Vancomycin-resistant Enterococci Screening Research Articles

Emergence of antimicrobial resistance and virulence factors among the unusual species of enterococci, from North India.

Several enterococcal species are increasingly being reported from clinical infections, besides the major species. This study was undertaken to determine the prevalence of unusual enterococcal species and their antimicrobial susceptibility patterns, virulence factors, and molecular characterization. The study was conducted in Department of Microbiology and associated Tertiary Care University Hospital in North India. Enterococcal isolates were collected for a period of 2 years from clinical specimens. Identification and elaborate phenotypic characterization was done biochemically. All the isolates were tested by Kirby-Bauer disc diffusion method and breakpoint minimum inhibitory concentration for susceptibility against standard antibiotics. Screening for vancomycin-resistant enterococci (VRE), high-level aminoglycoside resistance was done on brain heart infusion agar incorporated with 6 μg/ml vancomycin, 500 μg/ml gentamicin, and 2000 μg/ml streptomycin, respectively. VRE isolates were tested for the presence of vanA, vanB, and vanC genes and high-level gentamicin resistant (HLGR) isolates for aac-6'- aph-2' gene by polymerase chain reaction (PCR). Hemolysin and gelatinase production, hemagglutination and biofilm formation were detected along with asa1, gelE, esp, hyl, and cylA genes by multiplex PCR. Of 403 enterococci, 93 (23.07%) isolates were identified as unusual species and atypical variants. Resistance of 52.68%, 46.23%, 44.08%, and 6.45% for ampicillin, ciprofloxacin, high strength gentamicin, and vancomycin, respectively were noted. Presence of vanC gene in Enterococcus gallinarum and Enterococcus casseliflavus isolates and vanA gene in Enterococcus durans and Enterococcus hirae and aac-6'- aph-2'' gene was found in 33.14% (14/41) of the HLGR isolates. The most frequent virulence factor was biofilm production. Only a few isolates harbored asa1 (2), gelE (9), and hyl (3) genes. Considerable prevalence of pathogenic unusual species of enterococci was seen along with their emerging drug resistance and virulence. Complete identification and routine speciation is essential to limit their emergence as major species in near future.

Horizontal infection prevention measures and a risk-managed approach to vancomycin-resistant enterococci: An evaluation

The use of infection control measures in the management of vancomycin-resistant enterococci (VRE) is hotly debated. A risk-managed approach to VRE control after the introduction of 2 horizontal infection prevention measures-an environmental cleaning (EC) and an antimicrobial stewardship (AMS) program-was assessed. Routine screening for VRE was discontinued 6 and 4 months after introduction of the EC and AMS programs, respectively. Only 4 units (intensive care, burns-trauma, solid organ transplant, and bone marrow transplant units) where patients were deemed to be at increased risk for VRE infection continued screening and contact precautions. Cost avoidance and value-added benefits were monitored by the hospital finance department. VRE monitoring on these high-risk units and facility-wide comprehensive bacteremia surveillance continued as per established protocols. Surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI) remained unchanged. VRE bacteremia rates did not increase with the change to the VRE risk-managed approach. The number of patients requiring VRE isolation in all areas of the hospital decreased from an average of 32 to 6 beds per day. Statistically significant reductions in CDI and MRSA rates were observed possibly related to the aggressive decluttering, equipment cleaning, and AMS program elements. A risk-managed approach to VRE can be implemented without adverse consequences and potentially with significant benefits to a facility.

Is the prevalence of antibiotic-resistant organisms changing in Canadian hospitals? Comparison of point-prevalence survey results in 2010 and 2012

A national point-prevalence survey for infection or colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), and for Clostridium difficile infection (CDI) was done in Canadian hospitals in 2010. A follow-up survey was done in November 2012 to determine whether there were any changes in the prevalence of these organisms; we also determined the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CREs). Associations between prevalence and infection prevention and control policies were evaluated in logistic regression models. A total of 143 (67% of eligible facilities) hospitals with 29 042 adult inpatients participated in the survey, with representation from all 10 provinces; 132 hospitals participated in 2010 and 2012. There were no significant changes in the median prevalence of MRSA in 2010 (4.3%) compared to 2012 (3.9%), or of CDI in 2010 (0.8%) compared to 2012 (0.9%). A higher median prevalence of VRE was identified in 2012 (1.3%) compared to 2010 (0.5%) (p 0.04), despite decreased VRE screening in 2012. The median prevalence of ESBLs was 0.7% and was 0 for CREs; CREs were reported from only 10 hospitals (7.0%). A policy of routinely caring for patients with MRSA or VRE in a private isolation room was associated with lower prevalence of these organisms. Targeted screening of high-risk patients at admission was associated with lower MRSA prevalence; better hand hygiene compliance was associated with lower VRE prevalence. These data provide national prevalence rates for antibiotic-resistant organisms among adults hospitalized in Canadian hospitals. Certain infection prevention and control policies were associated with prevalence.

