Vancomycin-resistant Enterococcus Faecium Colonization Research Articles

Factors affecting vancomycin-resistant Enterococcus faecium colonization of in-hospital patients in different wards.

The prevalence of vancomycin-resistant Enterococcus faecium (VRE) infection at a medical center in Eastern Taiwan rose to 80.6%, exceeding the average prevalence of 55.6% among all medical centers nationwide during the same period. In recent years, the number of cases of VRE infection detected among hospitalized patients has increased annually. However, most of these patients in different wards are asymptomatic carriers. Therefore, restricting active screening to high-risk units will not improve the current situation, and it is necessary to review the risk factors for VRE colonization to provide a reference for future infection control policies. Between 2014 and 2019, there were 3188 VRE-positive cultures reported at our institution, as per the electronic medical records system. In the medical and surgical wards, patients who received penicillin (odds ratios [ORs]: 2.84 and 4.16, respectively) and third-generation cephalosporins (ORs: 3.17 and 6.19, respectively) were at higher risk of VRE colonization. In intensive care units, the use of carbapenems (OR: 2.08) was the most significant variable. This study demonstrated that the risk factors for VRE colonization differed between wards. Thus, policies should be established according to the attributes of patients in each ward, and active screening tests should be performed according to individual risks, instead of a policy for comprehensive mass screening.

Lacticaseibacillus rhamnosus GG Versus Placebo for Eradication of Vancomycin-Resistant Enterococcus faecium in Intestinal Carriers: A Systematic Review and Meta-Analysis.

The aim of this review was to assess the efficacy and safety of Lacticaseibacillus rhamnosus GG (LGG) (previously known as Lactobacillus rhamnosus GG) for the eradication of vancomycin-resistant Enterococcus faecium (VREfm) in colonized carriers. We searched Cochrane Central, EMBASE, and the PubMed Library from inception to 21 August 2023, for randomized controlled trials (RCTs) investigating the effectiveness of LGG for the eradication of gastrointestinal carriage of VREfm. An initial screening was performed followed by a full-text evaluation of the papers. Out of 4076 articles in the original screening, six RCTs (167 participants) were included in the review. All were placebo-controlled RCTs. The meta-analysis was inconclusive with regard to the effect of LGG for clearing VREfm colonization. The overall quality of the evidence was low due to inconsistency and the small number of patients in the trials. We found insufficient evidence to support the use of LGG for the eradication of VREfm in colonized carriers. There is a need for larger RCTs with a standardized formulation and dosage of LGG in future trials.

Impact of a new hospital with close to 100% single-occupancy rooms on environmental contamination and incidence of vancomycin-resistant Enterococcus faecium colonization or infection: a genomic surveillance study

Vancomycin-resistant Enterococcus faecium (VRE) is a leading cause of nosocomial infection, driven by its ability to spread between patients and persist in the hospital environment. To investigate the impact of a long-established cardiothoracic hospital moving to new premises with close to 100% single-occupancy rooms on the rates of environmentalcontamination and infection or colonization by VRE. Prospective environmental surveillance for VRE was conducted at five time-points between April and November 2019, once in the original building, and four times in the new building. Incidence rate ratios (IRRs) of VRE infection/colonization were determined for the one-year period before and after the hospital move, and compared to a nearby hospital. In the original location, the first environmental screen found 29% VRE positivity. The following four screens in the new location showed a significant reduction in positivity (1-6%; P<0.0001). The VRE infection/colonization rates were halved in the new location (IRR: 0.56; 95% confidence interval: 0.38-0.84), compared to the original location,contrasting with an increase in a nearby hospital (1.62; 1.17-2.27) over the same time-period. Genomic analysis of the environmental isolates was consistent with reduced transmission in the new hospital. The use of single-occupancy rooms was associated with reducedenvironmental contamination with VRE, and lower transmission and isolation of VRE from clinical samples. The cost-effectiveness of single-occupancy room hospitals in reducing healthcare-associated infections should be reassessed in the context of operational costs of emerging pandemic and increasing antimicrobial resistance threats.

