Vancomycin-resistant Enterococci Contamination Research Articles

Diversity and persistence of MRSA and VRE in skilled nursing facilities: environmental screening, whole-genome sequencing and development of a dispersion index

Environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) in skilled nursing facilities (SNFs) may contribute to patient acquisition. We assessed diversity and association of MRSA and VRE isolates in a SNF wing and developed a mathematical index to define each strain's tendency to persist in rooms and spread horizontally. Longitudinal study of MRSA and VRE colonization and contamination among successive patient occupancies in a cluster of nine SNF private rooms during eight months characterized by microbiological testing and whole genome isolate typing. 'Dispersion index" of a strain is defined as the number of rooms it was found in (including the patient), divided by the average of times it was found consecutively in the same room. MRSA (ten strain types) and VRE (seven types) were recovered from room or patient in 16.4% and 35.6% of the occupancies, respectively. MRSA showed moderate horizontal spread and several episodes of same-room persistence (three distinct strain types) (overall dispersion index: 1.08). VRE showed high tendency towards horizontal spread /new introductions (overall dispersion index: 3.25), and only one confirmed persistence episode. The emerging picture of high diversity among contaminating strains and high likelihood of room persistence despite terminal cleaning (MRSA) and horizontal spread between rooms (VRE) in this setting calls for improved cleaning practices, heightened contact precautions, and most of all to establish individually tailored facility screening programs to enable informed choices based on local, measurable and actionable epidemiologic parameters. University of Michigan OAIC REC Scholarship to M.C. National Institutes of Health K24 AG050685 to L.M.

The Role of Emergency Departments in Cross-Contamination: The Case of VRE

Colonized surfaces, equipment, individuals, and infected patients can be sources for the hospital spread of vancomycin-resistant enterococci (VRE), which is one of the important nosocomial pathogens. The basic epidemiological tools for the prevention and control of hospital-acquired infections are the typing methods. Pulsed-field gel electrophoresis (PFGE) is a highly discriminating method used frequently to detect clonal associations in epidemics and hospital-acquired VRE infections. This study aimed to investigate the presence of cross-contamination, which service or services come to the forefront in case of possible cross-contamination and clonal relationship between VRE strains isolated from rectal swab, clinical and environmental swab samples taken in two different periods in various clinics of Istanbul University Istanbul Medical Faculty Hospital by PFGE method. A total of 125 VREs isolated in two different periods were included in the study. Rectal and environmental swab samples were inoculated on Enterococcosel agar and sodium azide broth, urine samples were inoculated on chromogenic agar, and other clinical samples were inoculated on 5% sheep blood agar and incubated for 18-24 hours. VITEK 2 Compact automation system GP panel (bioMerieux, MarcyL'Etoile, France) was used for the species identification of catalase-negative, gram-positive colonies and disc diffusion and minimum inhibitory concentration (MIC) gradient tests were used to determine vancomycin susceptibility. Multiplex polymerase chain reaction was used to search for vanA and vanB resistance genes in isolates identified as VRE, and PFGE was used to determine clonal association. All isolates were identified as Enterococcus faecium with the vanA resistance gene. It was shown that PFGE clones were divided into six types with 65% similarity (A-F), and in this polyclonal spread, the major type was type A, which contained 108 isolates in 37 subtypes existed in the hospital for years. In patients from whom similar isolates were obtained, the high rate of hospitalizations in the same emergency room or in different emergency services in the same building drew attention. Our results showed that the presence of VRE was established in our hospital, new isolates were added from time to time, and there was a cross-contamination. It was observed that emergency services, where infection control measures were neglected due to working conditions, were among the high-risk areas for VRE contamination. In order to better understand the importance of emergency services in cross-contamination, it would be useful to conduct surveillance studies among patients hospitalized in emergency services and monitor the rate of VRE in the services where positive patients were transferred.

