Until 1995, there were no cases of vancomycin resistant enterococcus (VRE) identified at our university hospital. From May 1995 to August 1996, we investigated a cluster of 10 cases of phenotypic class Van B Enterococcus faecium.
Methods
Patients were matched with controls who were on the same unit for at least 7 days prior to the case developing VRE. Control patients were age and sex matched if possible, and had duration of hospitalization at least as long as the number of days it took the patient to become VRE positive. We analyzed 16 independent risk factors using Epi-info version 6. Environmental cultures were obtained in the MICU where 5 of the patients were located. All 10 patient isolates and environmental isolates were analyzed by pulsed field gel electrophoresis (PFGE).
Results
PFGE confirmed the genetic relatedness of all 10 patient isolates and environmental isolates. The VRE-positive group was more likely to be immunosuppressed and to have exposure to 3 physicians. In the MICU, significant, P<0.05) risk factors for VRE were higher Apache scores, location adjacent to a VRE case, duration of vancomycin and aminoglycoside use, duration of invasive catheter use, and diarrhea. Among the VRE-positive environmental cultures was a blood pressure cuff wash that was used on several patients.
Conclusion
We hypothesize that a VRE strain was introduced into our hospital environment and was spread by personnel or contaminated equipment. As a consequence of this study, a hospital-wide VRE policy was implemented.
LeclerqR, DerlotE, DuvalJ, CourvalinP. Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med1988;319:157–61.
2.
MorrisJG, ShayDK, HebdenJN, McCarterRJ, PerdueBE, JarvisW, JohnsonJA, DowlingTC, PolishLB, SchwalbeRS. Enterococci resistant to multiple antimicrobial agents, including vancomycin; establishment of endemicity in a university medical center. Ann Int Med1995;123:250–9.
3.
DembryLM, UzokweK, ZervosMJ. Control of endemic glycopeptide-resistant enterococci. Infect Control Hosp Epidemiol1996;17:286–92.
4.
National Nosocomial Infections Surveillance System. Nosocomial enterococci resistant to vancomycin-United States, 1989-1993. MMWR1993;42:597–9.
5.
GaynesR, EdwardsJ, and the National Nosocomial Infection Surveillance (NNIS) System. Nosocomial vancomycin resistant enterococci (VRE) in the United States, 1989-1995: the first 1000 isolates [abstract]. Abstracts of the Sixth Annual Meeting of the Society for Health Care Epidemiology of America 1996. Infection Control and Hospital Epidemiology1996;17:18.
6.
RhinehartE, SmithNE, WennerstenC, . Rapid dissemination of beta-lactamase-producing, aminoglycoside-resistant Enterococcus faecalis among patients and staff on a infant-toddler surgical ward. N Engl J Med1990;323:1814–8.
7.
MurrayBE, SinghKV, MarkowitzSM, LopardoHA, PattersonJE, ZervosMJ, RubeglioE, EliopoulosGM, RiceLB, GoldsteinFW, JenkinsSG, CaputoGM, NasnasR, MooreLS, WongES, WeinstockG. Evidence for clonal spread of a single strain of ß-lactamase-producing Enterococcus (Streptococcus) faecalis to six hospitals in five states. J Infect Dis1991;163:780–5.
8.
BoyceJM, OpalSM, Potter-BynoeG, . Emergence and nosocomial transmission of ampicillin-resistant enterococci. Antimicrob Agents Chemother1992;36:1032–9.
9.
KaranfilLV, MurphyM, JosephsonA, . A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol1992;13:195–200.
10.
LivorneseLL, DiasS, SamelC, RomanowskiB, TaylorS, MayP, PitsakisP, WoodsG, KayeD, LevisonME, JohnsonCC. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med1992;117:112–6.
11.
RubinLG, TucciV, CercenadoE, EliopoulosG, IsenbergHD. Vancomycin-resistant Enterococcus faecium in hospitalized children. Infect Control Hosp Epidemiol1992;13:700–5.
ChowJW, KuritzaA, ShlaesDM, GreenM, SahmDF, ZervosMJ. Clonal spread of vancomycin-resistant Enterococcus faecium between patients in three hospitals in two states. J Clin Microbiol1993;31:1609–11.
14.
