Vancomycin-resistant Enterococci Cases Research Articles

Epidemiology and infection control of vancomycin-resistant enterococci at a German university hospital: A three-year retrospective cohort study.

Vancomycin-resistant enterococci (VRE) occur in hospitalized patients, causing both infection and colonization. In recent years, there has been an increase in VRE in German and other hospitals, raising the question of how to control this epidemic best. To better understand the specific epidemiology and to guide infection control, we conducted a retrospective cohort study analyzing all patients with VRE at Hannover Medical School, a tertiary university clinic in Germany that specializes in solid organ transplantation. Epidemiologic and clinical characteristics of patients with VRE from 2015-2017 were collected. Basic epidemiologic parameters, including VRE incidence and incidence density, were calculated. Independent risk factors for nosocomial VRE infection compared to colonization were assessed using a logistic regression model. There were 1,492 VRE cases corresponding to 822 individual patients. The incidence was 0.8 VRE cases per 100 cases. A total of 536 (35.9%) of the 1,492 VRE cases were acquired nosocomially. Of the 1,492 cases, 912 cases had VRE-positive samples (894 Enterococcus (E.) faecium and 18 E. faecalis) in our hospital laboratory and the remaining cases were known VRE carriers. The vanB-phenotype was observed in 369 of the 894 (41.3%) E. faecium isolates and in 6 of the 18 (33.3%) E. faecalis isolates. There was an increase over time in the vanB-phenotype proportion in E. faecium (2015: 63 of 171, 36.8%, 2016: 115 of 322, 35.7% and 2017: 191 of 401, 47.6%). A total of 107 cases had a VRE infection (7.2% of all VRE cases) according to the criteria of the German National Reference Center for Surveillance of Nosocomial Infections. The remaining cases were only colonized. Among other factors, leukocytopenia (<1,000/μL), the use of a central venous catheter and the visceral surgery medical specialty were independently associated with nosocomial VRE infection. VRE imposed a relevant and increasing infection control burden at our hospital. Nosocomial VRE infection was predominantly found in certain medical specialties, such as hematology and oncology and visceral surgery. Infection control efforts should focus on these highly affected patient groups/specialties.

Clinical and economic burden of bacteremia due to multidrug-resistant organisms in Korea: a prospective case control study

The socioeconomic and clinical burden of multidrug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), multidrug-resistant Acinetobacter baumannii (MRAB), multidrug-resistant Pseudomonas aeruginosa (MRPA), and carbapenem-resistant Enterobacteriaceae (CRE) have not yet been adequately addressed. We prospectively searched for MDRO bacteremia cases with matched controls from 10 hospitals across Korea during a 6-month period in 2017. Patients were classified into the MDRO, susceptible organism, and no-infection groups. The corresponding susceptible or no-infection controls had been selected according to predefined criteria. We collected clinical information and estimated the total additional medical cost due to MDRO infections using the multistate model. During the 6-month period, a total of 486 MDRO bacteremia cases (260, 87, 18, 20, and 101 cases of MRSA, MRAB, MRPA, CRE, and VRE, respectively) were identified. The 90-d mortality rates were 30.4%, 63.2%, 16.7%, 55.0%, and 47.5%, respectively. The additional costs caused by bacteremia were $15 768, $35 682, $39 908, $72 051, and $33 662 per MDRO type, respectively. Based on these 6-month data, the estimated annual number of bacteremia cases due to these five MDRO in Korea were 7979 (4070, 1396, 218, 461, and 1834 cases, respectively). Overall, this caused an estimated 3280 (1237, 882, 36, 254, and 871, respectively) deaths and cost $294 505 002 ($84 707 359, $74 387 364, $10 344 370, $45 850 215, and $79 215 694, respectively) (range $170,627,020-$416,094,679) in socioeconomic loss. A tremendous clinical and economic burden is caused by MDRO bacteremia compared with antibiotic-susceptible and no-infection groups. Substantial investment and efforts by related government agencies and medical staffs are needed.

