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Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci
Abstract:
Infection control practices are not uniformly successful in limiting outbreaks of vancomycin-resistant enterococci (VRE). Despite the implementation of barrier precautions for VRE-infected patients, nearly one-half of the inpatients at our center were found to have gastrointestinal colonization by VRE. In an attempt to control the outbreak, we altered the antibiotic formulary by restricting the use of cefotaxime and vancomycin and adding beta-lactamase inhibitors to replace third-generation cephalosporins. The use of clindamycin was also restricted because of a concomitant outbreak of Clostridium difficile colitis. After 6 months, the average monthly use of cefotaxime, ceftazidime, vancomycin, and clindamycin had decreased by 84%, 55%, 34%, and 80%, respectively (P < .02). The point prevalence of fecal colonization with VRE decreased from 47% to 15% (P < .001), and the number of patients whose clinical specimens were culture positive also gradually decreased. A change in antibiotic use appears to have significantly affected our VRE outbreak when previous measures failed.
Insights
Restricting specific antibiotics like cefotaxime and vancomycin significantly reduced vancomycin-resistant enterococci (VRE) gut colonization. This antibiotic stewardship intervention proved effective when infection control measures alone failed to control VRE outbreaks.
Area of Science:
- Infectious Diseases
- Microbiology
- Hospital Epidemiology
Background:
- Vancomycin-resistant enterococci (VRE) outbreaks pose a significant challenge in healthcare settings.
- Standard infection control practices, including barrier precautions, were insufficient to curb VRE transmission and colonization at the study center.
- Gastrointestinal colonization with VRE affected nearly half of the inpatients, indicating widespread dissemination.
Purpose of the Study:
- To evaluate the impact of an altered antibiotic formulary on controlling a VRE outbreak.
- To assess the effectiveness of antibiotic stewardship in reducing VRE colonization and clinical infections.
Main Methods:
- Implemented an antibiotic formulary change, restricting cefotaxime, vancomycin, and clindamycin.
- Introduced beta-lactamase inhibitors to replace third-generation cephalosporins.
- Monitored antibiotic usage and VRE fecal colonization rates before and after the intervention.
Main Results:
- Significant reductions in the monthly use of restricted antibiotics were observed (e.g., cefotaxime by 84%, clindamycin by 80%).
- Point prevalence of VRE fecal colonization decreased substantially from 47% to 15%.
- A gradual decrease in the number of positive clinical cultures for VRE was noted.
Conclusions:
- Modifying antibiotic usage through formulary restrictions can be a highly effective strategy for controlling VRE outbreaks.
- Antibiotic stewardship interventions can complement and enhance traditional infection control measures.
- The study highlights the link between antibiotic selection pressure and the prevalence of VRE.