Diversity and persistence of MRSA and VRE in nursing homes: Environmental screening and whole-genome sequencing

Background: Transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) is of special concern among frail patients in nursing homes. To understand environmental contamination patterns in this setting, we screened a suitable section of a nursing home over time and assessed MRSA and VRE prevalence in patients and their rooms. We were especially interested in assessing whether MRSA and VRE strains persist in rooms during changes of occupancy after patient discharge. Methods: We conducted a prospective cohort study of MRSA and VRE colonization and contamination among successive patients in a cluster of 9 single-occupancy rooms. Using flocked swabs, 5 high-touch surfaces were screened 3 times a week for 34 weeks. Patients were also screened (ie, nares, groin, and hands), if they agreed to participate. Whole-genome sequencing was performed on 67 nonredundant MRSA and VRE strains. Single-nucleotide polymorphism heatmaps and similarity trees were generated to evaluate strain diversity and persistence the facility. Results: Overall, 146 distinct occupancy events were captured during the study (16.5 average per room; range, 11–22), with 387 study visits and 4,670 total swabs collected. All rooms were contaminated with VRE, and 8 of 9 were contaminated with MRSA at least once during the study period. New contamination of a room with MRSA or VRE was observed in 43 (23%) of 185 opportunities, with potential persistence during occupancy changes in 25 (32.9%) of 76 opportunities. Sequencing of 67 nonredundant isolates identified at least 6 enterococcal clades and 10 MRSA clades (6 USA100 and 4 USA300), indicating a high degree of diversity and probably multiple introductions in the facility during the study time. In 3 separate cases, whole-genome sequencing confirmed persistence of a specific MRSA strain during a change of room occupancy, including 1 case of a MRSA strain persisting in a clean room before admission of the next patient. For VRE, 2 cases of persistence during room occupancy changes were confirmed, along with 6 cases of possible persistence (contamination across noncontiguous room occupancy events). Conclusions: Active surveillance screening and a recurring evaluation of terminal cleaning procedures should be considered due to high levels of circulation and persistence of MRSA and VRE in the nursing home setting.Funding: NoneDisclosures: None

The effect of pulsed-xenon ultraviolet disinfection on surfaces contaminated with vancomycin-resistant Enterococci in a Japanese hospital

IntroductionRecently, a worldwide outbreak of vancomycin-resistant Enterococci (VRE) was reported. However, due to the low incidence of VRE infection and colonization, VRE contamination of hospital environments has not been fully investigated in Japan. MethodsSurfaces were swabbed, before and after manual cleaning and after pulsed xenon ultraviolet (PX-UV) disinfection, in five patient rooms that had been occupied by patients colonized with VRE. Difference in the number of VRE-positive samples and VRE colony forming units (CFUs), before and after disinfection, for each cleaning method was estimated. ResultsWe detected VRE contamination in 22/60 (37%) and 14/60 (23%) samples collected before and after manual cleaning, respectively. In contrast, VRE contamination was not detected in the samples collected after PX-UV disinfection. In addition, 3/5 (60%) spray nozzles of electric warm-water bidet toilet seats were found to be contaminated with VRE before terminal cleaning. Manual cleaning caused a significant decrease in the number of VRE CFUs compared with that before cleaning (P = 0.031). PX-UV disinfection also caused a significant decrease in the number of VRE CFUs compared to that of manual cleaning (P < 0.001). ConclusionWe identified hot spots of severe contamination, such as private bathrooms in patient rooms and areas around the bed of patients using diapers and required assistance. VRE contamination persisted even after terminal disinfection; PX-UV disinfection in addition to terminal disinfection was effective at eliminating VRE contamination. These results can be useful in controlling the spread of VRE infections in Japanese hospitals.

Spinning and Fully Integrated Microdevice for Rapid Screening of Vancomycin-Resistant Enterococcus.

This study introduces a spinning and fully integrated paper-based microdevice that can perform multiple functions, including DNA extraction, amplification, and colorimetric detection, for monitoring two major vancomycin-resistant Enterococci (VREs), which carry the vanA and vanB genes. The spinning microdevice is composed of a stationary part and a spinning part. The square-shaped stationary part has two zones: the lysis and reaction zones. The spinning part, which has a spin wheel-like shape, was inserted perpendicularly into the stationary part so that its two semicircles remained on the upper and lower parts. Sodium hydroxide-treated glass microfiber filter discs, inserted in the upper semicircle, were soaked in the lysis chambers by folding them toward the lysis zone to capture DNA in the lysis chambers. The captured DNA was transferred to the reaction chambers by folding the discs toward the reaction chambers. Water was added to the sodium hydroxide-treated glass microfiber filter discs to elute purified DNA into the reaction chambers. The upper semicircle was then unfolded, and the reaction chambers were sealed for subsequent loop-mediated isothermal amplification (LAMP) for 45 min. After the reaction, the spinning part was spun in the lysis zone direction to bring the lower semicircle, inserted with phenolphthalein-treated glass microfiber filter discs, toward the upper part of the stationary part. By folding it toward the reaction chambers, the lower semicircle came into contact with them and the phenolphthalein-treated glass microfiber filter discs were soaked in the reaction chambers and expressed color after 30 s. Based on the pH change during the LAMP reaction, the phenolphthalein-treated discs remained pink in the absence of target DNA, while those in contact with the positive samples turned colorless. A sensitive detection with a VRE limit of detection of 102 CFU/mL for tap water spiked with VRE carrying the vanA gene was achieved using this microdevice. Both VREs, carrying vanA and vanB genes, were successfully identified from tap water and contaminated equipment surfaces within 75 min. The introduced microdevice demonstrated a rapid, accurate, and sensitive performance for the environmental assessment of VRE contamination in resource-limited regions.