Vancomycin-resistant Enterococcus faecium: admission prevalence, sequence types and risk factors–a cross-sectional study in seven German university hospitals from 2014 to 2018

ObjectivesAssessment of vancomycin-resistant Enterococcus faecium (VREfm) prevalence upon hospital admission and analysis of risk factors for colonization. MethodsFrom 2014 to 2018, patients were recruited within 72 hours of admission to seven participating German university hospitals, screened for VREfm and questioned for potential risk factors (prior multidrug-resistant organism detection, current/prior antibiotic consumption, prior hospital, rehabilitation or long-term care facility stay, international travel, animal contact and proton pump inhibitor [PPI]/antacid therapy). Genotype analysis was done using cgMLST typing. Multivariable analysis was performed. ResultsIn 5 years, 265 of 17,349 included patients were colonized with VREfm (a prevalence of 1.5%). Risk factors for VREfm colonization were age (adjusted OR [aOR], 1.02; 95% CI, 1.01–1.03), previous (aOR, 2.71; 95% CI, 1.87–3.92) or current (aOR, 2.91; 95% CI, 2.60–3.24) antibiotic treatment, prior multidrug-resistant organism detection (aOR, 2.83; 95% CI, 2.21–3.63), prior stay in a long-term care facility (aOR, 2.19; 95% CI, 1.62–2.97), prior stay in a hospital (aOR, 2.91; 95% CI, 2.05–4.13) and prior consumption of PPI/antacids (aOR, 1.29; 95% CI, 1.18–1.41). Overall, the VREfm admission prevalence increased by 33% each year and 2% each year of life. 250 of 265 isolates were genotyped and 141 (53.2%) of the VREfm were the emerging ST117. Multivariable analysis showed that ST117 and non-ST117 VREfm colonized patients differed with respect to admission year and prior multidrug-resistant organism detection. DiscussionAge, healthcare contacts and antibiotic and PPI/antacid consumption increase the individual risk of VREfm colonization. The VREfm admission prevalence increase in Germany is mainly driven by the emergence of ST117.

130. Design and Preclinical Characterization of SER-155, an Investigational Cultivated Microbiome Therapeutic to Restore Colonization Resistance and Prevent Infection in Patients Undergoing Hematopoietic Stem Cell Transplantation

BackgroundDuring allogeneic hematopoietic stem cell transplant (HSCT), the diversity and stability of the GI microbiome is disrupted, increasing the risk of domination by pathogens associated with bacteremia, aGvHD, and mortality. SER-155 is an investigational, oral microbiome therapeutic composed of cultivated spores and vegetative bacterial strains rationally designed to reduce the risk of bacteremia and aGvHD in HSCT recipients by decolonizing potential pathogens and restoring GI colonization resistance. SER-155 was evaluated in vitro for key pharmacological properties associated with colonization resistance, and in vivo to assess its ability to restore colonization resistance by reducing Enterococcus and Enterobacteriaceae carriage.MethodsThe design of SER-155 leveraged genomic data from interventional and observational human datasets to include taxa associated with reduced risk of infection and aGvHD in HSCT. Strains of interest were phenotyped, and over 50 candidate consortia containing different combinations of over 150 species were designed and tested in vitro and in vivo. In vivo, candidate compositions were evaluated in mouse models of vancomycin-resistant Enterococcus faecium (VRE) and carbapenem-resistant Klebsiella pneumoniae (CRE) colonization. ResultsOral administration of SER-155 led to a 2-3 Log10 reduction in VRE and CRE titers compared to untreated mice (Figure 1). In vitro, the carbon source utilization profile of VRE, CRE, and SER-155 strains were assessed using a panel of 85 carbon sources. All 56 carbon sources used by CRE or VRE for anaerobic growth were also utilized by SER-155 strains, supporting a model in which nutrient competition may contribute to reducing CRE and VRE carriage and restoring colonization resistance. Figure 1. SER-155 Efficacy in Mouse Models of VRE and CRE Colonization.The titers of VRE or CRE were quantified in fecal pellets by plating on selective agar at the indicated time-points. The median A) VRE and B) CRE CFU per gram of feces was calculated for each group and plotted on the line graph (n=6-10 per group). L.O.D., limit of detection. Data were analyzed using the Mann-Whitney t-test and significance was determined as a p-value of p< 0.05*, p<0.01**, p<0.001***, p<0.0001****.ConclusionSER-155 is an investigational cultivated microbiome therapeutic intended to reduce the risk of infection by engrafting human-commensal bacterial strains in adults undergoing allogeneic HSCT. Preclinical assessments in vitro and in vivo support the ability of SER-155 to reduce VRE and CRE carriage and restore colonization resistance in the gut. A Phase 1b study evaluating SER-155 in allogeneic HSCT patients is being planned. Disclosures Elizabeth Halvorsen, PhD, Seres Therapeutics (Employee, Shareholder) Marin Vulic, PhD, Seres Therapeutics (Employee) Edward J. O’Brien, PhD, Seres Therapeutics (Employee, Shareholder) Jessica Byrant, PhD, Seres Therapeutics (Employee, Shareholder) Mary-Jane Lombardo, PhD, Seres Therapeutics (Employee, Shareholder) Christopher Ford, PhD, Seres Therapeutics (Employee, Shareholder) Matt Henn, PhD, Seres Therapeutics (Employee, Shareholder)