Multidrug-Resistant Bacterial Pathogens in Allogeneic Hematopoietic Cell Transplantation - a Retrospective Single Center Analysis

▪Multidrug-resistant bacterial pathogens (MRP) such as extended-spectrum beta-lactamase producing enterobacteriaceae (ESBL), vancomycin-resistant enterococci (VRE) and methicillin-resistant staphylococcus aureus (MRSA) are an emerging challenge in allogeneic hematopoietic cell transplantation (HCT). However, to our knowledge there are no data in the existing literature on the prevalence of MRP and of the impact of these multidrug-resistant pathogens on the outcome after allogeneic HCT. Thus, it was the purpose of this study to systematically analyze the issue of MRP in patients who underwent allogeneic HCT.PATIENTS AND METHODS: From 06/2010 to 12/2013 a total number of 72 (F: n=23; M: n=49) consecutive patients who received the first allogeneic HCT at our institution were retrospectively analyzed. The underlying diseases were AML (n=44), ALL (n=5), CML (n=4), MPN (n=2), lymphoma (n=5), MDS (n=9), and multiple myeloma (n=3). The conditioning regimen was myeloablative in 23 patients and reduced intensity in 49 patients. Patients were transplanted with peripheral blood stem cells (n=69) or bone marrow (n=3) from matched siblings (n=19), matched unrelated (n=45), mismatched (n=5) or haploidentical donors (n=3). As baseline investigation before commencing with the conditioning all patients underwent a comprehensive screening for MRP, i.e. ESBL, VRE and MRSA. For that reason swabs from nose, throat, axilla, urethra and anus as well as stool and urine were collected. The same screening was performed at discharge from hospital after allogeneic HCT and in case of a new admission into our institution. In addition routine microbiological investigations such as bacterial cultures from blood, urine, swabs, stool or central venous catheters were performed whenever clinically needed. Multidrug-resistant gram negative bacteria were categorized as 4MRGN (resistant to cephalosporins, piperacillin, fluorochinolones and to carbapenems) or as 3MRGN (resistant to 3 of these 4 antimicrobial drug groups). The primary endpoint of this analysis was day 100 non relapse mortality (NRM). Secondary endpoints were NRM and overall survival (OAS) two years post HCT.RESULTS: 23 out of 72 patients (32%) were colonized by multidrug-resistant bacterial pathogens (MRP+ group) either at baseline (baseline MRP+ group, n=13, 18%) or at any other time point until day 100 post transplantation. Four patients were positive for two MRP either simultaneously at baseline (n=1) or at different time points (n=3). Detected MRP (n=27) were as follows: 3MRGN Escherichia coli or Klebsiella pneumonia (n=11), 4MRGN Pseudomonas aeruginosa (P. aeruginosa, n=4), 3MRGN P. aeruginosa (n=2), 4MRGN Stenotrophomonas maltophilia (n=1), 3MRGN Citrobacter freundii (n=1), VRE (n=7) and MRSA (n=1). Out of these 23 patients 7 patients developed an infection with MRP after HCT: Septicemia with 3MRGN Escherichia coli (n=3), septicemia with 3MRGN Klebsiella pneumonia (n=1), septicemia with P. aeruginosa (4 MRGN n=2, 3MRGN n=1) and one patient with VRE septicemia and 4MRGN P. aeruginosa pneumonia. Out of the 4 patients with multidrug-resistant P. aeruginosa infection three died transplant related (two of these patients had been already colonized with 4MRGN P. aeruginosa at baseline). However, 2-year OAS of MRP colonized versus non-colonized patients was essentially the same (66.6% versus 63.0%, median follow up 23.8 months range 7.0 to 48.0 months). Day 100 NRM was higher in the baseline MRP+ group and in the entire MRP+ group in comparison with non-multidrug-resistant bacterial pathogens colonized patients (23.1% and 17.4% versus 10.2%, not statistically significant [ns]). Data for 2 year NRM were 32.7%, 22.2% and 17.1% (ns), respectively. The increased NRM of MRP+ patients was mainly due to the high NRM of patients infected by multidrug resistant P. aeruginosa.CONCLUSIONS: Colonization or infection with 3MRGN gram negative non-P. aeruginosa enterobacteriaceae or by VRE has no negative impact on the outcome after allogeneic HCT. Thus allogeneic HCT of patients colonized by MRP is feasible. However, patients colonized by multidrug-resistant P. aeruginosa seem to have a dismal outcome. Allogeneic HCT of these patients should be considered with care. We therefore suggest to include screening for MRP in the pretransplant recipient work up particularly to identify patients colonized by multidrug-resistant P. aeruginosa. DisclosuresNo relevant conflicts of interest to declare.