Nursing-Home Patient Functional and Microbiota Status Drive Environmental Contamination with Vancomycin-Resistant Enterococci

Background: Patient colonization and shedding of vancomycin-resistant enterococci (VRE) is a major source of environmental contamination leading to VRE transmission in nursing homes. We hypothesize that we can inform mitigation strategies by identifying patient clinical and microbiota features associated with environmental contamination with VRE. Methods: During a 6-month period of active surveillance in 6 Michigan nursing homes, 245 patients (with 806 follow-up visits) were enrolled. Patient clinical data and swabs for VRE were collected from multiple body sites and high-touch environmental surfaces. In total, 316 perirectal swabs were collected from 137 patients for gut microbiota analysis and community status type (CST) assignment based on taxonomic composition. The associations between VRE colonization pattern, gut microbial CST, and patient factors were examined using multivariable generalized estimating equations, adjusting for patient-and facility-level clustering. We used VRE colonization patterns to group study visits: “uncolonized” (patient−/environment−); “environment-only” (patient−/environment+); “patient-only” (patient+/environment−); “both” (patient+/environment+). Results: Across all study visits, VRE colonization on patient hand and groin/perirectal area was positively correlated with VRE contamination of high-touch environmental surfaces, suggesting direct transfer of VRE between patient and environment via patient hands (Figure 1A). We next set out to identify patient factors associated with patient colonization and environmental contamination. At baseline, while patients in the “both” group had anticipated risk factors such as longer prior hospitalization and more frequent broad-spectrum antibiotic use, they were unexpectedly younger than “uncolonized” patients and had similar functional status. This last feature contrasted with the “patient-only” group, characterized by higher urinary catheter use and higher functional dependence, suggestive of lower functional dependence facilitating patient contamination of their environment. No clinical features distinguished “uncolonized” and “environment-only” patients (Table 1). Lastly, in multivariable analyses, we determined the contribution of patient functional status and gut microbiota features to environmental contamination. Low-diversity CST, characterized by reduced anaerobic taxa, was weakly associated with “patient-only” and significantly associated with “both.” Notably, high functional dependence was significantly associated with “environment-only” and “patient-only” but not “both,” indicating high-functioning patients with disrupted gut microbiota as drivers of environmental contamination (Figure 1B). Conclusions: Our findings suggest that antimicrobial exposure disrupts patient gut microbiota, a significant mediator of colonization dynamics between patients and their environment, and that high-functioning patients may be more likely to spread VRE between their body sites and high-touch environmental surfaces (Figure 2). These findings highlight both antibiotic stewardship and patient hand hygiene as important targets for interrupting transmission mediated by environmental contamination.Funding: NoDisclosures: None

Global Prevalence of Vancomycin-Resistant Enterococci in Food of Animal Origin: A Meta-Analysis

