Vancomycin-resistant Enterococci Bloodstream Research Articles

Vancomycin-resistant enterococci infection: not just for the transplanted

Vancomycin-resistant enterococcal (VRE) blood stream infections (BSIs) pose significant hazards to patients with hematologic malignancy. We compared and examined VRE BSI rates, patient characteristics and clinical outcomes for two cohorts of patients: those who did and did not undergo hematopoietic cell transplant (HCT). In this single institution study, we retrospectively analyzed records of consecutive patients from 1998 through 2011. Over this 14-year period, VRE was identified in 14% of all BSIs in patients with HCT with a cumulative rate of 1.9% (48/2581 BSIs/patients). VRE was identified in 10% of all BSIs in non-HCT patients with a cumulative rate of 1.1% (35/3154 BSIs/patients). Transplant patients who developed VRE BSI tended to be younger, hospitalized more frequently, were exposed to vancomycin therapy frequently, and were more likely to have had a central venous catheter removed. VRE remains a significant cause of morbidity and mortality, as 22 deaths were directly or indirectly attributed to this infection. Both HCT and non-HCT patients are susceptible to VRE infection and are equally at risk for adverse outcomes related to VRE BSI.

Treatment considerations in vancomycin-resistant enterococcal bacteremia: daptomycin or linezolid? A review

Vancomycin resistant enterococcal bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. A search of the literature was undertaken to determine the optimal antimicrobial therapy for the management of vancomycin resistant enterococcal bloodstream infections. MEDLINE, EMBASE, and the Cochrane Library (unrestricted to time or language) were searched for studies of vancomycin resistant enterococcal bloodstream infections in adults reporting outcomes of direct comparisons of linezolid versus daptomycin on November 26, 2012. Studies of basic science, reviews, commentaries, pharmacologic, epidemiologic, or pediatric studies, and those studies examining conditions other than enterococcal bacteremia, a single antimicrobial agent or other antimicrobials were excluded. 226 studies were screened for eligibility and yielded eight studies evaluating a total of 807 patients. Inter-rater agreement was 100 %. Qualitative evaluation of the studies was performed using the Newcastle-Ottawa scale. No randomized controlled trials were identified. All studies were retrospective cohorts and non-randomized. 458 (57 %) patients treated with linezolid and 349 (43 %) with daptomycin were analyzed. Variable comorbidities and severity of illness were described in the included studies and reported here for comparison. The optimal treatment of vancomycin resistant enterococcal bloodstream infections is yet to be determined. Well-designed prospective studies are needed to lend more convincing evidence regarding choice of antimicrobial therapy for this important multidrug resistant organism.

Treatment of Vancomycin-Resistant Enterococcal Bacteremia in an Observational Cohort of Neutropenic Oncology Patients

Background Vancomycin-resistant Enterococcus (VRE) is an increasingly common nosocomial pathogen causing significant morbidity and mortality in patients with neutropenic cancer. We evaluated outcomes in an observed cohort of subjects with VRE bacteremia and compare the effectiveness of 2 antibiotics commonly used to treat VRE infections: daptomycin and linezolid. Methods Patients with neutropenic cancer with VRE blood stream infections treated with daptomycin or linezolid were identified through electronic medical record, and a retrospective chart review was conducted. Results Eighty-one patients were included. There were 49 men (60%) and 32 women; the mean age was 59.3 years. Mean white blood cell count at the time of blood stream infection was 0.3, and the median duration of bacteremia was 2 days (range, 1–25 days). Leukemia was the underlying diagnosis in 82.7%. Only 4 patients received anti-VRE therapy within 4 hours, 14 patients received VRE-specific therapy within 24 hours of first positive culture. The overall treatment failure rate was 35.8%; daptomycin, 41.4%; and linezolid, 21.7% (P = 0.13). Primary causes of treatment failure were persistent bacteremia and death. The 30-day mortality rate was 38.3%. Of these 31 deaths, 22.6% were directly attributable to VRE, with VRE being contributory in an additional 22.6%. Overall mortality in patients treated with daptomycin (39.7%) or linezolid (34.8%) did not differ (P = 0.80). Resistance to both agents was observed. Conclusions We found a 38.3% 30-day mortality rate, emphasizing the need for prevention and perhaps early inclusion of VRE-specific therapy for those with known colonization. Outcomes of culture-directed therapy with linezolid or daptomycin did not differ by antibiotic choice.