905Screening and Isolation/Contact Precautions for Multi-Drug Resistant Organisms (MDRO) in Acute Care Hospitals: Results from a National Survey

Background. Infections caused by MDRO lead to significant morbidity and mortality. Consequently, several states have mandated reporting of MDRO and C. difficile. Objectives of this study were: 1) to describe policies to screen and isolate for MDRO in U.S. hospitals; and 2) examine the relationship between state mandates for reporting of MDRO and implementation of screening and isolation/contact precaution policies. Methods. A cross-sectional survey of hospitals enrolled in the National Healthcare Safety Network was conducted in the Fall of 2011. Descriptive statistics were computed. Differences in policies between hospitals located in states with and without MDRO reporting mandates at the time of the survey were examined using chi-square tests. Results. 1,015 hospitals provided data (30% response rate). The majority (68%) reported targeted screening upon admission for methicillin-resistant Staphylococcus aureus (MRSA); screening for vancomycin-resistant Enterococci (VRE) and C. difficile were infrequently reported, 13% and 5%, respectively. Of hospitals with targeted MRSA screening, populations screened were ICU patients (73%) and transfers from skilled nursing facilities (57%) or other hospitals (43%). Contact precautions (CP) for patients with the following organisms were commonly reported: MRSA (95%), VRE (93%), and C. difficile (86%). While presumptive isolation/CP were common for C. difficile (78%), they were less common for MRSA (39%) and VRE (24%). Few hospitals routinely screened for other organisms, including methicillin-susceptible Staphylococcus aureus (12%), Acinetobacter spp (9%), Klebsiella pneumoniae (8%) and Pseudomonas spp (7%). Hospitals located in states with mandatory reporting of MRSA were more likely to have a policy for targeted MRSA screening (p < 0.001), and less likely to have a policy for presumptive isolation/CP pending a screen (p = 0.024). Conclusion. This study found variation in the adoption of MDRO screening and isolation/contact precautions. Further research is needed to provide additional insight on effective strategies and to examine the impact of mandatory reporting of infections on implementation of policies and infection rates. Disclosures. All authors: No reported disclosures.

Regional differences in vancomycin-resistant Enterococcus colonization rates in critically ill veterans

Screening for vancomycin-resistant Enterococcus (VRE) has not been universally implemented within the Department of Veterans Affairs (VA). A prospective study was conducted to identify the admission prevalence rate of VRE in patients admitted to the intensive care unit in 2 VA facilities. Significant regional differences were found between the 2 facilities. Further studies are needed to account for regional differences in VRE admission prevalence, to optimize infection control interventions.

Vancomycin-resistant enterococcus (VRE) transmission and risk factors in contacts of VRE carriers.

During a 2-year period, the vancomycin-resistant enterococcus (VRE) acquisition rate was 10.9% (40/368) in patients who had shared a room with a newly detected VRE carrier. Exposure to vancomycin and to anti-anaerobic antibiotics were identified as independent risk factors for VRE acquisition. Sensitivity of the first rectal VRE screening was less than 50%.