Vancomycin-resistant enterococci (VRE) are a leading cause of nosocomial infections in patients worldwide. VRE contamination in food of animal origin may create a risk for human health. This study was conducted to estimate the pooled prevalence of VRE in food of animal origin worldwide, to assess the result heterogeneity, and to determine cumulative evidence and the trend of the prevalence over time. Relevant studies were retrieved from PubMed, Scopus, and Web of Science. A random-effects model was used to calculate the pooled prevalence of VRE in food of animal origin. Subgroup meta-analysis was used to assess the heterogeneity of the results. A cumulative meta-analysis and meta-regression were conducted to determine cumulative evidence and the trend of the prevalence of VRE in food of animal origin over time, respectively. Of the 1352 retrieved studies, 50 articles were included. The pooled prevalence of VRE in food of animal origin was 11.7% (95% confidence interval [95% CI] = 8.4 to 16.0). Subgroup meta-analyses showed a significant difference in the prevalence of VRE for two characteristics. First, for the source of food, the prevalence of VRE was highest in aquatic food (43.4% [95% CI = 28.4 to 59.7]) and lowest in dairy food (4.1% [95% CI = 1.7 to 9.8]). Second, for continents, the prevalence of VRE was highest in Africa (18.5% [95% CI = 12.8 to 26.1]) and lowest in North America (0.3% [95% CI = 0.1 to 1.1]). Cumulative evidence showed two distinct features in two different periods. The pooled prevalence of VRE rapidly decreased from 79.3% in 1998 to 13.1% in 2003; it has slightly fluctuated between 10.5% and 20.5% since 2004. The results of the meta-regression indicated that the prevalence gradually decreased over time. In conclusion, the estimate of overall VRE prevalence worldwide in food of animal origin was ∼12%, indicating the burden of VRE contamination in food of animal origin.

Universal Decolonization Reduces MDRO Burden on High-Touch Objects in Nursing Home Resident Rooms and Common Areas

Background: More than half of nursing home (NH) residents harbor a multidrug-resistant organism (MDRO), and MDRO contamination of the environment is common. Whether NH decolonization of residents reduces MDRO contamination remains unclear. The PROTECT trial was a cluster-randomized trial of decolonization versus routine care in 28 California NHs from April 2017 through December 2018. Decolonization involved chlorhexidine bathing plus nasal iodophor (Monday–Friday, every other week), and it reduced resident nares and skin MDRO colonization by 36%. Methods: We swabbed high-touch objects in resident rooms and common areas for MDROs before and after the 3-month decolonization phase-in (April–July 2017). Five high-touch objects (bedrail, call button and TV remote, doorknob, light switch, and bathroom handles) were swabbed in 3 resident rooms per NH based on care needs (Alzheimer’s disease and related dementias (ADRD), ie, total care; ADRD, ambulatory care; and short stay). Five high-touch objects were also swabbed in the common area (nursing station, table, chair, railing, and drinking fountain). Swabs were processed for methicillin-resistant S. aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CRE). We used generalized linear mixed models to assess the impact of decolonization on MDRO environmental contamination when clustering by NH and room and adjusting for room type and object because unclustered and unadjusted results are likely to be inaccurate. Results: A high proportion of rooms were contaminated with any MDRO in control NHs: 43 of 56 (77%) in the baseline period and 46 of 56 (82%) in the intervention period. In contrast, decolonization NHs had similar baseline contamination (45 of 56, 80%) but lower intervention MDRO contamination (29 of 48, 60%). When evaluating the intervention impact using multivariable models, decolonization was associated with significantly less room contamination for any MDRO (OR, 0.25; 95% CI, 0.06–0.96; P = .04) and MRSA (OR, 0.16; 95% CI, 0.05–0.55; P = .004) but nonsignificant reductions in VRE contamination (OR, 0.86; 95% CI, 0.23–3.13) and ESBL contamination (OR, 0.13; 95% CI, 0.01–1.62). CRE was not modeled due to rare counts (2 rooms total). In addition, room type was important, with common areas associated with 5-fold, 9-fold, and 3-fold higher contamination with any MDRO, MRSA, and VRE, respectively, compared with short-stay rooms. Conclusions: The high burden of MDROs in NHs calls for universal prevention strategies that can protect all residents. Although decolonization was associated with an 84% reduction in odds of MRSA contamination of inanimate room objects, significant reductions in VRE or ESBL contamination were not seen, possibly due to the lower proportion of baseline contamination due to these organisms. Multimodal strategies are needed to address high levels of MDRO contamination in NHs.Funding: NoneDisclosures: Gabrielle Gussin: Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

Measures of prevention of operative field infections caused by vancomycin-resistant enterococci

