We describe an outbreak of vancomycin-resistant Enterococcus faecium (vanA phenotype) bacteremia on the oncology ward of a tertiary care community hospital. In 10 of the 11 cases the patients had leukemia and were neutropenic (median duration of neutropenia, 21 days) at the time of bacteremia. On average, patients received six antibiotic agents for a total of 61 agent-days prior to development of vancomycin-resistant E. faecium bacteremia. The mortality rate was 73%. Molecular typing of 22 isolates revealed that the majority (83%) represented a common strain, indicating nosocomial spread. When the 11 cases were compared to 22 matched control patients, gastrointestinal colonization with vancomycin-resistant E. faecium (odds ratio [denominator, 0] infinity, P = .005) and the use of antimicrobial agents with significant activity against anaerobes (metronidazole, clindamycin, and imipenem; odds ratio infinity, P = .02) were found to be risk factors for the development of vancomycin-resistant E. faecium bacteremia. Since no proven therapy for such infection exists, there is an urgent need to identify effective measures to prevent and control the development of vancomycin-resistant E. faecium bacteremia.
Previous studies have shown that bacteremia due to vancomycin-resistant Enterococcus species (VRE) is associated with mortality of 17%-100%, but comorbid conditions may have confounded the estimates. We designed a historical cohort study to determine the mortality attributable to VRE bacteremia. Twenty-seven patients with VRE bacteremia were identified as cases. Within 7 days of the onset of bacteremia, severe sepsis developed in 12 patients (44%) and septic shock developed in 10 (37%). Case patients were closely matched to control patients without VRE bacteremia (1:1) by time of hospitalization, duration of exposure, underlying disease, age, gender, and surgical procedure. The mortality was 67% among cases and 30% among matched controls (P = 0.1). Thus, the mortality attributable to VRE bacteremia was 37% (95% confidence interval [CI], 10%-64%) and the risk ratio for death was 2.3 [CI, 1.2-4.1). We conclude that VRE bacteremia is associated with high rates of severe sepsis and septic shock. The attributable mortality approaches 40%, and patients who have VRE bacteremia are twice as likely to die than closely matched controls.
The impact of discontinuing contact precautions for patients with MRSA and VRE colonization/infection on device-associated hospital-acquired infection rates at an academic medical center was investigated in this before-and-after study. In the setting of a strong horizontal infection prevention platform, discontinuation of contact precautions had no impact on device-associated hospital-acquired infection rates.
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