Evaluation of the Treatment of Vancomycin-Resistant Enterococcal Urinary Tract Infections in a Large Academic Medical Center

Vancomycin-resistant enterococci (VRE) are a common cause of nosocomial urinary tract infections (UTIs) among hospitalized patients. Clinicians need to differentiate between VRE-associated urinary colonization, asymptomatic bacteriuria, and UTIs to determine the need for treatment and length of therapy. To characterize the diagnosis and management of VRE from urinary sources, including compliance with institutional treatment guidelines, and identify risk factors associated with clinical failure. We performed a retrospective, single-center, cohort study among patients with VRE-positive cultures from urinary sources over a 3-year study period (July 2008-September 2011). Descriptive statistics were used to evaluate demographics, diagnostics, guideline compliance, pharmacotherapy, and outcomes. Risk factors associated with clinical failure were identified by multivariate logistic regression analysis. Two hundred sixty-nine distinct episodes of VRE met inclusion criteria among 252 patients. Forty-seven percent and 77% of episodes occurred in patients admitted to an intensive care unit and hospitalized for 7 or more days, respectively. Fifty-eight percent of the episodes were classified as asymptomatic bacteriuria or colonization. Compliance with institutional treatment guidelines for the appropriate drug, dose, and duration occurred in approximately 70% of the cases. Among noncompliant cases (n = 83), 48 (58%) were overtreated, and 35 (42%) were undertreated. Clinical failure among all cases was common, including mortality (17.1%). Factors independently associated with clinical failure determined on multivariate analysis included weight 100 kg or more (OR 5.30; 95% CI 1.42-12.21; p = 0.014), renal disease (OR 2.57; 95% CI 1.02-6.47; p = 0.048), indwelling catheter (OR 4.62; 95% CI 1.05-18.24; p = 0.046), and VRE bloodstream infection (OR 15.71; 95% CI 2.9-128.7; p < 0 .001). Improved education is needed to minimize cases of overtreatment and undertreatment of VRE-associated UTIs and decrease inappropriate drug-related costs and clinical failure rates. Risk factors for clinical failure can be used to risk stratify VRE-associated UTIs and further guide treatment decisions.

Polyclonal Outbreak of Vancomycin-resistant Enterococcus faecium in a Pediatric Oncology Department

We present a polyclonal outbreak of vancomycin-resistant enterococci (VRE) colonization in a pediatric oncology department and the role of a bundle of actions. After the occurrence of VRE bloodstream infections in 2 patients, an active surveillance of VRE colonization was started. Enhanced infection control measures and closure of the department to new admissions for the first 3 months were implemented. Among 32 patients screened for VRE, 21 were found colonized. Daily prevalence of VRE colonization among hospitalized patients ranged from 40% to 75%, but no new VRE infections occurred. Monthly incidence of VRE colonization decreased from 2.5 to 0.6 cases per 100 occupied bed-days at the end of this outbreak by the implementation of the above-mentioned measures. All VRE isolates tested were Enterococcus faecium carrying VanA gene. Pulsed field gel electrophoresis showed a polyclonal outbreak. A case-control study did not show any particular risk factors for colonization. High use of glycopeptide was noted before study outbreak that was drastically decreased during the study but only temporarily. Control of VRE in pediatric oncology departments with high colonization rates is challenging and requires a multifaceted strategy. Polyclonal spread of VRE found in this study suggests a possible effect of prior antimicrobial overuse and the critical need for antimicrobial stewardship especially in the era of multidrug-resistant bacteria.