&amp;lt;p&amp;gt;Introduction. Vancomycin-resistant enterococci (VRE) represent a major healthcare problem all around the world. The most effective methods for the control and prevention of these infections, as well as the methods controlling the growth of hospital-acquired VRE, have not been established yet. The aim of this systematic review of the literature was to investigate the research papers concerned with various preventive measures against the operative field infections caused by VRE, as well as to examine the level of effectiveness of these measures in reducing the infection incidence rate. Methods. PubMed and EBSCO databases were used in order to find the research papers concerned with the measures for preventing the transmission of VRE. The process of searching for the above-mentioned databases was ended on 8 September 2018. Results. Using different combinations of the key words, the databases were thoroughly searched for, which led to the identification of 174 appropriate studies on the basis of the title and the abstract. After the detailed examination of the papers, based on the clearly defined criteria, 7 studies were included in the final analysis. The results showed that the VRE contamination was reduced to 70%, using the personal protective equipment such as aprons and gloves in all types of patient-centered interactions. Ecological cleaning, environmental and equipment disinfection as well as the rational use of antibiotics led to reduction in Clostridium difficile infection rates from 12% to 6.6 %, reduction in Staphylococcus aureus infection rates of 25%, while the rate of VRE bacteremia was also significantly lower. The number of patients whose isolation was required due to VRE infection was reduced. Conclusion. The current measures recommended by the Center for Disease Control and Prevention and used to prevent the spread of VRE are effective if the existing protocols are used adequately.&amp;lt;/p&amp;gt;

Patient contact is the main risk factor for vancomycin-resistant Enterococcus contamination of healthcare workers' gloves and gowns in the intensive care unit.

To determine which healthcare worker (HCW) roles and patient care activities are associated with acquisition of vancomycin-resistant Enterococcus (VRE) on HCW gloves or gowns after patient care, as a surrogate for transmission to other patients. Prospective cohort study. Medical and surgical intensive care units at a tertiary-care academic institution.ParticipantsVRE-colonized patients on Contact Precautions and their HCWs. Overall, 94 VRE-colonized patients and 469 HCW-patient interactions were observed. Research staff recorded patient care activities and cultured HCW gloves and gowns for VRE before doffing and exiting patient room. VRE were isolated from 71 of 469 HCWs' gloves or gowns (15%) following patient care. Occupational/physical therapists, patient care technicians, nurses, and physicians were more likely than environmental services workers and other HCWs to have contaminated gloves or gowns. Compared to touching the environment alone, the odds ratio (OR) for VRE contamination associated with touching both the patient (or objects in the immediate vicinity of the patient) and environment was 2.78 (95% confidence interval [CI], 0.99-0.77) and the OR associated with touching only the patient (or objects in the immediate vicinity) was 3.65 (95% CI, 1.17-11.41). Independent risk factors for transmission of VRE to HCWs were touching the patient's skin (OR, 2.18; 95% CI, 1.15-4.13) and transferring the patient into or out of bed (OR, 2.66; 95% CI, 1.15-6.43). Patient contact is a major risk factor for HCW contamination and subsequent transmission. Interventions should prioritize contact precautions and hand hygiene for HCWs whose activities involve touching the patient.

Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: A review of the literature.

Chlorhexidine bathing is effective in reducing levels of pathogens on skin. In this review, we examine the evidence that chlorhexidine bathing can prevent colonization and infection with health care-associated pathogens and reduce dissemination to the environment and the hands of personnel. The importance of education and monitoring of compliance with bathing procedures is emphasized in order to optimize chlorhexidine bathing in clinical practice.

The effectiveness of a single-stage versus traditional three-staged protocol of hospital disinfection at eradicating vancomycin-resistant Enterococci from frequently touched surfaces

Environmental contamination is a reservoir for vancomycin-resistant enterococcus (VRE) in hospitals. Environmental sampling of surfaces was undertaken anytime before disinfection and 1 hour after disinfection utilizing a sodium dichloroisocyanurate-based, 3-staged protocol (phase 1) or benzalkonium chloride-based, single-stage clean (phase 2). VRE colonization and infection rates are presented from 2010 to 2011, and audits of cleaning completeness were also analyzed. Environmental samples collected before disinfection were significantly more likely to be contaminated with VRE during phase 1 than phase 2: 25.2% versus 4.6%, respectively; odds ratio (OR), 7.01 (P < .01). Environmental samples collected after disinfection were also significantly more likely to yield VRE during phase 1 compared with phase 2: 11.2% versus 1.1%, respectively; OR, 11.73 (P < .01). Rates of VRE colonization were higher during 2010 than 2011. Cleaning audits showed similar results over both time periods. During use of a chlorine-based, 3-staged protocol, significantly higher residual levels of VRE contamination were identified, compared with levels detected during use of a benzalkonium chloride-based product for disinfection. This reduction in VRE may be due to a new disinfection product, more attention to the thoroughness of cleaning, or other supplementary efforts in our institution.

Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms

BackgroundEnvironmental surfaces play an important role in transmission of healthcare-associated pathogens. There is a need for new disinfection methods that are effective against Clostridium difficile spores, but also safe, rapid, and automated.MethodsThe Tru-D™ Rapid Room Disinfection device is a mobile, fully-automated room decontamination technology that utilizes ultraviolet-C irradiation to kill pathogens. We examined the efficacy of environmental disinfection using the Tru-D device in the laboratory and in rooms of hospitalized patients. Cultures for C. difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) were collected from commonly touched surfaces before and after use of Tru-D.ResultsOn inoculated surfaces, application of Tru-D at a reflected dose of 22,000 μWs/cm2 for ~45 minutes consistently reduced recovery of C. difficile spores and MRSA by >2-3 log10 colony forming units (CFU)/cm2 and of VRE by >3-4 log10 CFU/cm2. Similar killing of MRSA and VRE was achieved in ~20 minutes at a reflected dose of 12,000 μWs/cm2, but killing of C. difficile spores was reduced. Disinfection of hospital rooms with Tru-D reduced the frequency of positive MRSA and VRE cultures by 93% and of C. difficile cultures by 80%. After routine hospital cleaning of the rooms of MRSA carriers, 18% of sites under the edges of bedside tables (i.e., a frequently touched site not easily amenable to manual application of disinfectant) were contaminated with MRSA, versus 0% after Tru-D (P < 0.001). The system required <5 minutes to set up and did not require continuous monitoring.ConclusionsThe Tru-D Rapid Room Disinfection device is a novel, automated, and efficient environmental disinfection technology that significantly reduces C. difficile, VRE and MRSA contamination on commonly touched hospital surfaces.

In Vitro Activity of Fidaxomicin (OPT-80) Tested against Contemporary Clinical Isolates of Staphylococcus spp. and Enterococcus spp

<i>In Vitro</i> Activity of Fidaxomicin (OPT-80) Tested against Contemporary Clinical Isolates of <i>Staphylococcus</i> spp. and <i>Enterococcus</i> spp

Skin and Environmental Contamination With Vancomycin-Resistant Enterococci in Patients Receiving Oral Metronidazole or Oral Vancomycin Treatment forClostridium difficile–Associated Disease

Oral metronidazole has been recommended for treatment of mild-to-moderate Clostridium difficile-associated disease (CDAD), in part because of concern that use of vancomycin may be more likely to promote colonization and transmission of vancomycin-resistant enterococci (VRE). The objective of our study was to compare the frequency of skin and environmental VRE contamination associated with metronidazole treatment for CDAD with such frequency associated with vancomycin treatment for CDAD. Prospective, observational study. This study was performed at the Cleveland Veterans Affairs Medical Center (Cleveland, OH). For patients with CDAD who had concurrent VRE colonization, stool, skin, and environmental samples were cultured for VRE before, during, and up to 3 weeks after therapy with metronidazole or vancomycin. The proportions of skin and environmental contamination were compared before and after resolution of diarrhea and during treatment with metronidazole or vancomycin. Of the 34 patients, 17 were treated with vancomycin and 17 were treated with metronidazole. The proportion of environmental cultures that were positive for VRE was significantly higher during resolution of diarrhea than it was after resolution of diarrhea (38% vs 28%; P=.025), whereas the proportion of skin cultures positive was not different during and after resolution of diarrhea (78% vs 71%; P=.60). There were no differences between patients who received metronidazole and patients who received vancomycin in the proportions of skin culture results (73% vs 77%; P=.80) or environmental culture results (37% vs 32%; P=.359) that were positive for VRE. Eleven patients (32%) had chronic fecal incontinence, and 28 (82%) had incontinence at least once during their CDAD episode. In VRE-colonized patients with CDAD who experienced frequent fecal incontinence, skin and environmental VRE contamination was common during and after resolution of diarrhea. The frequency of VRE contamination was similar between patients treated with metronidazole and patients treated with vancomycin.