Microbe-Metabolite Associations Linked to the Rebounding Murine Gut Microbiome Postcolonization with Vancomycin-Resistant Enterococcus faecium.

Vancomycin-resistant Enterococcus faecium (VREfm) is an emerging antibiotic-resistant pathogen. Strain-level investigations are beginning to reveal the molecular mechanisms used by VREfm to colonize regions of the human bowel. However, the role of commensal bacteria during VREfm colonization, in particular following antibiotic treatment, remains largely unknown. We employed amplicon 16S rRNA gene sequencing and metabolomics in a murine model system to try and investigate functional roles of the gut microbiome during VREfm colonization. First-order taxonomic shifts between Bacteroidetes and Tenericutes within the gut microbial community composition were detected both in response to pretreatment using ceftriaxone and to subsequent VREfm challenge. Using neural networking approaches to find cooccurrence profiles of bacteria and metabolites, we detected key metabolome features associated with butyric acid during and after VREfm colonization. These metabolite features were associated with Bacteroides, indicative of a transition toward a preantibiotic naive microbiome. This study shows the impacts of antibiotics on the gut ecosystem and the progression of the microbiome in response to colonization with VREfm. Our results offer insights toward identifying potential nonantibiotic alternatives to eliminate VREfm through metabolic reengineering to preferentially select for Bacteroides IMPORTANCE This study demonstrates the importance and power of linking bacterial composition profiling with metabolomics to find the interactions between commensal gut bacteria and a specific pathogen. Knowledge from this research will inform gut microbiome engineering strategies, with the aim of translating observations from animal models to human-relevant therapeutic applications.

Association between vancomycin-resistant Enterococcus faecium colonization and subsequent infection: a retrospective WGS study.

Since 2012, the incidence of vancomycin-resistant Enterococcus faecium (VREfm) has increased dramatically in Copenhagen and vanA E. faecium has become endemic and polyclonal. To examine whether a patient with a positive VRE clinical sample had the same VREfm in a preceding screening sample (within 60 days). We performed a 30 month retrospective study. From our laboratory information system (LIS), we identified all patients with an invasive VREfm isolate and a VREfm rectal screening isolate within 60 days before infection. VREfm pairs (screening isolate and invasive isolate) were whole-genome sequenced. All isolates were analysed using SeqSphere and core-genome MLST (cgMLST) types were determined. We examined all isolates for the presence of the three most dominant vanA plasmids in the Capital Region of Denmark. Two novel vanA plasmids were closed by Nanopore/Illumina sequencing. We found a total of 19 VREfm pairs. Of these, 13 patients had pairs with matching cgMLST types and vanA plasmids and a median number of 6 days from identification of carriage to clinical infection. One patient had a pair with non-matching cgMLST types but matching vanA plasmids and 24 days between identification of carriage to clinical infection. Five patients had pairs with non-matching cgMLST types and non-matching vanA plasmids and a median number of 18 days from identification of carriage to clinical infection. Of our 19 pairs, 13 were a match regarding cgMLST types (68%) and 1 more (5%) had matching vanA plasmids. Infection was thus preceded by colonization with the same isolates in 13 out of 19 patients. The five mismatches (26%) could be explained by the longer interval between colonization and infection.