Emergence of vancomycin-resistant Enterococcus bloodstream infections in southern Taiwan

An increased incidence of vancomycin-resistant enterococcal bloodstream infections (VRE BSI) in the United States has been noted in recent years. There were a few reports of VRE BSI in Taiwan. This study is intended to show the epidemiology, clinical features and outcomes of VRE BSI at a medical center in southern Taiwan. A retrospective study was conducted from January 1, 2005 to December 31, 2010. All patients with VRE BSI episodes were identified and their medical records were reviewed. A total of 69 episodes of VRE BSI were identified in the study period. The incidence rate increased from 0.01 episodes of VRE BSI/1000 patient-days in 2005 to 0.07 episodes of VRE BSI/1000 patient-days in 2010. The 30-day mortality rate was 52.17% for all patients with VRE BSI. The mortality rate of patients who received invitro active and inactive antimicrobial therapy for VRE BSI was 40% and 100%, respectively (p<0.001). Factors associated with mortality were shock [odds ratio (OR) 24.4, 95% confidence interval (CI) 3.6-163.2, p=0.001], renal failure (OR 90.9, 95% CI 1.9-4404.3, p=0.02), and underlying liver cirrhosis (OR 12.4, 95% CI 1.2-125.8, p=0.03). Use of linezolid for VRE BSI showed a trend for lower 30-day mortality than daptomycin therapy (35.5% vs. 56.3%, p=0.17). VRE BSI is increasingly important in the study hospital and is associated with a significant mortality rate. Appropriateness of antimicrobial therapy has a prognostic impact on patients with VRE BSI.

Certification in infection control matters: Impact of infection control department characteristics and policies on rates of multidrug-resistant infections

The study objective is to describe infection control policies aimed at multidrug-resistant organisms (MDRO) in California hospitals and assess the relationship among these policies, structural characteristics, and rates of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) bloodstream infections and Clostridium difficile infections. Data on infection control policies, structural characteristics, and MDRO rates were collected through a 2010 survey of California infection control departments. Bivariate and multivariable Poisson and negative binomial regressions were conducted. One hundred eighty hospitals provided data (response rate, 54%). Targeted MRSA screening upon admission was reported by the majority of hospitals (87%). The majority of hospitals implemented contact precautions for confirmed MDRO and C difficile patients; presumptive isolation/contact precautions for patients with pending screens were less frequently implemented. Few infection control policies were associated with lower MDRO rates. Hospitals with a certified infection control director had significantly lower rates of MRSA bloodstream infections (P < .05). Although most California hospitals are involved in activities to decrease MDRO, there is variation in specific activities utilized with the most focus placed on MRSA. This study highlights the importance of certification and its significant impact on infection rates. Additional research is needed to confirm these findings.

Vancomycin resistant enterococcus (VRE) bloodstream infections (BSI): a case-controlled analysis to assess implications on mortality in haematology patients at a single tertiary referral centre

<h3>Aims</h3> To describe vancomycin resistant enterococcus (VRE) patient characteristics and compare mortality rates to case-matched controls. <h3>Methods</h3> Admissions and microbiology from haematology-oncology ward (1/6/2009-1/6/2010) were reviewed. Case-controlled analysis of VRE impact on mortality was undertaken. <h3>Results</h3> VRE isolated in 29 [11 bloodstream infections (BSI)]. Mean length of stay (LOS) was significantly longer in VRE than overall haematology (19.2±4.8 versus 10.8±1.4, <i>p</i>=0.01). Acute myeloid leukaemia (AML) / acute lymphoblastic leukaemia (ALL) patients accounted for 7 VRE (4 BSI). 33 VRE isolates in 29 separate patients: 16 swabs (mostly rectal), 11 BSI, 5 urine. 16/29 VRE patients died, median time-to-death from detection 30 days (0–236). No significant increase in mortality with VRE BSI compared to other modes: 10/16 (63%) swab, 5/11 (45%) BSI and 4/5 (80%) urine. 8/15 deaths due to progressive disease, 3/15 deaths due to overwhelming sepsis. Case-controlled analysis performed: age, case and stage of disease matched analysis comparing 14 VRE and 14 non-VRE. Median follow-up 272 and 364 days, respectively. Mortality rate 50% versus 29%. Majority of deaths due to progressive disease. <h3>Discussion</h3> VRE detection by screening and BSI are increasingly observed at our hospital. Risk factors from our analysis are LOS >20 days and AML/ALL. VRE detection is associated with increased frequency of death but progressive disease remains the most common cause of death. VRE BSI does not appear to confer a worse prognosis.