Improving the detection rate of vancomycin-resistant enterococci colonisation using groin swabs

Vancomycin-resistant enterococci (VRE) are nosocomial pathogens associated with significant morbidity in immunosuppressed patients. Stool culture is considered the gold standard for VRE screening. However, in a clinical environment, there are...

Discontinuation of reflex testing of stool samples for vancomycin-resistant enterococci resulted in increased prevalence.

Discontinuation of reflex testing of stool submitted for Clostridium difficile testing for vancomycin-resistant enterococci (VRE) led to an increase in the number of patients with healthcare-associated VRE bacteremia and bacteriuria (0.21 vs 0.36 cases per 1,000 patient-days; P<.01). Cost-benefit analysis showed reflex screening and isolation of VRE reduced hospital costs.

Intestinal colonisation and blood stream infections due to vancomycin-resistant enterococci (VRE) and extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) in patients with haematological and oncological malignancies

In patients with haematological or oncological malignancies, we aimed to assess the rate of intestinal colonisation and blood stream infections (BSI) with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) and vancomycin-resistant enterococci (VRE), mortality and risk factors associated with ESBLE/VRE BSI, as well as the impact of faecal screening for ESBLE and VRE in combination with adapted empiric treatment of febrile neutropenia. Within 72 h of admission to our department, an ESBLE and VRE screening stool sample was collected. In the case of neutropenic fever, blood cultures were drawn. Data of all admitted patients were prospectively documented. Explorative forward-stepwise logistic regression analyses were used to identify risk factors for progression from intestinal colonisation to BSI. During the study period, 1,805 stool samples were obtained from 513 patients during 1,012 inpatient stays, and 2,766 blood cultures were obtained from 578 patients during 1,091 inpatient stays. Ninety (17.5 %) of these patients were colonised with ESBLE and 51 (9.9 %) with VRE. Proportions of 40 % (36/90) of ESBLE and 61 % (31/51) of VRE colonisations were healthcare-associated. Six of 90 (6.6 %) ESBLE-colonised patients and 1/51 (2 %) VRE-colonised patients developed BSI with the respective organism. None of these patients died after receiving early appropriate empiric antibiotics based on colonisation status. Colonisation with ESBLE or VRE was associated with increased risk ratios (RR) towards developing ESBLE BSI [RR 4.5, 95 % confidence interval (CI): 2.89–7.04] and VRE BSI (RR 10.2, 95 % CI: 7.87–13.32), respectively. Acute myelogenous leukaemia and prior treatment with platinum analogues or quinolones were identified as independent risk factors for ESBLE BSI in colonised patients. Intestinal ESBLE/VRE colonisation predicts BSI. Faecal screening in haematology/oncology patients in combination with directed empiric treatment may reduce ESBLE BSI-related mortality.

English

BACKGROUND: Identification of enterococci to species level in order to determine the species prevalent in this geographic region and also to determine the species-specific antimicrobial susceptibility pattern. OBJECTIVE: To detect and determine glycopeptide resistance by screening for vancomycin resistant enterococci (VRE) in both colonized and infected patients. METHODS: A total of 123 isolates of enterococcus species were recovered from various clinical and faecal samples of hospitalized patients, from September 2010 to June 2011. Various species of enterococci were identified by standard methods. Vancomycin susceptibility in enterococci was detected by disc diffusion method (DDM), vancomycin screen agar method (VSAM) and agar dilution method to determine minimum inhibitory concentration (MIC). RESULTS: E. faecalis was the predominant isolate from the clinical and faecal samples. Multidrug resistance was more in E. faecium than E. faecalis. MIC method could detect 7 VRE and 27 strains with reduced susceptibility to vancomycin. Disk diffusion test and vancomycin screen agar failed to detect 50 % and 29.4% of resistant strains respectively. CONCLUSION: Vancomycin resistance was also detected in less virulent strains of enterococcus like E. gallinarum and E. dispar. In laboratories where performance of MIC studies is not feasible, VSAM method should be preferred over the DDM for detection of vancomycin resistance in enterococci.