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

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

Epidemiological features of infections/colonization, caused by vancomycin-resistant enterococci in Saint-Petersburg hospitals in 2017–2020

Relevance. Enterococcus are ubiquitous, and can cause various infections, up to endocarditis. Vancomycin-resistant enterococcus (VRE) infections are difficult and expensive to treat. According to the AMRmap (Online Platform for Analysis of Antimicrobial Resistance Data in Russia) data for 2017–2020, VRE cases were reported in all federal districts of the Russian Federation, with one of the highest VRE rates in St. Petersburg (4.27%, 95% confidence interval [95% CI] 2.1–8.6)). But further, larger studies in each region are required. Aims. The study is to identify the epidemiological features of infections/colonization caused by VRE in Saint-Petersburg hospitals in 2017–2020. Materials and methods. A retrospective analysis of the prevalence of VRE isolated from hospital patients (51 hospitals of various profiles) in St. Petersburg for the period from 2017 to 2020 was performed. Results. During the study period, VRE rate was 5.3% (95% CI 5.1–5.6). The highest proportion (11.6%, 95% CI 10.4–13)) and incidence (0.6 per 1000 patients) of VRE was observed in children hospitals, the lowest – in maternity homes 0.5% (95% CI 0.3– 0.7). Throughout the analysis period VRE were detected in clinical specimens of patients from most of the departments. In adult hospitals, the proportion of VREs was significantly higher in oncohematology 14.6% (95% CI 9.6–21.7), neurology 10.8% (95% CI 7.4–15.6), and intensive care units 10.1% (95% CI 9.4–11.0). In 2020, there was a dramatic increase in VREs in neurology, cardiology, and infection departments in adult hospitals. Neonatology and intensive care units in children hospitals had the highest proportion of VRE, 40.7% (95% CI 34–48.3) and 29.8% (95% CI 21.04–40.3), respectively. In departments of other profiles, this rate varied from year to year, which may be related with clusters in hospitals and departments. Sporadic cases were detected in both neonatal and obstetric departments of maternity homes. The most common clinical specimen with isolated VRE was urine; this was characteristic of departments of almost all profiles and for children intensive care patients also VRE was isolated in gastric fluid and feces often. Conclusions. The proportion of VRE isolated from clinical specimens from patients in St. Petersburg hospitals is at an average level compared to other regions of the Russian Federation and other countries. The highest prevalence of VRE was noted in pediatric hospitals. Risk groups are patients of neonatology and intensive care departments in children's hospitals and oncohematology, neurology and intensive care departments in adult hospitals. VRE are most commonly found in the urine of patients. Screening for VRE among patients in at-risk units and contact precautions should be taken to VRE-infected/colonized patients.

Investigation and Analysis of Infection among Inpatients in a Tertiary Hospital in Shanghai.

Objectives This study is aimed at obtaining information about the prevalence of nosocomial infections (NIs) and the use of antibiotics in hospitalized patients and providing relevant references for further understanding, preventing, and controlling NIs. Methods The medical records of adult patients admitted to a hospital in Shanghai from November to December 2021 were analyzed. The patients were divided into the NI group, community-acquired infection (CAI) group, and uninfected or healed group according to their infection status. The survey results were summarized and analyzed. Results A total of 1485 patients were investigated, including 115 patients in the NI group, 172 patients in the CAI group, and 1198 patients in the uninfected or healed group. In the NI group, the main infection site was intra-abdominal tissue (49.6%), followed by lower respiratory tract (unrelated to application of catheters) (13%). There were 73 pathogens detected in the samples submitted from the NI group, mainly including 8 cases (11%) of Escherichia coli, 9 cases (12%) of Klebsiella pneumoniae, and 40 cases (55%) of negative microbiological test results. Thirteen of 115 patients with NIs had infections with drug-resistant bacteria, including 9 cases (69.2%) of CRE (carbapenem-resistant Enterobacteriaceae), 2 cases (15.38%) of VRE (vancomycin-resistant Enterococcus), 1 case (7.69%) of MRSA (methicillin-resistant Staphylococcus aureus), and 1 case (7.69%) of CRAB (carbapenem-resistant Acinetobacter baumannii). In terms of medication, single drug use accounted for the majority of the NI group (66.3%) and CAI group (60.6%); both groups had less frequent quadruple drugs. In the uninfected or healed group, single drug occupied 92.0%, and dual drug use accounted for 8.0%. Cefoperazone/sulbactam was the most commonly used antibacterial drug in the NI group (18.0%) and CAI group (17.6%), and piperacillin/tazobactam accounted for 14.0% and 17.6% in the two groups, respectively. In the uninfected or healed group, cefuroxime accounted for 59.8%, followed by cefoperazone/sulbactam (13.3%). Conclusion This study provides a scientific basis for effective control of NIs. Strict implementation of aseptic techniques, reduction of invasive operations, and rational use of anti-infective drugs can minimize the incidence of nosocomial infection to ultimately achieve effective prevention and control of NIs.