Vancomycin resistant enterococcus (VRE) bloodstream infections (BSI): a case-controlled analysis to assess implications on mortality in haematology patients at a single tertiary referral centre

Aims To describe vancomycin resistant enterococcus (VRE) patient characteristics and compare mortality rates to case-matched controls. Methods Admissions and microbiology from haematology-oncology ward (1/6/2009-1/6/2010) were reviewed. Case-controlled analysis of VRE impact on mortality was undertaken. Results VRE isolated in 29 [11 bloodstream infections (BSI)]. Mean length of stay (LOS) was significantly longer in VRE than overall haematology (19.2 ± 4.8 versus 10.8 ± 1.4, p = 0.01). Acute myeloid leukaemia (AML) / acute lymphoblastic leukaemia (ALL) patients accounted for 7 VRE (4 BSI). 33 VRE isolates in 29 separate patients: 16 swabs (mostly rectal), 11 BSI, 5 urine. 16/29 VRE patients died, median time-to-death from detection 30 days (0-236). No significant increase in mortality with VRE BSI compared to other modes: 10/16 (63%) swab, 5/11 (45%) BSI and 4/5 (80%) urine. 8/15 deaths due to progressive disease, 3/15 deaths due to overwhelming sepsis. Case-controlled analysis performed: age, case and stage of disease matched analysis comparing 14 VRE and 14 non-VRE. Median follow-up 272 and 364 days, respectively. Mortality rate 50% versus 29%. Majority of deaths due to progressive disease. Discussion VRE detection by screening and BSI are increasingly observed at our hospital. Risk factors from our analysis are LOS >20 days and AML/ALL. VRE detection is associated with increased frequency of death but progressive disease remains the most common cause of death. VRE BSI does not appear to confer a worse prognosis. To describe vancomycin resistant enterococcus (VRE) patient characteristics and compare mortality rates to case-matched controls. Admissions and microbiology from haematology-oncology ward (1/6/2009-1/6/2010) were reviewed. Case-controlled analysis of VRE impact on mortality was undertaken. VRE isolated in 29 [11 bloodstream infections (BSI)]. Mean length of stay (LOS) was significantly longer in VRE than overall haematology (19.2 ± 4.8 versus 10.8 ± 1.4, p = 0.01). Acute myeloid leukaemia (AML) / acute lymphoblastic leukaemia (ALL) patients accounted for 7 VRE (4 BSI). 33 VRE isolates in 29 separate patients: 16 swabs (mostly rectal), 11 BSI, 5 urine. 16/29 VRE patients died, median time-to-death from detection 30 days (0-236). No significant increase in mortality with VRE BSI compared to other modes: 10/16 (63%) swab, 5/11 (45%) BSI and 4/5 (80%) urine. 8/15 deaths due to progressive disease, 3/15 deaths due to overwhelming sepsis. Case-controlled analysis performed: age, case and stage of disease matched analysis comparing 14 VRE and 14 non-VRE. Median follow-up 272 and 364 days, respectively. Mortality rate 50% versus 29%. Majority of deaths due to progressive disease. VRE detection by screening and BSI are increasingly observed at our hospital. Risk factors from our analysis are LOS >20 days and AML/ALL. VRE detection is associated with increased frequency of death but progressive disease remains the most common cause of death. VRE BSI does not appear to confer a worse prognosis.