Eradication of an outbreak of vancomycin-resistant Enterococcus (VRE): the cost of a failure in the systematic screening

BackgroundVancomycin-resistant enterococci (VRE) are still a concern in hospital units tending to seriously ill patients. However, the cost-effectiveness of active surveillance program to identify asymptomatically VRE colonized patient remains debatable. This work aims at evaluating the cost of a failure in the active surveillance of VRE that had resulted in an outbreak in a French University Hospital.FindingsA VRE outbreak was triggered by a failure in the systematic VRE screening in a medico-surgical ward specialised in liver transplantation as a patient was not tested for VRE. This failure was likely caused by the reduction of healthcare resource. The outbreak involved 13 patients. Colonized patients were grouped in a dedicated part of the infectious diseases unit and tended by a dedicated staff. Transmission was halted within two months after discovery of the index case.The direct cost of the outbreak was assessed as the cost of staffing, disposable materials, hygiene procedures, and surveillance cultures.The loss of income from spare isolation beds was computed by difference with the same period in the preceding year. Payments were drawn from the hospital database. The direct cost of the outbreak (2008 Euros) was €60 524 and the loss of income reached €110 915.ConclusionsDespite this failure, the rapid eradication of the VRE outbreak was a consequence of the rapid isolation of colonized patient. Yet, eradicating even a limited outbreak requires substantial efforts and resources. This underlines that special attention has to be paid to strictly adhere to active surveillance program.

English

The increasing occurrence of Enterococcus species , worldwide, since late 1980s, is of particular concern due to the emergence of Vancomycin Resistant Enterococci (VRE). The appearance of VRE has limited the therapeutic options available for clinicians. VRE infection is the most common type of infection acquired by patients while hospitalized. Patients at risk for VRE are those who are already ill, and hospitalized, including individuals with diabetes, elderly, ICU patients, kidney failure patients, or patients requiring catheters. Present study was undertaken to detect vancomycin resistance in enterococcal isolates from hospitalized patients and the comparison of Kirby-Bauer disc diffusion method and vancomycin agar screen method to screen for vancomycin resistance. A total of 45 enterococcal isolates from various samples of hospitalized patients were speciated by standard biochemical reactions and screened to detect vancomycin resistance by Kirby-Bauer disc diffusion method and vancomycin agar screen method. Out of 45 enterococcal isolates, 26 (57.77%) were Enterococcus faecalis, 18 (40%) were Enrerococcus faecium and 1(3.33%) was Enterococcus avium. Resistance to vancomycin was 29% (13 isolates) where as 71% (32 isolates) were sensitive. By Kirby-Bauer disc diffusion method, 1 isolate (2%) showed resistance to vancomycin whereas by vancomycin screen agar, 13 (29%) showed resistance. The study highlights that vancomycin screen agar method is more sensitive than Kirby- Bauer disc diffusion method for detecting vancomycin resistance in enterococcal isolates. This study also signals the emergence of VRE in the hospital and highlights the importance of screening for VRE in enterococcal isolates from various samples.

Extensive contact tracing and screening to control the spread of vancomycin-resistant Enterococcus faecium ST414 in Hong Kong.

Proactive infection control management is crucial in preventing the introduction of multiple drug resistant organisms in the healthcare setting. In Hong Kong, where vancomycin-resistant enterococci (VRE) endemicity is not yet established, contact tracing and screening, together with other infection control measures are essential in limiting intra- and inter-hospital transmission. The objective of this study was to illustrate the control measures used to eradicate a VRE outbreak in a hospital network in Hong Kong. We described an outbreak of VRE in a healthcare region in Hong Kong, involving a University affiliated hospital and a convalescent hospital of 1600 and 550 beds respectively. Computer-assisted analysis was utilized to facilitate contact tracing, followed by VRE screening using chromogenic agar. Multi-locus sequence typing (MLST) was performed to assess the clonality of the VRE strains isolated. A case-control study was conducted to identify the risk factors for nosocomial acquisition of VRE. Between November 26 and December 17, 2011, 11 patients (1 exogenous case and 10 secondary cases) in two hospitals with VRE colonization were detected during our outbreak investigation and screening for 361 contact patients, resulting in a clinical attack rate of 2.8% (10/361). There were 8 males and 3 females with a median age of 78 years (range, 40 - 87 years). MLST confirmed sequence type ST414 in all isolates. Case-control analysis demonstrated that VRE positive cases had a significantly longer cumulative length of stay (P < 0.001), a higher proportion with chronic cerebral and cardiopulmonary conditions (P = 0.001), underlying malignancies (P < 0.001), and presence of urinary catheter (P < 0.001), wound or ulcer (P < 0.001), and a greater proportion of these patients were receiving β-lactam/β-lactamase inhibitors (P = 0.009), carbapenem group (P < 0.001), fluoroquinolones (P = 0.003), or vancomycin (P = 0.001) when compared with the controls. Extensive contact tracing and screening with a "search-and-confine" strategy was a successful tool for outbreak control in our healthcare region.