794. The Role of the Environment in Healthcare-associated Transmission of Vancomycin Resistant Enterococcus: A Proof of Concept Study

BackgroundTransmission of Vancomycin Resistant Enterococcus (VRE) from environment to patient and patient to patient can both occur in healthcare settings. Due to the COVID-19 pandemic, a cohort of exposed patients on an inpatient unit with an extensive VRE outbreak needed to switch physical locations with a non-exposed patient population. By comparing outcomes of both cohorts, we aimed to determine the role of the physical environment (both direct and indirect contact) as compared to the patient population, in ongoing VRE transmission.MethodsFrom 10 March to 21 April 2021, 41 new nosocomial acquisitions of VRE were detected as part of a VRE outbreak on a 34-bed acute care unit. Prior to the switch of units, extensive cleaning of the unit was conducted including electrostatic adjuncts to standard cleaning and environmental swabbing for VRE yielded no positive surfaces. The exposed cohort included 3 of 30 patients with VRE while the non-exposed cohort had 0 of 28 VRE positive patients based on prevalence testing on 21 April 2021. Following the physical relocation of both cohorts on 22 April, 2021, prospective VRE screening was performed on both units for one month including on admission, discharge and weekly prevalence screening. Hand hygiene compliance rates on both units was measured using group electronic monitoring. ResultsFigure 1 depicts the timeline and number of VRE cases before and after the unit switch. Following relocation of the VRE exposed cohort to the new unit, no further VRE transmission was detected (0/235 VRE screens; 0 VRE cases per 1000 patient days). Conversely, there were new VRE transmissions (3/99 VRE screens, 5 VRE cases per 1000 patient days) in the non-exposed cohort. When the units resumed their original location, one additional case of VRE was identified in the exposed cohort upon return to their original location. These transmissions occurred despite HH compliance of 94% (141,610/150,706) during the entire study period on the outbreak unit, which was consistently higher than on the non-outbreak unit (141,589/227,136, 62%).Figure 1. ConclusionThe environmental reservoir for VRE may be more important in transmission than the patient reservoir. These findings underscore the importance of environmental cleaning to contain VRE outbreaks. Disclosures All Authors: No reported disclosures

821. Changes in Cleaning Practices and Non-conventional Personal Protective Equipment Use due to SARS-CoV-2 and Association with Increases in Multi-drug Resistant Organism Cases

BackgroundDuring the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), policy at a Minnesota hospital changed to state that environmental services would not clean rooms of patients with confirmed or suspected SARS-CoV-2 infections, requiring nursing staff to perform these duties. Investigation of a cluster of carbapenem-resistant Enterobacterales (CRE) in patients hospitalized in the same or adjoining rooms on the medical intensive care unit (MICU) raised concern over whether SARS-CoV-2 cleaning practices and non-conventional personal protective equipment (PPE) use led to transmission of multi-drug resistant organisms (MDROs). MethodsInfection Prevention conducts passive surveillance for MDRO acquisition in inpatient units. Passive surveillance of SARS-CoV-2 was performed early in the pandemic. Active surveillance SARS-CoV-2 testing on admission was initiated in July 2020 and active surveillance testing for admitted patients every 7 days was initiated in December. Incident cases of vancomycin-resistant Enterococcus (VRE), extended-spectrum-β-lactamase-producing organisms (ESBL), methicillin-resistant S. aureus (MRSA), and CRE were determined for hospitalized patients between March 1, 2020 and February 28, 2021, excluding patients with infection on admission. Rates of hospitalized patients testing positive for SARS-CoV-2 per 100 patient days were compared to rates of patients testing positive for VRE, ESBL, MRSA, and CRE per 100 patient days respectively. The same rate comparisons were completed for the MICU. Using the F-Test Two-Sample to determine variance, the Two-Sample T-test assuming unequal variances was applied to each comparison. ResultsCorrelation was significant between rates of SARS-CoV-2 and VRE (p< 0.005), ESBL (p< 0.005), MRSA (p< 0.005), and CRE (p< 0.005) (Table 1). MICU correlation was significant between rates of SARS-CoV-2 and VRE (p< 0.005), ESBL (p< 0.005), MRSA (p< 0.005), and CRE (p< 0.005) (Table 2). Table 1: Two-sample T-test results assuming unequal variances: Hospital COVID rates per 100 patient days vs. rates of incident positive tests for VRE, ESBL, MRSA, and CRE per 100 patient days Table 2: Two-sample T-test results assuming unequal variances: MICU COVID rates per 100 patient days vs. rates of incident positive tests for VRE, ESBL, MRSA, and CRE per 100 patient days ConclusionThe relationships between the rates of SARS-CoV-2 and four MDROs were statistically significant. It can be inferred from this data that changes in hospital cleaning and non-conventional PPE use may have led to an increase in transmission of MDROs in this facility. Disclosures All Authors: No reported disclosures

