contact precautions since COVID-19 that remain in place. Heterogeneity exists in the use of transmission-based precautions and adjunctive infection prevention measures aimed at reducing MDRO transmission. This variation reflects a need for updated and specific guidance, as well as further research on the use of contact precautions in healthcare facilities.

Antimicrobial resistance profile of Enterococcus species and molecular characterization of Vancomycin resistant Enterococcus faecium from the fecal samples of newly diagnosed adult HIV patients in Dar es Salaam, Tanzania

BackgroundEnterococci are becoming clinically more important especially among immunocompromised patients. Of concern are vancomycin resistant enterococci (VRE) which have both intrinsic and acquired forms of resistance. This work aimed to determine the antimicrobial resistance patterns of Enterococcus spp. and characterize VRE isolate obtained from HIV-infected patient using whole genome sequencing (WGS).Methods:Antimicrobial susceptibility testing was done on 57 enterococci isolates by both the disk diffusion method and Epsilometer test (E-Test). WGS was performed on VRE isolate determined by E-test.ResultsOut of the 57 enterococci isolates; 58% (33/57) were E. faecalis, 39% (22/57) E. faecium and 4% (2/57) were E. gallinarum. The highest antimicrobial resistance was observed in E. faecalis isolates. The most prevalent antimicrobial resistance was observed towards quinupristin-dalfopristin (56%, 32/57), followed by ciprofloxacin (28%), tigecycline (18%), daptomycin (16%), chloramphenicol (14%), ampicillin and teicoplanin (2%). Multidrug resistance (MDR) was detected in 11% (6/57) of the isolates. Vancomycin resistance and high-level gentamycin resistance (HLGR) were observed in one E. faecium and one E. faecalis isolates respectively. The VRE was typed as ST80, carried vanA and other resistance genes for aminoglycosides, tetracyclines, quinolones and ampicillin. Furthermore, the isolate had chromosomal mutations responsible for quinolone (gyrA (p.S83I) and parC (p.S80I) and ampicillin (pbp5) resistance.ConclusionsThe detection of VRE, HLGR and MDR in the study settings underscores the sustained surveillance of VRE in high-risk groups and institution of infection control measures for prompt identification and isolation of carriers to prevent the spread of VRE in the community and hospital settings.

Does the Hooded Crow (Corvus cornix) harbour vancomycin-resistant enterococci in Hungary?

Vancomycin resistant enterococci (VRE) are high priority nosocomial bacteria with a potential for zoonotic transmission. Thus, its emergence outside health establishments is a major concern. In order to study the prevalence of VRE in wildlife, we collected 221 faecal samples from free-ranging Hooded Crow (Corvus cornix) from urban and rural habitats in Hungary, from March to August 2020. The screening for resistant enterococci was done using bile esculin azide (BEA) agar supplemented with Vancomycin, specific to the screening of VRE. None of the samples from either habitat types yielded VRE. It seems that Hooded Crows from Hungary do not necessarily constitute a reservoir of VREs at present. Nonetheless, a continuous surveillance of VRE in wildlife would be judicious.

Effectiveness of surveillance cultures for high priority multidrug-resistant bacteria in hematopoietic stem cell transplant units.

ABSTRACTSurveillance strategies to detect colonization are an important tool to prevent and control the spread of microorganisms in hematopoietic stem cell transplant (HSCT) units. The aim of this study was to evaluate routine surveillance cultures for screening colonization and infection by carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPa), and vancomycin-resistant enterococci (VRE). Surveillance cultures were collected (1,323 samples) from 200 patients admitted to an HSCT unit over one year; swabs were taken on admission and then weekly. We compared the positivity of cultures for each site, agent, clinical and epidemiological data according to the colonization status. Infection due to multidrug-resistant organisms (MDROs) occurred in 52 (21.5%) patients, 45 (86.5%) due to blood stream infection; 12 (23%) patients had a positive surveillance culture before the infection. Cultures of 554 (41.8%) samples were performed for CRPa, 413 (31.2%) for VRE and 356 (27%) for CRE. Of these, 179 (13.5%) were positive. Colonization by any MDRO, CRE or CRPa was associated with increased risk of infection (P < 0.05), but not with death. Previous colonization by an MDRO was a significant risk for infection by these pathogens, specially by CRE. Overall, rectal swabs had the highest positivity rate compared with other sites, oropharynx swabs were an option for CRPa, and fecal cultures showed low positivity. Although the impact of the strategy on the mortality of patients undergoing HSCT is not clear, routine VRE surveillance should be questioned with regard to patients undergoing auto-HSCT due to the additional cost and little impact on survival rates.