Performance of three chromogenic VRE screening agars, two Etest® vancomycin protocols, and different microdilution methods in detecting vanB genotype Enterococcus faecium with varying vancomycin MICs

Frequencies of vanB-type Enterococcus faecium increased in Europe during the last years. VanB enterococci show various levels of vancomycin MICs even below the susceptible breakpoint challenging a reliable diagnostics. The performance of 3 chromogenic vancomycin-resistant enterococci (VRE) screening agars, 2 Etest® vancomycin protocols, and different microdilution methods to detect 129 clinical vanB E. faecium strains was investigated. Altogether, 112 (87%) were correctly identified as VanB-type Enterococcus by microdilution MICs. An Etest® macromethod protocol was more sensitive than the standard protocol while keeping sufficient specificity in identifying 15 vanA/vanB-negative strains. Three chromogenic VRE agars performed similarly with 121 (94%), 123 (95%), and 124 (96%) vanB isolates that grew on BrillianceTM VRE Agar, CHROMagarTM VRE, and chromIDTM VRE agar, respectively. Using identical media and conditions, we did not identify different growth behaviour on agar and in broth. A few vanB strains showed growth of microcolonies inside the Etest® vancomycin inhibition zones, suggesting a VanB heteroresistance phenotype.

Intestinal colonisation and blood stream infections due to vancomycin-resistant enterococci (VRE) and extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) in patients with haematological and oncological malignancies

In patients with haematological or oncological malignancies, we aimed to assess the rate of intestinal colonisation and blood stream infections (BSI) with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) and vancomycin-resistant enterococci (VRE), mortality and risk factors associated with ESBLE/VRE BSI, as well as the impact of faecal screening for ESBLE and VRE in combination with adapted empiric treatment of febrile neutropenia. Within 72 h of admission to our department, an ESBLE and VRE screening stool sample was collected. In the case of neutropenic fever, blood cultures were drawn. Data of all admitted patients were prospectively documented. Explorative forward-stepwise logistic regression analyses were used to identify risk factors for progression from intestinal colonisation to BSI. During the study period, 1,805 stool samples were obtained from 513 patients during 1,012 inpatient stays, and 2,766 blood cultures were obtained from 578 patients during 1,091 inpatient stays. Ninety (17.5 %) of these patients were colonised with ESBLE and 51 (9.9 %) with VRE. Proportions of 40 % (36/90) of ESBLE and 61 % (31/51) of VRE colonisations were healthcare-associated. Six of 90 (6.6 %) ESBLE-colonised patients and 1/51 (2 %) VRE-colonised patients developed BSI with the respective organism. None of these patients died after receiving early appropriate empiric antibiotics based on colonisation status. Colonisation with ESBLE or VRE was associated with increased risk ratios (RR) towards developing ESBLE BSI [RR 4.5, 95 % confidence interval (CI): 2.89-7.04] and VRE BSI (RR 10.2, 95 % CI: 7.87-13.32), respectively. Acute myelogenous leukaemia and prior treatment with platinum analogues or quinolones were identified as independent risk factors for ESBLE BSI in colonised patients. Intestinal ESBLE/VRE colonisation predicts BSI. Faecal screening in haematology/oncology patients in combination with directed empiric treatment may reduce ESBLE BSI-related mortality.

Determining an Effective Measure of Testing for MRSA Colonization for Timely Placement in Appropriate Isolation Precautions.