Vancomycin-Resistant Enterococci and Extended-Spectrum β-Lactamase-Producing Bacterial Colonization of the Cervix after Emergency Cerclage: Is It Safe?

Antimicrobial resistance is currently becoming a global threat to human health. We performed a retrospective study on patients who underwent emergency cerclage between January 2016 and December 2018 at the Dongsan Medical Center. Cervical culture was first performed before surgery to confirm that there was no infection and was repeated on days 1, 4, and 7 after surgery. A total of 85 pregnant women underwent emergency cerclage. Among them, six patients had vancomycin-resistant enterococci (VRE) colonization in the cervix after cerclage, and 23 patients developed extended-spectrum β-lactamase (ESBL)-producing bacterial colonization in the cervix. The average gestational age at delivery was lower in the VRE group. Neonatal death was also significantly higher in the VRE group. The rate of occurrence of early-onset sepsis was also higher in the VRE group, and both VRE and ESBL-producing bacterial colonization cases in which early-onset sepsis occurred resulted in neonatal death. The prognosis of cervical VRE colonization after cervical surgery was poor, whereas the prognosis of ESBL-producing bacterial colonization in the cervix did not differ significantly from that of the control group. However, careful neonatal treatment is required considering that early-onset sepsis is fatal to the newborn.

An agent-based model to simulate the transmission of vancomycin-resistant enterococci according different prevention and control measures.

Despite the existence of various levels of infection prevention and control (IPC) measures aimed at limiting the transmission of vancomycin-resistant enterococci (VRE) in hospitals, these measures are sometimes difficult to implement. Using an agent-based model (ABM), we simulated the transmission of VRE within and between 3 care units according to different IPC measures. The ABM was modelled on short-stay medical wards, represented by 2 conventional care units and 1 intensive care unit. The scenarios consisted of the simulation of various compliance rates of caregivers with regard to hand hygiene (HH) in different contexts of IPC measures: (1) standard precautions for all patients, (2) additional contact precautions for VRE-carrier patients, (3) geographical cohorting of carrier patients, and (4) creation of an isolation unit with dedicated staff. With <50% HH compliance, the dissemination of VRE was not adequately controlled. With 80% compliance for all patients (ie, standard precautions scenario), there were no secondary VRE cases in 50% of the simulations, which represented the best scenario. A more realistic rate, 60% HH compliance for all patients, revealed interesting results. Implementing an isolation unit was effective only if the level of HH compliance was low. Patient cohorting was less effective. The present ABM showed that while contact precautions, geographic cohorting, and an isolation unit may represent good complements to standard precautions, they may theoretically not be necessary if HH is followed at a high level of compliance.

Healthcare-Associated Infection Decisions of Antibiotic-Resistant Organisms: A Data Quality Review