Observational study of the epidemiology and outcomes of vancomycin-resistantEnterococcusbacteraemia treated with newer antimicrobial agents

Vancomycin-resistant Enterococcus bloodstream infections (VRE-BSI) are a growing problem with few clinical trials to guide therapy. We conducted a retrospective study of management and predictors of mortality for VRE-BSI at a tertiary-care centre from January 2005 to August 2008. Univariate and multivariable analyses examined the relationship of patient characteristics and antibiotic therapy with 30-day all-cause mortality. Rates of VRE-BSI increased from 0·06 to 0·17 infections/1000 patient-days (P=0·03). For 235 patients, 30-day mortality was 34·9%. Patients were primarily treated with linezolid (44·2%) or daptomycin (36·5%). Factors associated with mortality were haemodialysis [odds ratio (OR) 3·2, 95% confidence interval (CI) 1·6-6·3, P=0·007], mechanical ventilation (OR 3·7, 95% CI 1·3-10·4, P=0·01), and malnutrition (OR 2·0, 95% CI 1·0-4·0, P=0·046). Use of linezolid, but not daptomycin (P=0·052) showed a trend towards an association with survival. In conclusion, VRE-BSI is a growing problem, associated with significant 30-day mortality. Multiple factors were associated with poor outcomes at our hospital.

Comparison of outcomes from daptomycin or linezolid treatment for vancomycin-resistant enterococcal bloodstream infection: A retrospective, multicenter, cohort study

Background: The optimal treatment for bloodstream infections (BSIs) with vancomycin-resistant enterococci (VRE) is unknown. Objective: This study examined outcomes in patients treated with daptomycin or linezolid for VRE BSI. Methods: A retrospective, multicenter, cohort study was performed via chart review. Hospitalized patients treated for VRE BSI with daptomycin or linezolid from September 1, 2003, to June 30, 2007, were identified via pharmacy and microbiology reports at each institution. Patients aged <18 years or with polymicrobial bacteremia were excluded from analysis. Linezolid and daptomycin were included because the participating institutions used either of the 2 agents as first-line treatment for VRE BSI. Univariate and multivariate analyses were performed to determine the effect of drug selection on mortality and duration of BSI. Duration of BSI was defined as the amount of time from the draw date of the first positive blood culture to the draw date of the first finalized negative blood culture. Adverse events were not assessed. Results: One-hundred one patients from 3 participating US hospitals experiencing VRE BSI were identified. Sixty-seven patients were treated with daptomycin and 34 with linezolid. Baseline characteristics appeared comparable between the daptomycin- and linezolidtreated groups, with the exception of shock ( P = 0.049), prior vancomycin treatment ( P = 0.002), and prior linezolid treatment ( P < 0.001), all of which occurred significantly more often in daptomycin-treated patients. Inpatient mortality occurred in 31 daptomycin- and 10 linezolid-treated patients (46.3% vs 29.4%; P = NS). Linear regression found that shock (P = 0.015), infective endocarditis ( P = 0.021), and concurrent rifampin or gentamicin treatment ( P = 0.01) were associated with prolonged duration of positive cultures. Logistic regression revealed that shock (odds ratio [OR] = 14.24; P = 0.008), infection with Enterococcus faecium (OR = 53.10; P = 0.024), previous linezolid treatment (OR = 6.63; P = 0.031), concurrent rifampin or gentamicin treatment (OR = 6.48; P = 0.046), and a nonline source of infection (OR = 6.67; P = 0.019) were associated with increased mortality. Conclusions: In this retrospective cohort analysis, there were no significant differences in mortality of VRE BSI between patients receiving daptomycin or linezolid. Underlying comorbidities appeared to best predict outcome; however, given the retrospective nature of this study, larger, prospective, randomized, comparative studies are needed to control for potential biases and determine definitive outcome differences between these 2 antimicrobials.

Surveillance and endemic vancomycin-resistant enterococci: some success in control is possible

Vancomycin-resistant enterococci (VRE) are prevalent in many Irish hospitals. We analysed surveillance data from 2001 to 2008 in a centre where VRE is endemic. All clinically significant enterococci were tested for susceptibility to vancomycin. All intensive care unit admissions were screened on admission and weekly thereafter. Interventions included isolating/cohorting VRE patients, monthly prevalence surveys of VRE patients, the introduction of an electronic alert system, programmes to improve hand and environmental hygiene, and the appointment of an antibiotic pharmacist. There was a significant increase in the number of positive VRE screening samples from 2001 (1.96 patients with positive VRE screens per 10 000 bed-days) to 2006 (4.98 per 10 000 bed-days) (P < or = 0.001) with a decrease in 2007 (3.18 per 10 000 bed-days) (P < or = 0.01). The number of VRE bloodstream infections (BSI) increased from 0.09 BSI per 10 000 bed-days in 2001 to 0.78 per 10 000 bed-days in 2005 (P < or = 0.001) but decreased subsequently. Linear regression analysis indicated a significant association between new cases of VRE and non-isolated VRE patients, especially between May 2005 and December 2006 [P=0.009; 95% confidence interval (CI): 0.08-0.46] and between May 2005 and December 2008 (P = 0.008; 95% CI: 0.06-0.46). Routine surveillance for VRE together with other measures can control VRE BSI and colonisation, even where VRE is endemic, and where facilities are constrained.