A descriptive study of vancomycin resistant enterococci in Tertiary Care Hospital of Western India

Enterococci are second most commonly isolated hospital-acquired pathogen from urinary tract and wounds. Being notorious organism enterococci has presented treatment challenges resulted in newer drug development followed by resistance development in segments; such as Vancomycin. Present study aims at detecting prevalence, distribution and susceptibility patterns of Vancomycin Resistant Enterococci (VRE) found in clinical isolates.A descriptive study was carried out in the Microbiology department of Tertiary care hospital, Western India including a total of 36,027 clinical isolates received in the duration over 2 years from indoor patients across disciplines. Enterococci were recognized by standard biochemical tests. Anti-microbial susceptibility testing was done as per CLSI guideline. VRE was distinguished by disc diffusion method and Minimum Inhibitory Concentration Test. Qualitative data were presented as proportions.On susceptibility testing, the prevalence of VRE was found out to be 11.13%. Maximum number of VRE isolates were from Urine (49.06%), followed by blood culture (32.08%), and swab (5.66%). Among VRE; 56.6% isolates were E. Faecium followed by other enterococcus (35.85%) and E. Faecalis (7.55%) respectively. Highest resistance was found for penicillin, ampicillin and levofloxacin, while most sensitive were linezolid and fosfomycin.Considering versatile ability to advance and transmit antimicrobial resistance, VRE represents a bottle neck in treatment strategies. Rational prescription of antibiotic, VRE surveillance and timely antibiogram in admitted cases is the need of hour.

Chlorhexidine bathing to prevent healthcare-associated vancomycin-resistant Enterococcus infections: A cluster quasi-experimental controlled study at intensive care units

Vancomycin-resistant Enterococcus (VRE), a multidrug-resistant, difficult-to-treat pathogen of healthcare-associated infections (HAIs), is now endemic at many intensive care units (ICUs). Chlorhexidine (CHG) bathing is a simple and highly effective intervention to decrease VRE acquisition, but its effect on VRE-HAIs has not been assessed in prospective studies at ICUs. This is a cluster quasi-experimental controlled study. Under active VRE surveillance and contact isolation of all identified VRE carriers, four ICUs were assigned to provide 2% CHG bathing for all patients on a daily basis (CHG group) during the intervention period, while another four ICUs were assigned to provide standard care without CHG bathing for all patients (standard care group) during the same period. The CHG group (n=1501) had a 62% lower crude incidence of VRE-HAIs during the intervention period, compared with the baseline period (1.0 vs. 2.6 per thousand patient-days, P=0.009), while VRE-HAIs incidence did not change in standard care group (n=3299) (1.1 vs. 0.5 per thousand patient-days, P=0.139). In multivariable analyses, CHG bathing was independently associated with a 70% lower risk of VRE-HAIs (adjusted odds ratio [OR] 0.3, 95% confidence interval [CI], 0.2 to 0.7, P=0.006). In contrast, standard care during the same period had no effect on the risk of VRE-HAIs (adjusted OR 1.8, 95% CI: 0.7 to 4.7, P=0.259). CHG bathing is a highly effective approach to prevent VRE-HAIs at ICUs, in the context of active VRE surveillance with contact isolation.

Vancomycin-Resistant Enterococci (VRE) in Nigeria: The First Systematic Review and Meta-Analysis.