Background/Objectives: Patients are increasingly being admitted to hospitals colonized with vancomycin resistant Enterococcus (VRE). Many hospitals are evaluatingmethods to screen patients for VRE, particularly in intensive care units. This study sought to evaluate the economic implications of VRE screening using different culture and polymerase chain reaction (PCR) methods. Methods: We used decision analysis to model VRE screening using two chromogenic media (CM), one PCR, and one traditional culture approach.We alsomodeled a no screening strategy and a hypothetical perfect screen for comparison. The model estimated the cost and outcome implications of alternative methods of screening for VRE in the ICU setting and took into account spread of VRE, spread of vancomycin resistance, and whether hospitals were prepared to act immediately upon screening results. Outcomes included correct classification, unnecessary isolation costs, unnecessary infection costs, and total costs. Sensitivity analysis tested main model parameters. Results: Baseline analysis assumed: 1) a 17% colonization rate, 2) only patients with a positive screen were isolated, 3) 18 hours passed before action was taken on screening results, and 5) no patients were decolonized. The CM approach was associated with the highest combined rates of correct classification (99.7% and 99.2% for CM versus 93.4% for PCR and 77.1% for traditional culture) and positive predictive value (PPV) (99.0% and 98.5% for CM, 72.6% for PCR, and 42.0% for traditional culture). CM was also associated with lower unnecessary isolation costs per patient than PCR ($16.80 and $25.20 for CM, $675 for PCR, and $1,962 for traditional culture) and lower unnecessary infection costs ($3.42 and $11.79 for CM, $6.09 for PCR, and $30.43 for traditional culture). Conclusions: For hospitals considering a screening strategy for VRE in the intensive care unit, a CM approach appears to offer the highest rates of PPV and correct classification, and lowest overall unnecessary isolation and infection costs under baseline assumptions. Hospitals also need to weigh other factors such as time to action and isolation costs.

Financial Implications of VRE Screening Intensive Care Units

Patients are increasingly being admitted to hospitals colonized with vancomycin resistant Enterococcus (VRE). Many hospitals are evaluating methods to screen patients for VRE, particularly in intensive care units. This study sought to evaluate the economic implications of VRE screening using different culture and polymerase chain reaction (PCR) methods.

Utility of a focused vancomycin-resistant enterococci screening protocol to identify colonization in hospitalized children

Screening for vancomycin-resistant enterococci (VRE) is controversial, and disagreement exists on policy implementation. This study investigated the likelihood of a positive test using 1, 2, or 3 rectal screenings for VRE colonization. In this descriptive study of positive VRE screening cultures, a total of 1211 VRE screens identified 41 positive results. The mean age of these positive patients was 5.7 years. Thirty-nine of the 41 had a chronic illness, and only 2 were healthy. Diagnoses included pulmonary disease in 11 patients and chronic gastrointestinal abnormality in 7. Six patients had been born preterm, and 12 had been treated in a neonatal intensive care unit within the previous 6 months. Thirty-six of the 41 positive results were identified on the first screen. The likelihood of subsequently having a positive screen after a negative screen was 0.43% (95% confidence interval, 0.15%-1.02%). The cost of cultures plus isolation was $50,000 for the study period. Our data show that the likelihood of detecting a positive VRE culture after an initial negative was low, particularly in otherwise healthy children.

Regional spread and control of vancomycin-resistant Enterococcus faecium and Enterococcus faecalis in Kyoto, Japan

The purpose of this investigation was to control the post-outbreak prevalence of vancomycin-resistant enterococci (VRE) in the affected Kyoto region. The study period was from 2005 to 2010. Faecal samples were subjected to VRE screening, and vancomycin resistance genes were detected by polymerase chain reaction (PCR). The genotype was determined by pulsed-field gel electrophoresis (PFGE) of genomic DNA digested with SmaI and by multilocus sequence typing (MLST). A VRE control programme was established in 2006, consisting of a laboratory-based faecal VRE screening system, annual surveillance of hospital inpatients and the promotion of adequate infection control measures. vanA-Enterococcus faecium, vanB-E. faecium and vanB-E. faecalis were detected at 35, 12 and 5 hospitals, respectively. Genotype analysis revealed that all of the vancomycin-resistant E. faecium isolates obtained since 2005 belonged to ST78, and that clonally related vanB-E. faecalis of ST64 had spread to three hospitals. The rate of faecal VRE carriage among the patients enrolled in the annual surveillance increased until 2007, when it reached 24 (1.2%) of the 2,035 enrolled patients. The rate began to decrease in 2008 and, by 2010, reached a low of 4 (0.17%) of the 2,408 enrolled patients. While VRE did spread within the Kyoto region, the VRE control programme succeeded in controlling the overall VRE spread.