HandwergerS, RaucherB, AltaracD, EmonkaJ, MarchioneS, SinghKV, MurrayBE, WolffJ, WaltersB. Nosocomial outbreak due to Enterococcus faecium highly resistant to vancomycin, penicillin, and gentamicin. Clin Infect Dis1993;16:750–5.
15.
BoyceJM, OpalSM, ChowJW, ZervosMJ, Potter-BynoeG, ShermanCB, RomuloRL, FortnaS, MedeirosAA. An outbreak of multi-drug resistant Enterococcus faecium with transferable van B class vancomycin resistance. J Clin Microbiol1994;32:1148–53.
16.
MontecalvoMA, HorowitzH, GedrisC, CarbonaroTenover, IssahFCA, CookP, WormserGP. Outbreak of vancomycin-, ampicillin-, and aminoglycoside-resistant Enterococcus faecium bacteremia in an adult oncology unit. Antimicrob Agents Chemother1994;38:1363–7.
17.
WellsCL, JuniBA, CameronSB, MasonKR, DunnDL, FerrieriP, RhameFS. Stool carriage, clinical isolation, and mortality during an outbreak of vancomycin-resistant enterococci in hospitalized medical and/or surgical patients. Clin Infect Dis1995;21:45–50.
MorenoF, GrotaP, CrispC, MagnonK, MelcherGP, JorgensenJH, PattersonJE. Clinical and molecular epidemiology of vancomycin-resistant Enterococcus faecium during its emergence in a city in Southern Texas. Clin Infect Dis1995;21:1234–7.
SlaughterS, HaydenMK, NathanC, HuTC, RiceT, Van VoorhisJ, MathusekM, FranklinC, WeinsteinRA. A comparison of the universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med1996;125:448–56.
23.
ZervosMJ, KauffmanCA, TherassePM, BergmanAG, MikesellTS, SchabergDR. Nosocomial infection with gentamicin-resistant Streptococcus faecalis: an epidemiologic study. Ann Intern Med1987;106:687–91.
24.
JordensJZ, BatesJ, GriffithsDT. Faecal carriage and nosocomial spread of vancomycin-resistant Enterococcus faecium. J Antimicrob Chemother1994;34:515–28.
25.
WeinsteinJW, RoeM, TownsM, SandersL, ThorpeJJ, CoreyGR, SextonDJ. Resistant enterococci: a prospective study of prevalence, incidence, and factors associated with colonization in a university hospital. Infect Control Hosp Epidemiol1996;17:36–41.
26.
LeonardRB, MayerJ, SasserM, WoodsML, MooneyBR, BrintonBG, Newcomb-GaymanPL, CarrollKC. Comparison of MIDI Sherlock System and Pulsed-Field Gel Electrophoresis in characterizing strains of methicillin-resistant Staphylococcus aureus from a recent hospital outbreak. J Clin Micro1995;33(10):2723–7.
27.
TenoverFC, ArbeitRD, GoeringRV, MickelsenPA, MurrayBE, PersingDH, SwaminathanB. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Micro1995;33(9):2233–9.
28.
GarnerJS, JarvisWR, EmoriTG, HughesJM. CDC definitions for nosocomial infections, 1988. Am J Infect Control1988;16:128–40.
29.
KnausWA, WagnerDP, DraperEA, ZimmermanJE, BergnerM, BastosPG, SirioCA, MurphyDJ, LotringT, DamanioA, HarrellFE. The Apache III prognostic system; risk prediction of hospital mortality for critically ill hospitalized adults. Chest1991;100:1619–36.
30.
Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Commitee (HICPAC). MMWR, September 22, 1995;44(RR-12):1–13.
31.
LindenPK, PasculleAW, ManezR, KramerDJ, FungJJ, PinnaAD, KusneS. Differences in outcome for patients with bacteremia due to vancomycin-resistant Enterococcus faecium or vancomycin-susceptible Enterococcus faecium. Clin Infect Dis1996;22:663–70.
32.
EvansME, KortasKJ. Vancomycin use in a university medical center: comparison with Hospital Infection Control Practices Advisory Committee Guidelines. Infect Control Hosp Epidemiol1996;17:356–9.
33.
LindenP, PasculleAW, ManezR, KramerD, MartinM, StarzlT. Failure of oral doxycycline to eradicate fecal carriage of vancomycin-resistant Enterococcus faecium. Proceedings of the 92nd General Meeting of the American Society for Microbiology; New Orleans, LA; May1992.