Vancomycin-Resistant Enterococci (VRE) are on the rise worldwide. Here, we report the first prevalence of VRE in Nigeria using systematic review and meta-analysis. International databases MedLib, PubMed, International Scientific Indexing (ISI), Web of Science, Scopus, Google Scholar, and African journals online (AJOL) were searched. Information was extracted by two independent reviewers, and results were reviewed by the third. Two reviewers independently assessed the study quality using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. OpenMeta analyst was used. The random effect was used, and publication bias was assessed using a funnel plot. Between-study heterogeneity was assessed, and the sources were analysed using the leave-one-out meta-analysis, subgroup analysis, and meta-regression. Nineteen studies met the eligibility criteria and were added to the final meta-analysis, and the study period was from 2009–2018. Of the 2552 isolates tested, 349 were VRE, and E. faecalis was reported the most. The pooled prevalence of VRE in Nigeria was estimated at 25.3% (95% CI; 19.8–30.8%; I2 = 96.26%; p < 0.001). Between-study variability was high (t2 = 0.011; heterogeneity I2 = 96.26% with heterogeneity chi-square (Q) = 480.667, degrees of freedom (df) = 18, and p = 0.001). The funnel plot showed no publication bias, and the leave-one-out forest plot did not affect the pooled prevalence. The South-East region had a moderate heterogeneity though not significant (I2 = 51.15%, p = 0.129). Meta-regression showed that all the variables listed contributed to the heterogeneity except for the animal isolate source (p = 0.188) and studies that were done in 2013 (p = 0.219). Adherence to proper and accurate antimicrobial usage, comprehensive testing, and continuous surveillance of VRE are required.

The Role of Healthcare Worker-Mediated Contact Networks in the Transmission of Vancomycin-Resistant Enterococci.

BackgroundUser- and time-stamped data from hospital electronic health records (EHRs) present opportunities to evaluate how healthcare worker (HCW)-mediated contact networks impact transmission of multidrug-resistant pathogens, such as vancomycin-resistant enterococci (VRE).MethodsThis is a retrospective analysis of incident acquisitions of VRE between July 1, 2016 and June 30, 2018. Clinical and demographic patient data were extracted from the hospital EHR system, including all recorded HCW contacts with patients. Contacts by an HCW with 2 different patients within 1 hour was considered a “connection”. Incident VRE acquisition was determined by positive clinical or surveillance cultures collected ≥72 hours after a negative surveillance culture.ResultsThere were 2952 hospitalizations by 2364 patients who had ≥2 VRE surveillance swabs, 112 (4.7%) patients of which had incident nosocomial acquisitions. Patients had a median of 24 (interquartile range [IQR], 18–33) recorded HCW contacts per day, 9 (IQR, 5–16) of which, or approximately 40%, were connections that occurred <1 hour after another patient contact. Patients that acquired VRE had a higher average number of daily connections to VRE-positive patients (3.1 [standard deviation {SD}, 2.4] versus 2.0 [SD, 2.1]). Controlling for other risk factors, connection to a VRE-positive patient was associated with increased odds of acquiring VRE (odds ratio, 1.64; 95% confidence interval, 1.39–1.92).ConclusionsWe demonstrated that EHR data can be used to quantify the impact of HCW-mediated patient connections on transmission of VRE in the hospital. Defining incident acquisition risk of multidrug-resistant organisms through HCWs connections from EHR data in real-time may aid implementation and evaluation of interventions to contain their spread.

Is there a higher prevalence of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization in patients with antibiotic allergy labels?

