Third-Generation Cephalosporins and Vancomycin as Risk Factors for Postoperative Vancomycin-Resistant Enterococcus Infection

Abstract

To examine use of third-generation cephalosporins (3GCs) alone and in association with vancomycin hydrochloride as a risk factor for vancomycinresistant enterococcus (VRE) infection in surgical patients. Design: Case-control retrospective study analyzing antibiotic use in the 30 days preceding culture of VRE or vancomycin-sensitive enterococcus from an infected site. Setting: A large tertiary care teaching hospital. Patients: Surgical inpatients with VRE infections between September3,1993,andJanuary29,1997,werematchedwith patients with vancomycin-sensitive enterococcus infections. Matches were based on surgical procedure, initial infection site, and immunosuppression. Matches were found for 32 of 50 surgical patients with VRE. Twenty matched pairs of patients were recipients of solid organ transplants. Main Outcome Measures: Multivariate logistic regression analysis was done to examine 3GCs and vancomycin as risk factors for VRE infection. Univariate analysis of use of other antibiotic agents and demographic data was also performed. Results: Multivariate analysis showed significant differences in the use of 3GCs both alone and concurrently with vancomycin. Univariate analysis also showed higher use of metronidazole, concurrent vancomycin and metronidazole, concurrent vancomycin and ceftazidime, and all antibiotics combined in patients with VRE infections. Conclusions: This matched control study showed that use of 3GCs, alone (P = .05) or concurrently with vancomycin (P = .05), was a risk factor for VRE infection in surgical patients. Judicious administration of thirdgeneration antibiotics is warranted in surgical patients with other risk factors for VRE.

Nosocomial infections due to methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci at a university hospital in Taiwan from 1991 to 2003: resistance trends, antibiotic usage and in vitro activities of newer antimicrobial agents

“…High rates of vancomycin or third-generation cephalosporin use have been reported to be associated with increased prevalence of VRE in hospitals [1,2,9,33,34]. The risk of VRE colonisation varies during exposure to different ␤-lactam antimicrobials, with higher tendency to promote colonisation in cefotetan, ceftriaxone or ceftazidime [7,12,33]. Our study also confirmed that consumption of all fluoroquinolones (but not injectable ciprofloxacin alone) is positively correlated with an increased rate of VRE.…”

“…Among the resistant Grampositive pathogens, methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate or -resistant S. aureus (VISA or VRSA) and vancomycinresistant enterococci (VRE) are of great concern because of the importance of these organisms in causing various types of nosocomial infections [1][2][3][4][5]. Increases in the prevalence of these resistant pathogens in hospitals are frequently related to the high selective pressure of antibiotics, including extended-spectrum cephalosporins, fluoroquinolones and glycopeptides [1,3,[6][7][8][9][10][11][12][13][14]. Newer antimicrobial agents (oxazolidinones, daptomycin and streptogramins) with novel antimicrobial mechanisms have been developed to 0924-8579/$ -see front matter © 2005 Elsevier B.V. and the International Society of Chemotherapy.…”

The Incidence of Antimicrobial Allergies in Hospitalized Patients

“…The Centers for Disease Control and Prevention address vancomycin use in instances of penicillin allergy by suggesting its appropriateness only when patients have a serious or life-threatening allergy to ␤-lactam antibiotics. 11 Many studies have established prior vancomycin use as a risk factor for colonization and infection with vancomycin-resistant enterococci, [12][13][14][15][16][17] yet it continues to be our hospital's most commonly prescribed antimicrobial agent. Not only does the high level of reported penicillin allergy often lead to the prescribing of agents we are trying to control in order to manage increasing resistance at our medical center, but, in some instances, the prescribing of alternate antimicrobial agents puts pa-tients at risk for colonization/infection with resistant organisms and/or treatment failure due to suboptimal therapy.…”

Two new treatment options for infections due to drug-resistant gram-positive cocci.

“…5 And not just vancomycin: although vancomycin exerts selective pressure for the development of VRE, cephalosporins and antianaerobic agents are playing an increasingly important role in promoting colonization and infection. 6,7 Inhibition of competing bacteria, particularly by antianaerobic antibiotics with extensive biliary excretion, apparently accounts for VRE overgrowth. 7 Infections are just the tip of the iceberg: for every person with a full-blown VRE infection, 10 more are colonized, silently carrying the organism without symptoms.…”