Hematologic Safety Profile of Linezolid in the Early Periengraftment Period after Allogeneic Stem Cell Transplantation

Vancomycin-resistant enterococci (VRE) are common pathogens of bloodstream infections in the peritransplantation period. Linezolid is approved by the FDA for treating VRE infections, but has been associated with low rates of hematologic toxicity in the general population; thus, there are concerns about its potential myelotoxicity in the allogeneic hematopoietic stem cell transplantation (HSCT) setting. We examined the impact of linezolid treatment on the times to neutrophil and platelet engraftment in 33 patients who underwent HSCT. In this retrospective case-controlled study conducted from 2000 through 2007, cases received > or = 7 consecutive days of linezolid therapy, starting before day +8 post-HSCT. Controls received > or = 7 consecutive days of vancomycin therapy before day +8 and were matched to cases by age and conditioning regimen. The cumulative incidence function was used to estimate the probabilities for the times to neutrophil and platelet engraftment. A competing-risk regression model was used to determine whether times to engraftment differed for cases and controls. A total of 33 cases were compared with 33 controls. The median duration of treatment after stem cell infusion was 14 days (range, 7 to 34 days) for linezolid and 16 days (range, 8 to 33 days) for vancomycin. The rates of neutrophil and platelet engraftment were similar between the cases and controls. After adjusting for baseline characteristics, no difference in the times to neutrophil or platelet engraftment was seen between the 2 groups. Our findings demonstrate no adverse effect on the times to neutrophil or platelet engraftment with linezolid use. Larger prospective studies are needed to fully determine the hematologic safety of linezolid in patients undergoing HSCT.

Vancomycin resistant enterococci (VRE) infections in hematopoietic stem cell transplant (HSCT) recipients

7036 Background: VRE blood stream infections (BSI) pose significant hazards to HSCT patients. Risk factors predisposing patients for a relatively nonpathogenic organism to become bacteremic include immune suppression, neutropenia, renal failure, antibiotic exposure, indwelling catheters, and VRE colonization. Some studies suggest that a VRE BSI is simply a marker of primary disease severity or an indicator of poor outcome, while other data demonstrate VRE BSI as an independent predictor of mortality. Methods: We performed a retrospective chart analysis of HSCT patient data using the electronic medical record and written charts using a standard data collection tool from February 1994 to October 2008. Vancomycin susceptibility was determined using the Dade Berhing panel. Results: We noted 625 infections in 385 HSCT patients; 26 patients developed 27 VRE infections over the course of 15 years. All isolates were Enterococcus faecium and not polymicrobial. Host characteristics included mean age of 49.5 yrs, all had central venous catheters, and 26 received linezolid treatment. Persistent infection was identified in 11 patients with central access removal in 4. VRE colonization was identified in stool (18 patients) and urine (5 patients) and 4 patients had a prior VSE BSI. 16 patients received vancomycin within 30 days of developing VRE BSI. 21 patients were neutropenic (mean duration15 days). 8 patients were not receiving immunosuppressants during time of bacteremia. Gastrointestinal endoscopy was identified in 6 patients prior to BSI. 16 patients died during the hospitalization. Conclusions: VRE accounted directly or indirectly for 13 of 16 deaths during incident hospitalization. In this population, blood, urine, stool surveillance is warranted to prevent morbidity/mortality related to developing a VRE BSI. Prolonged neutropenia was associated with development of a VRE BSI prophylactic granulocyte transfusion might be useful to prevent BSI. In contrast to prior studies, many patients were not receiving immunosuppressants and did not undergo GI instrumentation. VRE BSI prevention should include identifying patients with urinary or stool colonization, appropriate isolation and early central venous catheter removal if a VRE BSI is identified. No significant financial relationships to disclose.