A penicillin allergy label has been associated with significantly higher rates of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization, and correspondingly poorer clinical outcomes. However, there are limited data examining the association between any antibiotic label and colonization rates. We sought to evaluate if there is a relationship between patients with an antibiotic allergy label and prevalence of MRSA or VRE colonization. We retrospectively reviewed all patients with an MRSA surveillance culture between December 15, 2014 and January 31, 2015, or a VRE surveillance culture between January 1, 2013 and January 31, 2015, at a tertiary community-based teaching hospital. Our primary objective was to evaluate the prevalence of MRSA or VRE colonization among patients with and without antibiotic allergies. Bivariate analyses included the χ² test and the Student t test to determine statistical significance for categorical and continuous variables, respectively. We included a total of 1,053 unique patients screened for MRSA, and 290 unique patients screened for VRE. The rate of MRSA and VRE colonization was 5.8% (62 of 1,053) and 32.4% (94 of 290), respectively, in our cohort. Antibiotic allergies were documented in approximately 1 out of 3 patients, 337 (32%) for the MRSA group and 94 (32%) for VRE group. There was a significant difference in MRSA colonization between patients with and without an antibiotic allergy, 28 of 337 (8.3%) versus 34 of 716 (4.7%) (P = .025), respectively. In contrast, there was no significant difference in antibiotic allergy rates with and without VRE colonization, 34 of 94 (36.2%) versus 92 of 196 (46.9%) (P = .10), respectively. An antibiotic allergy label was associated with significantly higher rates of MRSA colonization but no statistical difference with VRE colonization.

577. The Role of Healthcare Worker-Mediated Contact Networks in the Transmission of Vancomycin-Resistant Enterococci

BackgroundHealthcare workers (HCWs) commonly contact multiple patients daily and serve as an important vector for transmission of pathogens such as vancomycin-resistant enterococci (VRE). Characterizing the HCW-patient network is difficult, which limits understanding of the role of HCWs in the horizontal transmission of pathogens. Electronic health records (EHR) present an opportunity to generate HCW-mediated contact networks and evaluate their impact on transmission.MethodsRetrospective analysis of patients (PT) admitted to a medical intensive care unit and solid-organ transplant unit between July 2016 and June 2017. Clinical and demographic information, including VRE surveillance swab outcomes, were extracted from the hospital EHR system. PT-HCW-PT connections were defined as HCW contacts with a patient within an hour of another patient. Multi-variable logistic regression was used to analyze factors associated with unit-acquired VRE colonization incidence.ResultsA total of 2,336 patients had a recorded interaction with 4,956 unique HCWs. 146 patients were colonized with VRE on unit-admission, and 29 patients had unit-acquired VRE colonization. HCWs had contact with ~2 (range: 1–23) patients a day and ~6 (range: 1–58) contacts with patients per day (Figure 1), though rates varied by HCW-type. Patients were contacted by ~7 different HCWs resulting in ~28 contacts per day, with nurses being the most common (Figure 2). This resulted in approximately 10 PT-HCW-PT connections per day (range: 1–33) to an average of 3 other patients. After adjusting for known VRE acquisition risk factors, HCW connections to other patients with VRE significantly increased the risk of VRE acquisition (odds ratio = 1.32; 95% CI: 1.20–1.44; Table 1).ConclusionUnderstanding how HCWs connect patients can elucidate how pathogens, such as VRE, spread in the hospital. We demonstrated how EHR data can inform how HCWs connect patients to spread HAIs and the impact of those connections on the spread of VRE. Though EHR data have limitations, as certain activities and contacts are not logged into the system, they provide a scalable and generalizable source for understanding how patients are connected and can be utilized to reduce the spread of nosocomial infections. Disclosures All authors: No reported disclosures.

574. Reporting of Vancomycin-Resistant Enterococcus Bacteremia among National Healthcare Safety Network Acute Care Hospitals