Impact of an Environmental Cleaning Intervention on the Presence of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci on Surfaces in Intensive Care Unit Rooms

To evaluate the adequacy of discharge room cleaning and the impact of a cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) on environmental surfaces in intensive care unit (ICU) rooms. Prospective environmental study. Convenience sample of ICU rooms in an academic hospital. METHODS AND INTERVENTION: The intervention consisted of (1) a change from the use of pour bottles to bucket immersion for applying disinfectant to cleaning cloths, (2) an educational campaign, and (3) feedback regarding adequacy of discharge cleaning. Cleaning of 15 surfaces was evaluated by inspecting for removal of a preapplied mark, visible only with an ultraviolet lamp ("black light"). Six surfaces were cultured for MRSA or VRE contamination. Outcomes of mark removal and culture positivity were evaluated by chi(2) testing and generalized linear mixed models, clustering by room. The black-light mark was removed from 44% of surfaces at baseline, compared with 71% during the intervention (P < .001). The intervention increased the likelihood of removal of black-light marks after discharge cleaning (odds ratio, 4.4; P < .001), controlling for ICU type (medical vs surgical) and type of surface. The intervention reduced the likelihood of an environmental culture positive for MRSA or VRE (proportion of cultures positive, 45% at baseline vs 27% during the intervention; adjusted odds ratio, 0.4; P = .02). Broad, flat surfaces were more likely to be cleaned than were doorknobs and sink or toilet handles. Increasing the volume of disinfectant applied to environmental surfaces, providing education for Environmental Services staff, and instituting feedback with a black-light marker improved cleaning and reduced the frequency of MRSA and VRE contamination.

Occurrence and antimicrobial resistance of enterococci in retail foods

This study aimed to show the vancomycin-resistant enterococci VRE contamination and antibiotic resistance profiles of Enterococcus spp. in different kinds of food acquired from various markets between January 2007 and June 2007. Two hundred samples were used in the research. They consisted of 50 samples of meat (20 chicken, 20 beef, 10 fish), 50 samples of cheese (20 cheddar, 20 Turkish white, 10 cream), 50 samples of RTE (10 burgers, 10 pizzas, 10 chicken nuggets, 10 milk deserts, 5 beef roast and 5 salads), 30 samples of spice (10 black pepper, 10 red pepper, 10 curry) and 20 samples of yogurt. The results of the study indicated high levels of contamination with Enterococcus spp. in 100 of all the samples (50 %). The highest resistance was recorded for a cream cheese sample, with resistance to 12 types of antibiotics. The lowest resistance was in a chicken sample, with resistance to 2 types of antibiotics. Only 4 strains were identified as vancomycin-resistant enterococcus (VRE), four of which were E. faecalis and originated from chicken. The results of this study underline the public health implications of VRE and the urgency about the preventive measures that must be taken to control the antibiotic use at farm level.

Risk of Environmental and Healthcare Worker Contamination With Vancomycin-Resistant Enterococci During Outpatient Procedures and Hemodialysis

To assess the risk of environmental and healthcare worker (HCW) contamination with vancomycin-resistant enterococci (VRE) during outpatient procedures performed on fecally continent patients currently colonized with VRE (cVRE) or previously colonized with VRE (pVRE). Observational study. Outpatient consultation and radiology rooms and the hemodialysis unit in a university teaching hospital. Fecally continent cVRE and pVRE patients. Both cVRE and pVRE patients attended standardized mock outpatient consultations and routine hemodialysis sessions in an area that had been thoroughly cleaned and microbiologically confirmed to be free of VRE contamination. After each session, the patient, environment, and participating HCW were tested for VRE contamination. Fourteen cVRE patients participated in 49 mock outpatient consultation sessions and radiology sessions or 26 actual hemodialysis sessions, and 7 pVRE patients participated in 28 outpatient consultation sessions. Sessions with cVRE patients had higher rates of contamination of the environment (chair cultures were positive for VRE in 36% of outpatient consultation sessions, 58% of hemodialysis sessions; couch cultures were positive in 48% of outpatient consultation sessions, 42% of radiology sessions, and 45% of hemodialysis sessions), contamination of HCW gowns (gown cultures were positive in 20% of outpatient consultation sessions, 4% of radiology sessions, and 30% of hemodialysis sessions), and contamination of patients' own hands (hand cultures were positive in 36% of outpatient consultation sessions, 25% of radiology sessions, and 54% of hemodialysis sessions). Overall, contamination rates associated with pVRE patients attendance at outpatient consultations were 12% of those noted for cVRE patients (odds ratio, 0.10; 95% confidence interval, 0.03-0.42; P = .001). Given the nature of the contamination risk posed by fecally continent cVRE patients undergoing outpatient procedures, infection control measures should focus on effective HCW and patient hand hygiene and chair and couch cleaning, to minimize transmission of VRE.