Background: Infection Prevention and Control (IPC) for Alberta Health Services and Covenant Health in the province of Alberta, Canada conducts surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) on all individuals admitted to acute-care and acute tertiary-care rehabilitation care facilities. Objective: The objective of this study was to determine the consistency and accuracy of infection decisions for MRSA and VRE. Methods: Surveillance cases of antibiotic-resistant organisms (AROs) collected using the provincial data entry surveillance platform between April 1, 2015, and March 31, 2017, across the province were reabstracted by infection control professionals and physicians using the NHSN infection definitions and compared to the original case severity decisions. Interrater agreement (Cohen’s ) and validity (sensitivity, specificity and predictive values) were calculated to compare the original and reabstracted infection decisions. Results: Collectively, 97% (87 of 90) of the IPC program staff and physicians who were initially invited re-abstracted 264 MRSA cases and 103 VRE cases within the review period. Provincially, 20% of the ARO cases reviewed (74 of 367) differed from the original infection decision. Among these 74 cases, 46 cases (34 MRSA and 12 VRE cases) changed from infection (original decision) to colonization (reabstracted decision) and 28 cases (21 MRSA and 7 VRE cases) changed from colonization to infection. The Cohen values for MRSA and VRE were 0.55 and 0.56, respectively, suggesting a moderate level of agreement for decisions made among IPC program staff. The sensitivity of the infection decision was higher with MRSA (86.5%) than for VRE (74.1%), meaning that there were more MRSA cases than VRE cases classified as infection in the original decision that remained infection following the review. Conclusions: Observed discordances on infection decisions were identified and may be attributed (1) to variations in the interpretation of the NHSN definitions, (2) to additional information that may have been available in the re-abstracted review compared to the original review, or (3) a difference in the information that was accessed to perform the original review compared to the reabstraction. This data-quality review provided an opportunity for IPC staff and physicians to become more familiar with infection definitions and such reviews will continue to be a regular process used to assess data quality within the IPC department.Funding: NoneDisclosures: None

Epidemiologic Investigation of an Outbreak of Vancomycin-resistant Enterococcus in a Tertiary Care Neonatal Intensive Care Unit

<h3>Background</h3> Increasingly prevalent vancomycin-resistant Enterococcus (VRE) amongst neonatal and pediatric patients may cause outbreaks and result in infections associated with significant morbidity. We describe a VRE outbreak in our 52-bed neonatal intensive care unit (NICU), its control methods, and recommendations for prevention. <h3>Methods</h3> This outbreak was declared on August 7, 2018, upon discovery of two new cases one week after the index case identification in our NICU. Outbreak management strategies implemented included contact precautions, weekly unit VRE screening, optimization of hand hygiene, enhanced environmental cleaning and disinfection, cohorting of cases and healthcare worker (HCW) and parent education. Typing by pulsed-field gel electrophoresis (PFGE) was performed for all outbreak strains and compared to VRE strains from the adjoining adult hospital. <h3>Results</h3> Six VRE cases occurred during the 4-week-long outbreak: 5 were colonizations and 1 patient eventually developed a central line-associated bloodstream infection. All colonized neonates had been physically located in the same area of the NICU at some point prior to becoming colonized. Hand hygiene compliance was 62% at the start of the outbreak. PFGE typing confirmed horizontal transmission of a single strain (pulsovar E) which was not related to other typed strains from the adult hospital. The source of the outbreak was not identified. None of the mothers of the colonized patients had been screened for VRE antenatally. In total, 348 VRE screening tests were performed. After three consecutive weeks without new cases, the outbreak was declared over. The need for HCW and parent education on VRE prevention and control was identified. <h3>Conclusions</h3> A multi-faceted approach to controlling a VRE outbreak is key, with emphasis on hand hygiene and HCW and parent education, especially as VRE prevalence in pediatric centers is low. In addition, antenatal maternal screening for VRE could be beneficial to identify neonates at risk for colonization.

Risk perception of antimicrobial resistance by infection control specialists in Europe: a case-vignette study

BackgroundUsing case-vignettes, we assessed the perception of European infection control (IC) specialists regarding the individual and collective risk associated with antimicrobial resistance (AMR) among inpatients.MethodsIn this study, sixteen case-vignettes were developed to simulate hospitalised patient scenarios in the field of AMR and IC. A total of 245 IC specialists working in different hospitals from 15 European countries were contacted, among which 149 agreed to participate in the study. Using an online database, each participant scored five randomly-assigned case-vignettes, regarding the perceived risk associated with six different multidrug resistant organisms (MDRO). The intra-class correlation coefficient (ICC), varying from 0 (poor) to 1 (perfect), was used to assess the agreement for the risk on a 7-point Likert scale. High risk and low/neutral risk scorers were compared regarding their national, organisational and individual characteristics.ResultsBetween January and May 2017, 149 participants scored 655 case-vignettes. The perceptions of the individual (clinical outcome) and collective (spread) risks were consistently lower than other MDRO for extended spectrum beta-lactamase producing Enterobacteriaceae cases and higher for carbapenemase producing Enterobacteriaceae (CPE) cases. Regarding CPE cases, answers were influenced more by the resistance pattern (93%) than for other MDRO. The risk associated with vancomycin resistant Enterococci cases was considered higher for the collective impact than for the individual outcome (63% vs 40%). The intra-country agreement regarding the individual risk was globally poor varying from 0.00 (ICC: 0–0.25) to 0.51 (0.18–0.85). The overall agreement across countries was poor at 0.20 (0.07–0.33). IC specialists working in hospitals preserved from MDROs perceived a higher individual (local, p = 0.01; national, p < 0.01) and collective risk (local and national p < 0.01) than those frequently exposed to bacteraemia. Conversely, IC specialists working in hospitals with a high MDRO clinical burden had a decreased risk perception.ConclusionsThe perception of the risk associated with AMR varied greatly across IC specialists and countries, relying on contextual factors including the epidemiology. IC specialists working in high prevalence areas may underestimate both the individual and collective risks, and might further negatively promote the MDRO spread. These finding highlight the need to shape local and national control strategies according to risk perceptions and contextual factors.