BackgroundThe National Healthcare Safety Network’s (NHSN’s) Multidrug-resistant Organism/Clostridioides difficile (MDRO/CDI) Module serves as a surveillance platform for tracking antibiotic-resistant laboratory-identified (LabID) organisms. LabID event surveillance, which does not require submission of clinical data to NHSN, provides proxy measures for MDRO burden. While surveillance of some organisms is federally mandated, these requirements do not extend to vancomycin-resistant Enterococcus (VRE). We sought to describe the extent of acute care hospital (ACH) participation in NHSN VRE surveillance and identify facility-level factors associated with VRE bacteremia. These could explain differences in VRE incidence and be used in preparation for a national risk-adjusted benchmark.MethodsACHs that reported at least one month of facility-wide inpatient (FacWideIN) VRE bacteremia LabID Event data to NHSN in 2017 were included in the analysis. LabID events were categorized as healthcare facility-onset (HO), defined as a laboratory result for a specimen collected ≥4 days after admission, or community-onset (CO), defined as a specimen collected < 4 days after admission. Monthly patient day and admission denominators were used to calculate FacWideIN HO incidence and CO prevalence rates. Univariate analyses were performed on facility-level factors from NHSN’s annual hospital survey to assess their relationship with HO VRE bacteremia.ResultsA total of 544 HO VRE bacteremia events were reported by 498 hospitals in 37 states. About 67% of reporting hospitals were located in California. The national rate of HO VRE bacteremia was 0.27 per 10,000 patient-days and the CO VRE bacteremia rate was 0.58 per 10,000 admissions. Major medical school affiliation, hospital type, larger number of beds and ICU beds, longer average length of stay and the presence of an oncology unit were significantly associated with HO VRE bacteremia (Table 1).ConclusionBased on the VRE data reported to NHSN, certain facility-level factors may contribute to a higher incidence of HO VRE bacteremia. Future analyses can allow us to determine whether these factors are independently associated with VRE. Risk-adjusted surveillance data can help guide facilities and states to compare their burden of VRE to a national benchmark. Disclosures All authors: No reported disclosures.

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.

Multidrug-Resistant Organisms (MDRO) Surveillance: How do We Look At The Picture, Horizontally or Vertically?

BACKGROUND Surveillance for multidrug-resistant organisms (MDRO) is a cornerstone for infection prevention efforts. High risk patients for MDRO colonization should be the focus of surveillance. The aim of this study is to evaluate the effectiveness of surveillance for patients with high risk clinical criteria for MDRO colonization within critical care units (CCU). METHODS An automated daily report was developed that alerted the infection control department of new intensive care unit (ICU) admissions with at least two of the following criteria: admission from an outside facility, readmission within 90?days, presence of a chronic wound, tracheostomy or indwelling catheters. A retrospective review of these clinical criteria was performed over the last two years with excellent correlation and reported. MDRO included Methicillin-resistant Staph aureus (MRSA), Vancomycin resistant Enterococci (VRE), Carbapenem resistant Enterobacteriaceae (CRE) and extended spectrum Beta lactamase producing organisms (ESBL). Rectal swabs and groin sponges were obtained on admission for MRSA, ESBL, CRE and VRE. RESULTS From October 1st, 2017 to April 30th, 2018 samples were collected from 200 CCU patients. MDRO was recovered from 30% and 22.4% of rectal and groin cultures respectively. Gram negative MDRO (ESBL & CRE) represented 71% of the pathogens isolated. Rectal cultures were more effective than groin cultures for capturing all MDRO. CONCLUSIONS Rectal and groin surveillance for CRE, ESBL, VRE and MRSA for high risk patients is a very effective method of establishing MDRO colonization. Identifying the colonization status of CCU patients is an essential step in hospital associated infection prevention and outbreak investigations. Surveillance for multidrug-resistant organisms (MDRO) is a cornerstone for infection prevention efforts. High risk patients for MDRO colonization should be the focus of surveillance. The aim of this study is to evaluate the effectiveness of surveillance for patients with high risk clinical criteria for MDRO colonization within critical care units (CCU). An automated daily report was developed that alerted the infection control department of new intensive care unit (ICU) admissions with at least two of the following criteria: admission from an outside facility, readmission within 90?days, presence of a chronic wound, tracheostomy or indwelling catheters. A retrospective review of these clinical criteria was performed over the last two years with excellent correlation and reported. MDRO included Methicillin-resistant Staph aureus (MRSA), Vancomycin resistant Enterococci (VRE), Carbapenem resistant Enterobacteriaceae (CRE) and extended spectrum Beta lactamase producing organisms (ESBL). Rectal swabs and groin sponges were obtained on admission for MRSA, ESBL, CRE and VRE. From October 1st, 2017 to April 30th, 2018 samples were collected from 200 CCU patients. MDRO was recovered from 30% and 22.4% of rectal and groin cultures respectively. Gram negative MDRO (ESBL & CRE) represented 71% of the pathogens isolated. Rectal cultures were more effective than groin cultures for capturing all MDRO. Rectal and groin surveillance for CRE, ESBL, VRE and MRSA for high risk patients is a very effective method of establishing MDRO colonization. Identifying the colonization status of CCU patients is an essential step in hospital associated infection prevention and outbreak investigations.