Microbiota-derived lantibiotic restores resistance against vancomycin-resistant Enterococcus.

Intestinal commensal bacteria can inhibit dense gut colonization by vancomycin-resistant Enterococcus faecium (VRE), a leading cause of hospital-acquired infections 1, 2. A consortium of commensal bacteria containing Blautia producta BPSCSK can reverse antibiotic-induced susceptibility to VRE infection 3. Herein we demonstrate that BPSCSK reduces VRE growth by secreting a lantibiotic similar to nisin-A produced by Lactococcus lactis. Although in vitro VRE growth is inhibited by BPSCSK and L. lactis, only BPSCSK colonizes the colon and reduces VRE density in vivo. In comparison to nisin-A, the BPSCSK lantibiotic has reduced activity against intestinal commensal bacteria. In patients at high risk for VRE infection, high lantibiotic gene abundance is associated with reduced E. faecium density. In germ free mice transplanted with patient-derived feces, resistance to VRE colonization correlates with lantibiotic gene abundance. Lantibiotic-producing commensal strains of the gastrointestinal tract reduce VRE colonization and represent potential probiotic agents to reestablish resistance to VRE.

Shape Follows Function: Gastrointestinal Signals for Enterococcal Colonization

Vancomycin-resistant Enterococcus faecium (VRE) is a major cause of nosocomial infections. A new study by McKenney et al. (Cell Host Microbe 2019;25:695-705.e5) reports that VRE undergo a morphotype switch in response to lithocholic acid (LCA) to facilitate gastrointestinal (GI) tract colonization. This metabolic cue is a potential target to decrease VRE colonization and subsequent transmission of antibiotic resistance.

Neonatal sepsis due to glycopeptide resistant Enterococcus faecium from colonized maternal gut- rare case evidence

BackgroundVancomycin-resistant enterococcal infections in the neonatal ICU are growing global problems. We report a case of neonatal septicemia by multidrug-resistant vancomycin-resistant Enterococcus faecium (VRE), the source of infection being the mother’s gut.Case presentationA newborn male child admitted to the neonatal intensive care unit (NICU) was diagnosed to have mild meconium aspiration syndrome, early onset neonatal septicemia, and bacteremia by multidrug and vancomycin-resistant Enterococcus faecium. Screening of gut flora of the baby and the mother were carried out to trace the source of infection. Stool cultures of the mother and the baby yielded Vancomycin-Resistant Enterococcus faecium. All three isolates of Enterococcus faecium had similar antibiogram, harbored the vanA gene and similar pulsed-field gel electrophoresis pattern. Baby responded to the 1 week therapy with oral linezolid suspension 20 mg/kg/day, 1 ml/t.d.s. No VRE was isolated from baby on a repeat stool culture 1 week after the linezolid therapy. He was discharged with the advice for the continuance of linezolid for seven more days.ConclusionIsolation of MDR-VRE from the blood culture of the baby and stool specimens of the mother and the baby with the same antibiogram profile and clonal similarities reveals that maternal gut colonization was responsible for neonatal sepsis. Optimal infection control measures and the development of guidelines for monitoring VRE colonization in pregnant women might be useful in reducing the occurrence of neonatal sepsis.

Effect of Vancomycin, Tylosin, and Chlortetracycline on Vancomycin-Resistant Enterococcus faecium Colonization of Broiler Chickens During Grow-Out.

