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Vancomycin-resistant enterococci in intensive care units: high frequency of stool carriage during a non-outbreak
B E Ostrowsky1, L Venkataraman, E M D'Agata
1Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA. bao6@cdc.gov
Background:
We aimed to define the epidemiological associations of vancomycin-resistant enterococci (VRE) in intensive care units (ICUs) during a non-outbreak period by examining prevalence, risk factors for colonization, frequency of acquisition, and molecular strain types.
Design:
A prospective cohort design was followed. Consecutive patient admissions to 2 surgical ICUs at a tertiary care hospital were enrolled. The main outcome measures were results of serial surveillance cultures screened for VRE.
Results:
Of 290 patients enrolled, 35 (12%) had colonization with VRE on admission. The VRE colonization or infection had been previously detected by clinical cultures in only 4 of these patients. Using logistic regression, VRE colonization at the time of ICU admission was associated with second- and third-generation cephalosporins (odds ratio [OR] = 6.0, P<.0001), length of stay prior to surgical ICU admission (OR = 1.06, P = .001) greater than 1 prior ICU stay (OR = 9.6, P = .002), and a history of solid-organ transplantation (OR = 3.8, P = .021). Eleven (12.8%) of 78 patients with follow-up cultures acquired VRE. By pulsed-field gel electrophoresis, 2 strains predominated, one of which was associated with an overt outbreak on a non-ICU ward near the end of the study period.
Conclusions:
Colonization was common and usually not recognized by clinical culture. Most patients who had colonization with VRE and were on the surgical ICU acquired VRE prior to surgical ICU entry. Exposure to second- and third-generation cephalosporins, but not vancomycin, was an independent risk factor for colonization. Prospective surveillance of hospitalized patients may yield useful insights about the dissemination of nosocomial VRE beyond what is appreciated by clinical cultures alone.
Insights
Vancomycin-resistant enterococci (VRE) colonization is common in intensive care units (ICUs), often unrecognized. Most VRE acquisition occurs before ICU admission, with cephalosporin use being a key risk factor.
Area of Science:
- Infectious Diseases
- Epidemiology
- Critical Care Medicine
Background:
- Vancomycin-resistant enterococci (VRE) pose a significant challenge in healthcare settings.
- Understanding VRE epidemiology in intensive care units (ICUs) is crucial for infection control.
Purpose of the Study:
- To define the epidemiological associations of VRE in ICUs during a non-outbreak period.
- To examine VRE prevalence, risk factors for colonization, acquisition frequency, and molecular strain types.
Main Methods:
- Prospective cohort study design.
- Inclusion of consecutive patient admissions to two surgical ICUs.
- Serial surveillance cultures to screen for VRE.
Main Results:
- 12% of enrolled patients (35/290) were colonized with VRE on admission, often undetected by clinical cultures.
- Independent risk factors for VRE colonization included exposure to second- and third-generation cephalosporins (OR=6.0), prolonged prior hospital stay, prior ICU admissions, and a history of solid-organ transplantation.
- 12.8% of patients with follow-up cultures acquired VRE during their ICU stay.
Conclusions:
- VRE colonization is prevalent in ICUs and frequently unrecognized by standard clinical cultures.
- VRE acquisition primarily occurs before surgical ICU entry.
- Exposure to specific antibiotics, particularly cephalosporins, is a significant risk factor for VRE colonization, highlighting the need for enhanced surveillance.