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

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

The fight to keep resistance at bay, epidemiology of carbapenemase producing organisms (CPOs), vancomycin resistant enterococci (VRE) and methicillin resistant Staphylococcus aureus (MRSA) in Norway, 2006 - 2017.

IntroductionScandinavian countries have traditionally had a low prevalence of resistant organisms, but have in recent years experienced a change in their epidemiology. We aim to describe the epidemiology of carbapenemase-producing organisms (CPOs), vancomycin-resistant enterococci (VRE) and methicillin-resistant S. aureus (MRSA) in Norway, measure the importance of infections contracted abroad, and assess the morbidity and mortality associated with these resistant bacteria in Norway.Methods and materialsWe used data from the Norwegian surveillance system for communicable diseases covering all findings of the selected resistant bacteria including both infections and colonisation, in the period 2006–2017. Annual trends were assessed using negative binomial regression. For MRSA, we were able to calculate the Morisita-Horn index and transmission numbers following importation in order to assess the effect this had on further domestic transmission.ResultsThe incidence rates (per 100,000 personyears) of the three groups of resistant bacteria have increased during the period. In 2017 the incidence rates were 0.82 for CPOs, 7.09 for VRE and 43.8 for MRSA. 81% of CPO cases were diagnosed in hospitals, but 73% were infected abroad. Most VRE cases were infected in Norwegian hospitals, 85% were associated with hospitals outbreaks. MRSA was predominantly diagnosed in the community, only 21% were diagnosed in hospitals. Of all MRSA cases, 35% were infected in other countries. Most MRSA spa-types were not identified again after introduction, resulting in a transmission of MRSA equivalent to a mean of 0.30 persons infected from each spa-type identified (range: 0–22). The proportion of infections among all notified cases within each diagnose was 44% for MRSA, 9% for VRE and 45% for CPOs. Among persons notified with bacteraemia, the 30 days all-cause mortality were 20%, 16% and 50% for MRSA, VRE and CPOs respectively.DiscussionThe incidence rates of CPOs, VRE and MRSA in Norway are low, but increasing. The continuing increase of notified resistant bacteria highlights the need for a revision of existing infection prevention and control guidelines.

Emerging resistance of van genotype in enterococci: A potential menace for therapeutic failure.

Objectives:Emerging cases of vancomycin-resistant enterococci (VRE) are detrimental for the patients. The current study aimed to ascertain the occurrence of VRE, their antibiogram and the van genotype responsible for vancomycin resistance.Methods:A total number of 2,958 clinical specimens were processed at Microbiology Department of the Alrazi Health Care, Lahore during the one year (2016-2017) using microbiological culture media, biochemical and serology. Antibiogram of enterococcal strains was performed using disc diffusion and E-test. ATCC Enterococcus faecalis 29212 was used as a quality control strain. The detection of van genotypes was accomplished by multiplex PCR assay.Results:Out of the 147 enterococci, 139 (94.6%) were E. faecalis, and 8 (5.4%) were E. faecium. Statistically significant associations of urine (p < 0.001), pus (p < 0.001) and wound swabs (p = 0.001) were observed with E. faecalis. A significant correlation of enterococcal infections (p = 0.05) was seen with female patients. Four (2.9%) strains of E. faecalis found to be VRE with vanB (75%) and vanA (25%) genotypes.Conclusion:The emerging strains of VRE (vanB and vanA genotype) in the current study are a potential menace for therapeutic failure, which left the physicians with only linezolid as a therapeutic option.