Broiler chickens may serve as reservoirs for human colonization by vancomycin-resistant Enterococcus (VRE). We examined the effects of vancomycin and two commonly used antimicrobial feed additives on VRE colonization in broiler chickens during grow-out. Chicks received unsupplemented feed or feed containing vancomycin, chlortetracycline, or tylosin from day of hatch to grow-out at 6 weeks. At 3 days of age, chicks received by crop gavage 107 colony-forming units (CFUs) of a human or poultry VRE isolate. Cecal contents were monitored weekly for VRE, short-chain fatty acids (SCFAs), and bacterial denaturing gradient gel electrophoresis (DGGE) profile methods. Vancomycin promoted persistent and high-level colonization with human- and poultry-derived VRE to grow-out in comparison with controls, while treatment with chlortetracycline and tylosin did not. Colonization by the poultry isolate in control, chlortetracycline, and tylosin groups persisted throughout the grow-out period with low concentrations present at 6 weeks, whereas the human isolate decreased to an undetectable level by week 6. Vancomycin resulted in significant reductions in cecal acetic acid and butyric acid in comparison with controls, but chlortetracycline and tylosin did not. DGGE profiles contained two main clusters with all vancomycin profiles in a smaller cluster and all other profiles in a larger cluster. These results demonstrate that vancomycin, but not chlortetracycline or tylosin, disrupted the indigenous microbiota and SCFA patterns of broiler chickens and promoted colonization by VRE.

Is it worth screening for vancomycin-resistant Enterococcus faecium colonization?: Financial burden of screening in a developing country

The screening of critically ill patients at high risk of vancomycin resistant enterococci (VRE) colonization, to detect and isolate colonized patients, is recommended to prevent and control the transmission of VRE. Screening asymptomatic carriers brings financial burden for institutions. In this study, we performed risk analysis for VRE colonization and determined the financial burden of screening in a middle-income country, Turkey. We retrospectively analyzed the VRE surveillance data from a pediatric hospital between 2010 and 2014. A case-control study was conducted to identify the risk factors of colonization. Total cost of VRE screening and additional costs for a VRE colonized patient (including active surveillance cultures and contact isolation) were calculated. During the 4-year period, 6,372 patients were screened for perirectal VRE colonization. The rate of culture-positive specimens among all patients screened was 239 (3.75%). The rate of VRE infection was 0.04% (n = 3) among all patients screened. Length of hospital stay, malignancy, and being transferred from another institution were independently associated risk factors for colonization. Annual estimated costs for the laboratory were projected as $19,074 (76,295/4) for all patients screened. Cost of contact isolation for each patient colonized in a ward and an intensive care unit was $270 and $718, respectively. In developing countries, institutions should identify their own high-risk patients; screening priorities should be based on prevalence of infection and hospital financial resources.

Outbreak of vanB vancomycin-resistant Enterococcus faecium colonization in a neonatal service

To describe successful termination of an outbreak of vancomycin-resistant Enterococcus faecium (VREfm) colonization within a neonatal service. Multisite neonatal intensive care unit and special care nurseries within a single health care service. Forty-four cases of VREfm-colonized neonatal inpatients-including 2 clinical isolates (eye swab and catheter-urine specimen) and 42 screening isolates. Active surveillance cultures, patient isolation, contact precautions, enhanced environment cleaning, and staff and parent education. Whole genome sequencing and multilocus sequence typing were used to characterize the outbreak and refine infection control procedures. Peak prevalence of VREfm colonization across all sites was 31% upon discovery of the outbreak. Subsequent to the intervention, transmission was halted within 8 weeks and no further isolates of the outbreak strain have been detected as of 12months following outbreak cessation. Environmental swabs revealed VREfm colonization of baby-weighing scales, a baby bath, and a pharmacy refrigerator within the neonatal intensive care unit. All isolates were of a single multilocus sequence type (sequence type 796) and highly clonal at the core genome level. Bundled infection control interventions were effective in rapidly terminating a clonal outbreak of sequence type 796 VREfm colonization within a neonatal inpatient service. Strain-typing and active surveillance cultures were critical in guiding the management of this outbreak. The closed environment of a neonatal unit likely facilitated eradication of the patient and environment reservoirs of VREfm colonization.