The risk of developing a vancomycin-resistant Enterococcus bloodstream infection for colonized patients

Between 2 to 4 million patients each year develop health care-acquired infections in the United States. Infection resulting from vancomycin-resistant Enterococcus (VRE) is now the second to third most common cause of nosocomial infections in the United States. VRE is most often transmitted by the contaminated hands, clothing, and equipment of health care workers. Patients with VRE bloodstream infections (BSIs) have increased rates of recurrent BSI (16.9% vs 3.7%, respectively, P < .0001), increased crude case fatality rates (relative risk [RR], 2.57; 95% confidence interval [CI]: 2.27-2.91), increased mortality because of bacteremia (RR, 1.79; 95% CI: 1.28-2.50), and increased hospital costs of $27,000 per episode of BSI (P = .04) compared with those with vancomycin-susceptible BSI. Additionally, transfer of the gene responsible for vancomycin resistance to S aureus has been demonstrated in vitro, and reports of clinical infections because of vancomycin-resistant Staphylococcus aureus have been reported from many areas of the world, including the United States. Risk factors for VRE colonization and infection include prolonged length of hospital stay, use of broad-spectrum antibiotics, having an indwelling invasive device, and close proximity to another VRE-colonized or -infected patient; however, risk factors for developing VRE BSI among colonized patients have not been fully described. Infection control measures for VRE include antibiotic-usage control, reducing contamination of the environment with proper cleaning and disinfection, and reducing contamination of health care workers by use of contact precautions. Health care-acquired BSIs can also be effectively controlled by closely following central venous line prevention guidelines and complying with the central venous line bundle. Control and prevention of VRE colonization and thus infection would be expected to reduce morbidity, reduce health care costs, and save lives.

The burden of vancomycin-resistant enterococcal infections in US hospitals, 2003 to 2004

Despite significant concern in the health care community regarding vancomycin-resistant enterococci (VRE), there are no estimates of the total number of VRE infections that occur each year in US hospitals. Using data from a national survey of hospital discharges and a national antimicrobial resistance surveillance system, we estimated the annual number of US hospitalization with VRE bloodstream, urinary tract, and wound or intra-abdominal infections. Because of the inexact nature of hospital discharge diagnosis coding, we made both a conservative and liberal estimate of hospitalization with VRE infection by using a variety of data sources. For the years 2003 and 2004, we conservatively estimated that there were 20 777 and 20 931 VRE infections, respectively; for those same years, the liberal estimates were 78 330 and 85 586, respectively. Because there are such a large number of hospital discharges for which an infection is coded without an organism code, it is likely that the conservative estimate is an underestimate of the true burden. These estimates highlight the importance of controlling VRE and the need to develop improved methods for tracking the burden of such infections.

Risk of Vancomycin-ResistantEnterococcus(VRE) Bloodstream Infection Among Patients Colonized With VRE