Impact of an alternating first-line antibiotics strategy in febrile neutropenia.

BackgroundRising antibiotic resistance poses a challenge to the management of febrile neutropenia in patients with haematological malignancies receiving chemotherapy.AimWe studied an alternating first-line antibiotic strategy to determine its impact on all-cause mortality and bacteremia rates in patients with febrile neutropenia.MethodsAn alternating first-line antibiotic strategy was established in mid-2013. Data for 2012 (before strategy implementation) and 2014 (post-strategy implementation) were compared. Antibiotic Heterogeneity Index (AHI) for each of the two time-periods was also calculated.FindingsThere were 2012 admissions (26082 patient-days) in 2012 and 1843 admissions (24331 patient-days) in 2014. There was no significant difference in the baseline characteristics of patients in the two groups. The defined daily doses (DDD) of cefepime (CEF) fell while the DDD of piperacillin-tazobactam (PTZ) rose in 2014 compared with 2012. Vancomycin DDD fell in 2014. The AHI was 0.466 in 2012 and 0.582 in 2014. The difference in all-cause mortality was not statistically significant. There was no difference in rates of bacteremia with CEF-resistant, PTZ-resistant and carbapenem-resistant gram-negative organisms in the two groups. Rates of new cases of Methicillin-resistant Staphylococcus aureus (MRSA) were 2.38/1000 and 2.59/1000 patient-days in 2012 and 2014 respectively. Rates of new cases of Vancomycin-resistant Enterococcus (VRE) were 1.84/1000 and 1.81/1000 patient-days in 2012 and 2014 respectively. There was no Carbapenem-resistant Enterobacteriaceae (CRE) bacteremia in 2012 and 1 in 2014.ConclusionAn alternating first-line antibiotic strategy resulted in an increase in antibiotic heterogeneity, without increasing mortality. There was also no significant increase in bacteremia rates.

Impact of discontinuing contact precautions against vancomycin resistant Enterococcus: Multicenter study in Argentina

Background: Contact precautions (CP) are widely recommended to prevent multidrug-resistant organism (MDRO) transmission avoiding colonization and infection. However, conflicting data exist regarding their effectiveness. Recent studies suggest that for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococcus (VRE), standard measures and decolonization for MRSA could be effective. In Argentina there is no formal recommendation, however, most centers implement CP and only a few discontinue them. Our purpose is to evaluate the impact on the EVR infections after discontinuing CP in centers located in Buenos Aires. Methods & Materials: Multicenter, retrospective, quasi-experimental study of patients admitted to acute care facilities in Buenos Aires. We included centers that perform health care associated infections surveillance according to NHSN definitions and discontinued CP for more than 1 year. The CP included the use of gloves, gowns, personnel items or their subsequent disinfection and individual or cohort rooms. EVR infection was defined as the presence of signs and symptoms associated with EVR isolation in clinical samples 48 hours after admission. We compared the number of cases of VRE infections/1000 discharges 1 year before and after discontinuing CP. P 0 .05 was considered statistically significant. During the study, CP were continued for other MDRO (MRSA, multidrug resistant gram-negative bacilli and Clostridium difficile) in addition with the hand hygiene program. Results: Five institutions were included (4 tertiary acute care University Private - 1 Public), 4 polyvalent. Total beds 1308, only 2 centers have shared rooms. One institution reported UCI data. In the preintervention period occurred 27 infections / 61099 discharges (rate 0.44 / 1000 discharges), after CP discontinuation there were 32 infections / 61668 discharges (rate 0.52 / 1000 discharges) (p0.62). The average adherence to hand hygiene in the initial period was 58% and post-intervention 66%. Conclusion: This experience, in different centers, shows that discontinuation of CP was not associated with a significant increase of VRE infections and should be accompanied by cross-sectional measures such as Hand Hygiene. The prevalence of different MDRO infections should be considered to evaluate the cost effectiveness of CP.