Vancomycin-resistant Enterococcus outbreak in a neonatal intensive care unit: Epidemiology, molecular analysis and risk factors

Vancomycin-resistant Enterococcus faecium (VRE) may cause outbreaks in neonatal intensive care units (NICU). We describe a biphasic VRE outbreak and identify risk factors for VRE acquisition. After the occurrence of 2 cases of VRE infections in a 44-bed NICU, a bundle of interventions was implemented that included active surveillance cultures for VRE, enhanced infection control measures, and audits on antimicrobial use, from June to December 2008. Analysis was performed using polymerase chain reaction and pulse-field gel electrophoresis techniques. A case-control study was conducted to identify risk factors. Among 253 neonates screened, 101 (39.9%) were found to be colonized with VRE. During the first 9 weeks of the study period, 59 new cases were detected. Molecular analysis showed 1 predominant clone. During weeks 10-12, no new cases of VRE colonization were detected; however, at week 13, just when the outbreak appeared to be over, a second wave occurred, with 42 new cases and multiple clones detected. Multivariate analysis identified administration of antimicrobial therapy for late-onset neonatal sepsis and hospitalization during the first month of this outbreak as significant risk factors for VRE colonization. Both a high prevalence of VRE colonization and antimicrobial use promoted the transmission of VRE during this biphasic outbreak. Adherence to infection control measures and antimicrobial stewardship policies are of utmost importance.

Controlling outbreak of vancomycin-resistant Enterococcus faecium among infants caused by an endemic strain in adult inpatients

Vancomycin-resistant Enterococcus faecium (VREfm) is commonly associated with hospital outbreaks and has been found to be associated with increased morbidity, mortality, length of stay, and health care costs. We sought to investigate and control an outbreak of VREfm in the neonatal intensive care unit (NICU) of a public academic hospital with a level III NICU. The index case was an infant in the NICU incidentally identified with urinary colonization with VREfm. Aggressive control measures were initiated promptly. Investigation included active surveillance cultures in infants, parents of colonized infants, and birth mothers of newborn admitted to NICU; molecular strain typing of available isolates of VREfm including adult inpatients; and medical record review. After identification of index case, 13 additional infants were identified with VREfm colonization. Age at culture was 6 to 87 days; birth weight was 1,070 to 2,834 g. VREfm isolated from majority of infants (12/14 [85.7%]), the birth mother of a pair of colonized twins, and a pulse oximeter device used in adult inpatients belonged to a single strain. Outbreak control measures were successful in the NICU. The outbreak-causing strain was found to be endemic among adult inpatients. Adult patients with the outbreak-causing strain of VREfm were more likely to have received previous therapy with meropenem (Mann-Whitney 2-tailed P value= .038). VRE colonization was identified in 0.3% (1/310) of birth mothers with newborn admitted to NICU. An endemic strain of VREfm among adult inpatients was responsible for a subsequently controlled outbreak in the NICU.

Vancomycin-resistant Enterococcus faecium outbreak caused by patient transfer in 2 separate intensive care units

This report describes an outbreak involving vancomycin-resistant Enterococcus faecium colonization in 2 separate intensive care units (ICUs). Outbreak investigation including pulsed-field gel electrophoresis demonstrated that transfer of a vancomycin-resistant Enterococcus faecium colonized patient between ICUs contributed to the outbreaks that occurred simultaneously in 2 separate ICUs.

Risk factors for prolonged carriage of vancomycin-resistant Enterococcus faecium among patients in intensive care units: a case-control study

The aim of this study was to identify the risk factors for prolonged carriage of vancomycin-resistant Enterococcus faecium (VREF) in intensive care units (ICUs). A retrospective case-control study was performed in the ICUs of a university hospital in Korea from September 2006 to July 2009. VREF carriage was identified through weekly active surveillance rectal cultures. Clinical characteristics and the risk factors for VREF acquisition were compared between cases with prolonged VREF carriage (≥ 5 weeks, n = 58) and controls with shorter VREF carriage (<3 weeks, n = 36) in a multivariate logistic regression model. The effect of vancomycin consumption on vancomycin-resistant enterococci (VRE) colonization pressure was investigated using time-series analysis with an autoregressive error model. Out of a total of 6327 rectal swab cultures examined, 1915 (30.3%) specimens from 266 patients were positive for VREF. The weekly VRE colonization pressure ranged from 0.77% to 42.42%. Vancomycin use after VREF acquisition significantly increased VREF carriage (adjusted odds ratio = 4.09; 95% confidence interval = 1.32-12.65). The case group had higher in-hospital mortality than the control group [21 (36.2%) versus 4 (11.1%), P = 0.007]. Increment of VRE colonization pressure was significantly associated with vancomycin consumption of 1week before (i.e. time t - 1) (P = 0.0028) and moderately associated with that of the corresponding week (i.e. time t) (P = 0.0595). Vancomycin use in patients with VREF colonization might prolong the duration of carriage. Restriction of vancomycin use should be strengthened in these patients through infection control measures.