Mathematical modelling of vancomycin-resistant enterococci transmission during passive surveillance and active surveillance with contact isolation highlights the need to identify and address the source of acquisition

BackgroundClinical studies and mathematical simulation suggest that active surveillance with contact isolation is associated with reduced vancomycin-resistant enterococci (VRE) prevalence compared to passive surveillance. Models using pre- and post-intervention data that account for the imperfect observation and serial dependence of VRE transmission events can better estimate the effectiveness of active surveillance and subsequent contact isolation; however, such analyses have not been performed.MethodsA mathematical model was fitted to surveillance data collected pre- and post-implementation of active surveillance with contact isolation in the haematology-oncology ward. We developed a Hidden Markov Model to describe undetected and observed VRE colonisation/infection status based on the detection activities in the ward. Bayesian inference was used to estimate transmission rates. The effectiveness of active surveillance was assumed to be via increased detection and subsequent contact isolation of VRE positive patients.ResultsWe estimated that 31% (95% credible interval: 0.33–85%) of the VRE transmissions were due to cross-transmission between patients. The ratio of transmission rates from patients with contact isolation versus those without contact isolation was 0.33 (95% credible interval: 0.050–1.22).ConclusionsThe majority of the VRE acquisitions in the haematology-oncology ward was estimated to be due to background rates of VRE, rather than within ward patient to patient acquisition. The credible interval for cross-transmission was wide which results in a large degree of uncertainty in the estimates. Factors that could account for background VRE acquisition include endogenous acquisition from antibiotic selection pressure and VRE in the environment. Contact isolation was not significantly associated with reduced VRE transmission in settings where the majority of VRE acquisition was due to background acquisition, emphasising the need to identify and address the source of acquisition. As the credible interval for the ratio of VRE transmission in contact isolated versus non-contact isolated patients crossed 1, there is a probability that the transmission rate in contact isolation was not lower. Our finding highlights the need to optimise infection control measures other than active surveillance for VRE and subsequent contact isolation to reduce VRE transmission. Such measures could include antimicrobial stewardship, environmental cleaning, and hand hygiene.

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

Practical methods for effective vancomycin-resistant enterococci (VRE) surveillance: experience in a liver transplant surgical intensive care unit.

We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling. Prospective, patient-level surveillance program of incident VRE colonization. Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.PatientsAll patients admitted to the SICU from June to August 2015. We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test. In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001). We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.

Rising Vancomycin-Resistant Enterococcus Infections in Hospitalized Children in the United States.