Chlorhexidine Gluconate to Cleanse Patients in a Medical Intensive Care Unit

Historically, methods of interrupting pathogen transmission have focused on improving health care workers' adherence to recommended infection control practices. An adjunctive approach may be to use source control (eg, to decontaminate patients' skin). We performed a prospective sequential-group single-arm clinical trial in a teaching hospital's medical intensive care unit from October 2002 to December 2003. We bathed or cleansed 1787 patients and assessed them for acquisition of vancomycin-resistant enterococci (VRE). We performed a nested study of 86 patients with VRE colonization and obtained culture specimens from 758 environmental surfaces and 529 health care workers' hands. All patients were cleansed daily with the procedure specific to the study period as follows: period 1, soap and water baths; period 2, cleansing with cloths saturated with 2% chlorhexidine gluconate; and period 3, cloth cleansing without chlorhexidine. We measured colonization of patient skin by VRE, health care worker hand or environmental surface contamination by VRE, and patient acquisition of VRE rectal colonization. Compared with soap and water baths, cleansing patients with chlorhexidine-saturated cloths resulted in 2.5 log(10) less colonies of VRE on patients' skin and less VRE contamination of health care workers' hands (risk ratio [RR], 0.6; 95% confidence interval [CI], 0.4-0.8) and environmental surfaces (RR, 0.3; 95% CI, 0.2-0.5). The incidence of VRE acquisition decreased from 26 colonizations per 1000 patient-days to 9 per 1000 patient-days (RR, 0.4; 95% CI, 0.1-0.9). For all measures, effectiveness of cleansing with nonmedicated cloths was similar to that of soap and water baths. Cleansing patients with chlorhexidine-saturated cloths is a simple, effective strategy to reduce VRE contamination of patients' skin, the environment, and health care workers' hands and to decrease patient acquisition of VRE.

Prevent transmission: Isolating vancomycin-resistant Enterococci (VRE) and breaking the chain of contagion

BACKGROUND: In July 2003, VRE prevalence on a 25-bed medical unit and 10-bed medical intensive care unit (MICU) was 27% (7/24) and 57% (4/7), respectively. Environmental contamination was 37% (3/8) and 25% (1/4). Pulsed-field gel electrophoresis (PFGE) was used to analyze VRE cultures. Findings suggested cross-transmission between patients and environment. Two of three positive environmental cultures were highly related to five of seven positive medicine patient cultures. One positive MICU environmental culture was highly related to one MICU patient culture. METHODS: A root cause analysis (RCA) team compiled of housekeeping, nursing, medicine, supply, and infection control analyzed causes of VRE cross-transmission. The team addressed the role of environmental contamination, compliance to contact precautions, and other risks for transmission applying SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of <i>Staphylococcus aureus</i> and Enterrococcus (May 2003). Actions included: 1) Use disposable wipes to clean and disinfect hard nonporous environmental surfaces. 2) Track VRE in the electronic medical record. 3) Improve the use of and accessibility to waterless alcohol hand rub. 4) Install glove dispensers next to hand rubs at the entrance to patient rooms. 5) Implement disposable perineal wash clothes. 6) Improve availability of personal protective equipment. 7) Educate staff. 8) Simplify contact precaution signage. 8) Evaluate alternatives to computer keyboards to improve disinfection. RESULTS: In December 2003, after implementation of the disposable equipment wipes, improved accessibility to hand rub and gloves, staff education, and simplified isolation signs, a repeat prevalence survey was conducted. There were no positive cultures found from 10 environmental swabs, a significant improvement in decreasing environmental contamination. (p < 0.01) The VRE prevalence rate in the medical unit decreased to 22% (6/26) and in the MICU to 20% (2/10) (p>0.05). Daily compliance monitoring of hand antisepsis and disposable washcloths was recently implemented. Results of January 2005 prevalence study are pending. CONCLUSION: VRE prevalence rate decreased following the multidisciplinary RCA actions, and an environment free of VRE contamination was achieved. Antisepsis compliance monitoring may further decrease VRE prevalence.