The Clinical Impact of Daptomycin Non-susceptible Enterococcus Bacteremia in Hematologic Malignancy

BackgroundPatients with hematologic malignancies are prone to colonization and infection with vancomycin-resistant Enterococcus (VRE), and VRE blood stream infections (BSI) in this population have been associated with a 30-day all-cause mortality approaching 40%. Daptomycin nonsusceptible Enterococci(DNSE) are on the rise, with institutional rates as high as 15%. The objective of this study was to determine the attributable mortality associated with resistance to daptomycin among VRE isolates.MethodsWe performed a retrospective cohort study of hematologic malignancy patients who developed either DNSE or daptomycin-susceptible VRE bacteremia between January 1, 2008 and December 31, 2016. Categorical variables were analyzed with chi-square or Fisher’s exact test and continuous variables were analyzed with a t-test or Wilcoxon rank sums test when appropriate. A p-value <0.05 was considered significant.Results34 cases of DNSE and 65 cases of VRE were identified. There were no significant differences noted in demographic data. At time of bacteremia, both DNSE and VRE cohorts had similar APACHE II scores (medians for DNSE and VRE were 19). The DNSE cohort had longer periods of neutropenia prior to the diagnosis of bacteremia [median 32.1 days vs.. 19.3 days, OR 1.85 95% CI (0.75-1.60)]. Patients with DNSE had a longer time to initiation of appropriate antibiotics (median 3.5 days vs. 2.0 days, P = 0.01). There were similar rates of bone marrow transplantation (53 % of DNSE vs. 51% of VRE), however, DNSE cases were more likely to develop graft vs. host disease [OR 3.6 95% CI (1.07-12.38)]. In the 90-day period prior to bacteremia, daptomycin exposure occurred in only 12 (35.3%) of DNSE cases vs.. 1 (1.5%) VRE case [OR 34.9 95% CI (4.3-284.1)]. Median lengths of stay (LOS) were similarly high in both groups, however, DNSE patients were more likely to have a LOS over 50 days as compared with VRE (P = 0.048). 30-day mortality in the DNSE cohort was 50% compared with 38% in the VRE group (P = 0.12).ConclusionIn a retrospective study, the 30-day mortality associated with DNSE bacteremia was 50%. Infection prevention interventions targeting this particular multi-drug-resistant organism are warranted in this vulnerable population.Disclosures All authors: No reported disclosures.

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

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

MiBAlert—a new information tool to fight multidrug-resistant bacteria in the hospital setting

BackgroundAlthough the timely isolation of patients is an essential intervention to limit spread of drug-resistant bacteria, information about the colonization status is often unavailable or lost when patients are readmitted or transferred between hospitals. Therefore, carriers of drug resistant bacteria are not recognized sufficiently early, and proper and timely isolation precautions are not taken. Consequently, resistant bacteria of public health concerns including vancomycin resistant enterococci (VRE) and methicillin resistant Staphylococcus aureus (MRSA) can spread epidemically. To ensure timely identification and proper isolation of such patients we developed an automatic real-time alert of carriers of drug resistant bacteria. ObjectivesThe aim of this paper is to describe the system, called MiBAlert, and share the initial experiences in connection with an outbreak of VRE in the greater Copenhagen area (the Capital region), Denmark. MethodsWe obtained data on cases of VRE from hospitals in Copenhagen during the period when the first version of MiBAlert was implemented and log-data on the use of MiBAlert. Furthermore, a survey was conducted among 88 staff members to investigate their experiences of MiBAlert. ResultsThe alert is a tool directed toward healthcare personnel accessing the electronic health record (EHR) and those further involved in the care and treatment of the patient. It is based on a web service using data from the national microbiological database, MiBa. MiBAlert is a real-time electronic non-intrusive alert generated automatically in the header of the EHR each time record is accessed. On February 15, 2015 a pilot version of MiBAlert was launched. All positive tests for VRE throughout 1year were shown with alert status by MiBAlert visible to all medical staff with access to EHR.The alert system was automatically updated directly in the EHR across the five hospitals in the Capital region. We found that the system performed satisfactorily, being operational 24/7 all 135 trial days, apart from 72min, for all the hospitals. Of the staff who responded to the survey, 82% considered that MiBAlert overall improved compliance with isolation precautions regarding VRE-positive patients. We found a marked decline of new patients infected or colonized with VRE concomitant with the implementation of MiBAlert and the survey results. ConclusionWe found that MiBAlert was a valuable tool in a bundle approach to counter a multiple hospital outbreak of VRE, and that it has a great potential to improve the control of other drug-resistant bacteria.