Vancomycin-resistant Enterococcus (VRE) is an emerging drug-resistant organism responsible for increasing numbers of nosocomial infections in adults. Few data are available on the epidemiology and impact of VRE infections in children. We hypothesized a significant increase in VRE infections among hospitalized children. Additionally, we predicted that VRE infection would be associated with certain comorbid conditions and increased duration and cost of hospitalization. A retrospective study of inpatient pediatric patients was performed using data on hospitalizations for VRE from the Healthcare Cost and Utilization Project Kids' Inpatient Database from 1997 to 2012. We used a multivariable logistic regression model to establish factors associated with VRE infection and a high-dimensional propensity score match to evaluate death, length of stay, and cost of hospitalization. Hospitalizations for VRE infection showed an increasing trend, from 53 hospitalizations per million in 1997 to 120 in 2012 (P < .001). Conditions associated with VRE included Clostridium difficile infection and other diagnoses involving immunosuppression and significant antibiotic and health care exposure. Patients with VRE infection had a significantly longer length of stay (attributable difference [AD] 2.1 days, P < .001) and higher hospitalization costs (AD $8233, P = .004). VRE infection was not associated with an increased risk of death (odds ratio 1.03; 95% confidence interval 0.73-1.47). VRE infections among hospitalized children are increasing at a substantial rate. This study demonstrates the significant impact of VRE on the health of pediatric patients and highlights the importance of strict adherence to existing infection control policies and VRE surveillance in certain high-risk pediatric populations.

Characteristics of Vancomycin-Resistant Enterococcus Strains in the West Balkans: A First Report.

Vancomycin-resistant enterococci are among the major causes of nosocomial infections and represent a growing problem in many European countries. Among the most common enterococcal isolates, Enterococcus faecium is considered to be the reservoir of VanA and VanB-mediated resistance to glycopeptides. Enterococci with VanA-mediated resistance can transfer resistance genes to other enterococci and gram-positive bacteria. Hence, monitoring and surveillance of vancomycin-resistant enterococci (VREs) are crucial for the prevention of the spread of glycopeptide resistance. No reports have yet been published that document the resistance rates and typization of VREs in the region of Bosnia and Herzegovina as well as Croatia. In this study, 64 clinical enterococcal strains that were isolated in clinical centers, Mostar, Sarajevo, and Zagreb, were studied and findings regarding characteristics of vancomycin-resistant strains found in the West Balkan region are reported for the first time. All of the strains were identified using conventional phenotypic methods, and the resistance to glycopeptides was determined using the disk diffusion method, Vitek 2, and genotypic Enterococcus assay. The results of genotyping showed that 40 strains were identified as VREs (30% Enterococcus faecalis and 70% E. faecium), while the sensitivity of the phenotypic methods was 87.5%. Furthermore, VanA and VanB resistance types were found in Bosnia and Herzegovina and Croatia, with slightly higher prevalence of the latter (72.5%) over the former (27.5%).

The clinical and molecular epidemiology of pre-transplant vancomycin-resistant enterococci colonization among liver transplant recipients.

Vancomycin-resistant enterococci (VRE) infections cause significant morbidity in liver transplant recipients. The epidemiology and impact of pre-transplant colonization with VRE among patients who undergo liver transplantation are poorly understood. We conducted an observational cohort study to identify risk factors and outcomes associated with pre-transplant VRE colonization and described the molecular diversity among VRE strains colonizing patients who undergo liver transplantation. Perirectal VRE surveillance cultures were performed prior to transplantation. Repetitive sequence-based polymerase chain reaction (rep-PCR) testing was used to identify clonality among VRE isolates. Of 61 patients who underwent pre-transplant VRE surveillance and subsequent liver transplantation, 27 (44%) were colonized with VRE. In multivariate analysis, pre-transplant VRE colonization was associated with central venous catheterization (OR 9.4, 95% confidence interval [CI]= 1.3-70.2, p = 0.03) and rifaximin use (OR 15.4, 95% CI 1.5-159.7, p = 0.02). Pre-transplant VRE colonization was associated with more hospital days post-transplant (26.6 vs. 16.1 d, p = 0.04). Of VRE-colonized patients analyzed with rep-PCR, 68% were colonized with the same strain as another patient in the cohort. Active surveillance identifies VRE-colonized patients who may benefit from targeted antimicrobial prophylaxis and enhanced infection prevention measures to prevent VRE spread. The relationship between rifaximin receipt and VRE colonization warrants further study. The identification of similar VRE isolates may suggest linked transmission during pre-transplant hospitalizations, which should be further investigated in prospective studies.