Correspondence
Vancomycin-Resistant Enterococci in Health Care Facilities
N Engl J Med 2001; 345:768-769September 6, 2001
- Article
To the Editor:
The report by Ostrowsky et al. (May 10 issue)1 provides evidence that active infection-control interventions can reduce or eliminate the transmission of vancomycin-resistant enterococci in health care facilities. One limitation of that study, as they point out, is the relatively small proportion of patients in acute health care facilities who participated in the study, which may have limited its ability to assess the true prevalence of vancomycin-resistant enterococci.
We recently experienced an outbreak of vancomycin-resistant enterococci in a 560-bed university teaching hospital. Vancomycin-resistant enterococci were first isolated from a clinical specimen in November 1998. A point-prevalence survey of all hospitalized patients revealed that 46 patients (8.2 percent) were colonized with vancomycin-resistant enterococci. All isolates were vanA-containing Enterococcus faecium. A predominant strain (pulsovar S2) was characterized by pulsed-field gel electrophoresis.
A system of surveillance cultures, infection-control procedures, and educational efforts was implemented according to the recommendations of the Centers for Disease Control and Prevention.2 Despite these measures, by March 1999, more than 150 patients had tested positive for vancomycin-resistant enterococci. We then began to use a newly validated, highly accurate polymerase-chain-reaction (PCR) assay for the rapid detection (in less than 24 hours) of vancomycin-resistant enterococci in rectal specimens.3 This assay permitted us to intensify our efforts to prevent the spread of vancomycin-resistant enterococci. Its use allowed us to screen patients more often and reduced the delay before the implementation of preventive measures. A questionnaire was introduced in the emergency room to identify and screen readmitted patients. All patients who tested positive were isolated on the same ward. The number of patients with vancomycin-resistant enterococci declined sharply during the next three months. Since then, no cross-contamination has been observed, suggesting that the transmission of vancomycin-resistant enterococci has been eliminated in our center.
3 ReferencesMichel Roger, M.D., Ph.D.
Pierre St.-Antoine, M.D.
François Coutlée, M.D.
Hôpital Notre-Dame, Montreal, QC H2L 4M1, Canada
michel.roger@ssss. gouv. qc. ca 1
Ostrowsky BE ,Trick WE ,Sohn AH , et al. Control of vancomycin-resistant enterococcus in health care facilities in a region. N Engl J Med 2001;344:1427-1433
Full Text | Web of Science | Medline2
Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep 1995:44(RR-12):1-13.
3
Roger M ,Faucher MC ,Forest P ,St-Antoine P ,Coutlee F . Evaluation of a vanA-specific PCR assay for detection of vancomycin-resistant Enterococcus faecium during a hospital outbreak. J Clin Microbiol 1999;37:3348-3349[Erratum, J Clin Microbiol 2000;38:945.]
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree with Dr. Roger and colleagues that the control of vancomycin-resistant enterococcus (and other pathogens resistant to antimicrobial agents) in health care settings requires active surveillance, the use of barrier precautions or isolation, and compliance by health care workers with current recommendations.1 They note that one of the limitations of our study was the lower rate of patient participation in the acute care facilities than in the long-term care facilities. Although the participation rate in acute care facilities was lower, the rate of inclusion of high-risk patients was higher (e.g., 74 to 100 percent of the patients in some intensive and intermediate care units). Most of the patients not included in our study were patients at low risk for vancomycin-resistant enterococci (e.g., patients with short hospitalizations — day-surgery or obstetrical patients and those with little exposure to antimicrobial agents). Thus, we believe (and the results confirm) that we were able to identify the majority of patients colonized with vancomycin-resistant enterococci. The acute care facilities were also tracking vancomycin-resistant enterococci and found similar decreases throughout the year (not just on the yearly point-prevalence surveys).
The experience of Dr. Roger et al. in trying to control the transmission of vancomycin-resistant enterococci at their facility is similar to that reported by many others.2-4 It would be interesting to know what the compliance rate of health care workers was when they implemented the infection-control measures throughout the hospital. Many studies have documented poor rates of compliance with infection-control recommendations2-4; this may explain why their outbreak was not terminated until they placed all the patients colonized with vancomycin-resistant enterococci on one ward. Trying to control vancomycin-resistant enterococci throughout an institution is much more difficult4 than isolating all such patients on a single ward.2,4
Thus, it is not clear in this instance whether improved rates of compliance by health care workers or the use of the PCR test was responsible for controlling vancomycin-resistant enterococci. We are unaware of any data that show that either the detection of patients with low levels of vancomycin-resistant enterococci (presumably not detected by culture and probably at lower risk for transmitting the pathogen to others) or the more rapid detection of patients colonized with vancomycin-resistant enterococci (one day with PCR as compared with two to three days with culture) results in decreased transmission. On the other hand, the requirements for technical expertise and the cost of PCR are greater than those of routine culture. As an alternative, some of the facilities in the Siouxland region isolated high-risk patients until their vancomycin-resistant–enterococci status was known (thereby implementing prevention measures early).
Regardless of the approach, our data and those of Roger et al. demonstrate that vancomycin-resistant enterococci (and presumably other antimicrobial-resistant pathogens) can be controlled by the use of active screening and enhanced infection-control precautions. These examples should encourage efforts by others to control the transmission of these pathogens.
4 ReferencesBelinda Ostrowsky, M.D., M.P.H.
Medical College of Virginia Campus at Virginia Commonwealth University, Richmond, VA 23298-0019
bostrow@hsc.vcu. edu William Jarvis, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 303331
Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practice Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep 1995;44:1-13
Medline2
Shay DK ,Maloney SA ,Montecalvo M , et al. Epidemiology and mortality risk of vancomycin-resistant enterococcal bloodstream infections. J Infect Dis 1995;172:993-1000
CrossRef | Web of Science | Medline3
Morris JG Jr ,Shay DK ,Hebden JN , et al. Enterococci resistant to multiple antimicrobial agents, including vancomycin: establishment of endemicity in a university medical center. Ann Intern Med 1995;123:250-259
Web of Science | Medline4
Montecalvo MA ,Jarvis WR ,Uman J , et al. Infection-control measures reduce transmission of vancomycin-resistant enterococci in an endemic setting. Ann Intern Med 1999;131:269-272
Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
T. H. Dellit, R. C. Owens, J. E. McGowan, D. N. Gerding, R. A. Weinstein, J. P. Burke, W. C. Huskins, D. L. Paterson, N. O. Fishman, C. F. Carpenter, P. J. Brennan, M. Billeter, T. M. Hooton. (2007) Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases 44:2, 159-177
CrossRef2
Ann Huletsky, Pierre Lebel, Francois J. Picard, Marthe Bernier, Martin Gagnon, Nathalie Boucher, Michel G. Bergeron. (2005) Identification of Methicillin‐Resistant Staphylococcus aureus Carriage in Less than 1 Hour during a Hospital Surveillance Program. Clinical Infectious Diseases 40:7, 976-981
CrossRef3
C. Glen Mayhall. (2002) Control of Vancomycin‐Resistant Enterococci: It Is Important, It Is Possible, and It Is Cost‐Effective • . Infection Control and Hospital Epidemiology 23:8, 420-423
CrossRef