Vancomycin-Resistant Enterococcus Faecium Surveilance and Infection in Autologous and Allogeneic Transplantation

Vancomycin-Resistant Enterococcus Faecium Surveilance and Infection in Autologous and Allogeneic Transplantation

Genotyping and Preemptive Isolation to Control an Outbreak of Vancomycin-Resistant Enterococcus faecium

Control of vancomycin-resistant Enterococcus faecium (VRE) in European hospitals is hampered because of widespread asymptomatic carriage of VRE by healthy Europeans. In 2000, our hospital (The University Medical Center Utrecht, Utrecht, The Netherlands) was confronted with a large outbreak of VRE. On the basis of genotyping (by pulsed-field gel electrophoresis), epidemic and nonepidemic VRE strains were distinguished, and infection-control measures were exclusively targeted toward epidemic VRE. The outbreak was retrospectively divided into 3 periods of different infection-control measures. Compliance with use of alcohol-based hand rubs was enforced during all periods. Period I involved active surveillance, isolation of carriers, and cohorting (duration, 4 months); preemptive isolation of high-risk patients for VRE colonization was added in period II (7 months); and cohorting and preemptive isolation were abandoned in period III (18 months). When the outbreak was identified, 27 patients in 6 wards were colonized; 93% were colonized with an epidemic VRE strain. Detection rates of nonepidemic VRE were 3.5%, 3.0%, and 2.9% among 683, 810, and 977 screened patients in periods I, II, and III, respectively, comparable to a prevalence of 2% (95% confidence interval [CI], 1%-3.5%) among 600 nonhospitalized persons. The relative risks of detecting epidemic VRE in periods II and III, compared with period I, were 0.67 (95% CI, 0.41-1.10) for period II and 0.02 (95% CI, 0.002-0.6) for period III. Infection-control measures were withheld for patients colonized with nonepidemic VRE (76 [54%] of 140 patients with a test result positive for VRE). Use of alcohol-based hand rubs increased by 31%-275% in outbreak wards. Genotyping-targeted infection control, isolation of VRE carriers, enhancement of hand-hygiene compliance, and preemptive isolation successfully controlled nosocomial spread of epidemic VRE infection.

Risk factors for development of vancomycin-resistant enterococcal bloodstream infection in patients with cancer who are colonized with vancomycin-resistant enterococci.

Vancomycin-resistant Enterococcus faecium (VRE) is a common nosocomial isolate, especially among patients with cancer. VRE infections have substantial attributable mortality among patients with cancer. The purpose of this study was to identify risk factors for developing bloodstream infection with VRE in patients with cancer who are colonized with VRE. VRE colonization was prospectively identified in 197 patients with cancer during 4-year period, of whom 179 (91%) had complete records for evaluation. Of these 179 patients, 24 (13.4%) developed hospital-acquired VRE bloodstream infections. Risk factors for VRE bloodstream infection included vancomycin use (relative risk [RR], 1.98; 95% confidence interval [CI], 1.25-3.14), diabetes mellitus (RR, 3.91; 95% CI, 1.20-12.77), gastrointestinal procedures (RR, 4.56; 95% CI, 1.05-19.7), and acute renal failure (RR, 3.10; 95% CI, 1.07-8.93). Strategies for preventing VRE bloodstream infection in VRE-colonized patients with cancer should include limiting vancomycin use and, perhaps, gastrointestinal procedures.