Colonization with vancomycin-resistant Enterococcus (VRE) is a risk factor for subsequent VRE bloodstream infection (BSI); however, risk factors for BSI among colonized patients have not been adequately described. We sought to determine the proportion of VRE-colonized patients who subsequently develop VRE BSI and to identify risk factors for VRE BSI among these patients. Records of 768 patients colonized with VRE from January 2002 through June 2005 were reviewed. The proportion of patients who developed VRE BSI was calculated, and the characteristics of these patients were compared, in a 2:1 ratio, with those of patients who did not develop VRE BSI. To identify risk factors for VRE BSI and for death, we used univariate logistic regression analysis and then multivariate logistic regression analysis. Using pulsed-field gel electrophoresis (PFGE), we compared the isolate recovered when the patient was colonized and the isolate recovered when the patient developed VRE BSI. Of the 768 patients colonized with VRE, 31 (4.0%) developed VRE BSI. Multivariate analysis identified the following independent risk factors for developing VRE BSI: infection of an additional body site other than blood (adjusted odds ratio [aOR], 3.9; P = .04), admission to the hospital from a long-term care facility (aOR, 12.6; P = .04), and receipt of vancomycin (aOR, 10.6; P = .001). The independent risk factors for death among patients colonized with VRE were immunosuppression (aOR, 12.9; P = .001) and VRE BSI (aOR, 9.1; P = .002). Of the 31 patients who developed VRE BSI, 23 (74%) had a pair of isolates representing VRE colonization and VRE BSI. For 19 (83%) of these 23 patients, the isolate representing BSI was genetically related to the isolate representing VRE colonization: 12 pairs of isolates (52%) had identical banding patterns, 5 had closely related patterns, and 2 had possibly related patterns. Of the 768 patients colonized with VRE, 31 (4.0%) usually developed VRE BSI due to a related strain. Independent risk factors for BSI among colonized patients were admission from a long-term care facility, infection of an additional body site, and exposure to vancomycin. Independent risk factors for death were immunosuppression and VRE BSI.

Vancomycin-Resistant Enterococcus: Containing an Outbreak in a University-Based Children's Hospital

ISSUE: Following onset of a dramatic increase in vancomycin-resistant enterococcus (VRE) bloodstream infections (BSI) among patients (n = 7) on the bone marrow transplant unit at a university based children's hospital, a multifaceted intervention was designed to identify and isolate colonized patients, to educate healthcare workers on the importance of adherence to isolation practices, and to reduce the rate of VRE colonization in the population.

Colonization, Bloodstream Infection, and Mortality Caused by Vancomycin-Resistant Enterococcus Early after Allogeneic Hematopoietic Stem Cell Transplant

Bloodstream infection caused by vancomycin-resistant enterococcus (VRE) is associated with very high mortality among allogeneic hematopoietic stem cell transplant (alloHSCT) recipients. However, it remains unclear whether VRE bloodstream infection directly causes mortality in the early posttransplant period or is simply a marker of poor outcome. To determine the risk factors for VRE bloodstream infection and its effect on outcome, we followed 92 patients screened for stool colonization by VRE upon admission for alloHSCT. Patient records were reviewed to determine outcomes, including mortality and microbiologic failure. Colonization by VRE was extremely common, occurring in 40.2% of patients. VRE bloodstream infection developed in 34.2% of colonized patients by day +35, compared to 1.8% without VRE colonization ( P < .01). VRE bloodstream infection was associated with a significant decrement in survival and frequent microbiologic failure, despite treatment with linezolid and/or daptomycin. Five (35.7%) of 14 patients with VRE bloodstream infection had attributable mortality or contributing mortality from the infection. Strain typing by pulsed-field gel electrophoresis identified 9 different VRE strains among the 37 colonized patients and 5 patients with different strains recovered from the stool and the blood. In conclusion, stool screening effectively identified patients at extremely high risk for VRE bloodstream infection. The high mortality of VRE in the early posttransplant period supports the use of empiric antibiotics with activity against VRE during periods of fever and neutropenia in colonized patients.

Daptomycin in the treatment of vancomycin-resistant Enterococcus faecium bacteremia in neutropenic patients

Vancomycin resistant enterococcal (VRE) blood stream infection (BSI) in neutropenic patients is associated with poor outcome. We report our experience in treating VRE BSI in febrile, neutropenic patients with daptomycin, a recently licensed lipopeptide with bactericidal activity against VRE. Patients with fever, neutropenia and VRE BSI were treated with more than one dose of daptomycin (either 6 mg/kg/day or 4 mg/kg/day) in an open label, emergency-use trial. Patients were then assessed for clinical and microbiological cures and survival. MIC's of isolates to daptomycin were determined. Nine febrile, neutropenic patients with VRE BSI received daptomycin. Four of 9 courses (44%) had clinical and/or microbiologic cure. Two of the 5 who failed cure died within 3 days of initiation of daptomycin. Five subjects survived to 30 days after the onset of BSI. Use of daptomycin in neutropenic patients with VRE BSI deserves further study as a treatment for VRE BSI in neutropenic patients.