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Nair P, Sankar S, Neelusree P. Study on Biofilm Formation Among Enterococcus Isolates and Association With Their Antibiotic Resistance Patterns. Cureus 2024; 16:e53594. [PMID: 38449981 PMCID: PMC10915696 DOI: 10.7759/cureus.53594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/04/2024] [Indexed: 03/08/2024] Open
Abstract
Background Enterococci are a part of the normal intestinal flora of humans. They have emerged as one of the leading causes of nosocomial infection. The evolved antibiotic resistance mechanisms coupled with the virulence properties of enterococci have made it a successful pathogen. Aim This study aimed to determine the ability of biofilm formation among the clinical enterococci isolates and the antimicrobial resistance pattern of the strains. Materials and methods Clinical samples of patients who attended Saveetha Medical College and Hospital, Chennai, India, over six months. Identification and characterization of Enterococcus species were done using various biochemical tests. Antibiotic susceptibility patterns for each isolate were performed using the Kirby- Bauer disc diffusion method. Results The formation of biofilm formation was detected using the microtiter plate method. In total, 90 Enterococcus species were isolated; Enterococcus faecalis were 63 (70%), Enterococcus faecium were 25 (28%) and Enterococcus gallinarum were 2 (2%)independently. E. faecalis displayed advanced resistance rates compared to other Enterococcus species. Resistance against penicillin was found in 42 strains (47%) and resistance to ampicillin was observed in 39 strains (43%). This was followed by resistance to high-level gentamicin in 35 strains (39%) and resistance to ciprofloxacin in 32 strains (36%). Resistance to vancomycin and linezolid also were noted in some strains. Conclusion Our results indicate that E. faecalis exhibits an increasing rate of antimicrobial resistance but lower biofilm conformation. The unique traits of E. faecalis raise concerns for the associated infections, especially hospital-acquired infections.
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Affiliation(s)
- Pooja Nair
- Department of Microbiology, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - Sathish Sankar
- Department of Microbiology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
| | - P Neelusree
- Department of Microbiology, Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, IND
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Tang YF, Lin YS, Su LH, Liu JW. Increasing trend of healthcare-associated infections due to vancomycin-resistant Enterococcus faecium (VRE-fm) paralleling escalating community-acquired VRE-fm infections in a medical center implementing strict contact precautions: An epidemiologic and pathogenic genotype analysis and its implications. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:1045-1053. [PMID: 37599123 DOI: 10.1016/j.jmii.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To clarify whether there were clandestine intra-hospital spreads of vancomycin-resistant Enterococcus faecium (VRE-fm) isolates that led to specific strain of VRE lingering in the hospital and/or developing outbreaks that rendered a progressively increasing trend of healthcare-associated infections due to VRE-fm (VRE-fm-HAIs). SETTING Despite implementing strict contact precautions for hospitalized patients with VRE-fm-infection/colonization, number of VRE-fm-HAIs in a medical centre in southern Taiwan were escalating in 2009-2019, paralleling an increasing trend of community-acquired VRE-fm- infections. METHODS We analyzed epidemiologic data and genotypes of non-duplicate VRE-fm isolates each grown from a normally sterile site of 89 patients between December 2016 and October 2018; multilocus sequence typing (MLST) and pulse-field gel electrophoresis (PFGE) typing were performed. RESULTS Totally 13 sequence types (STs) were found, and the 3 leading STs were ST17 (44%), ST78 (37%), and ST18 (6%); 66 pulsotypes were generated by PFGE. Four VRE-fm isolates grouped as ST17/pulsotype S, 2 as ST17/pulsotype AS, 2 as ST17/pulsotype AU, and 3 as ST78/pulsotype V grew from clinical specimens sampled less than one week apart from patients staying at different wards/departments and/or on different floors of the hospital. CONCLUSIONS Despite possible small transitory clusters of intra-hospital VRE-fm spreads, there was no specific VRE-fm strain lingering in the hospital leading to increasing trend of VRE-fm-HAIs during the study period. Strict contact precautions were able to curb intra-hospital VRE-fm spreads, but unable to curb the increasing trend of VRE-fm-HAIs with the backdrop of progressively increasing VRE-fm-infections/colorizations in the community.
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Affiliation(s)
- Ya-Fen Tang
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yin-Shiou Lin
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Li-Hsiang Su
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jien-Wei Liu
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Amiraslani S, Darbemamieh G, Karimian F, Tabatabai Ghomsheh F. Design, Fabrication, and Testing of a Novel Surgical Handwashing Machine. Surg Innov 2020; 28:323-328. [PMID: 32921227 DOI: 10.1177/1553350620958241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Surgical hand scrub is strongly recommended as an essential measure to reduce surgical site infections (SSIs). SSI results in morbidity and additional cost. Micropunctures may occur on surgical gloves during operation, thus hand scrub cannot be omitted in any condition. Generally speaking, the adequacy of hand scrub is decided by the surgeon. Only occasionally, surveillance of hygienic status of hands is performed after scrub. Therefore, the potential exists that suboptimal handwash leads to SSIs. There are standards for preoperative handwash, but all of them are operator dependent, and continuous surveillance is actually impossible. One solution is to omit the role of surgeon in handwashing. This can be achieved by designing a standard procedure, performed mechanically by a machine, considering the detailed requirements of hygienic surgical hand scrub. The goal of this study was to develop a procedure that works on the design, fabrication, and trial of a new handwashing machine, for surgical hand scrub. Methods. A machine with a reciprocal spraying mechanism was designed that covers from the fingertips up to the elbow. Various combinations of staged irrigations with antiseptic solutions and water were to be programmed and implemented. Clinical experiments were performed several times with different handwashing programs, and swabs were taken from the skin surface and creases. Results. There was no microbial growth after 72 hours with any handwashing program. Conclusion. The preliminary experiments with this new handwashing machine show promising results for its application in surgical hand scrub.
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Affiliation(s)
- Shahryar Amiraslani
- Department of Biomedical Engineering, Central Tehran Branch, 201585Islamic Azad University, Tehran, Iran
| | - Goldis Darbemamieh
- Department of Biomedical Engineering, Central Tehran Branch, 201585Islamic Azad University, Tehran, Iran
- Hard Tissue Engineering Research Center, Tissue Engineering and Regenerative Medicine Institute, Central Tehran Branch, 201585Islamic Azad University, Tehran, Iran
| | - Faramarz Karimian
- Department of Surgery, IK Teaching Hospital, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Tabatabai Ghomsheh
- Pediatric Neurorehabilitation Research Center, 48533University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Goić-Barišić I, Radić M, Novak A, Rubić Ž, Boban N, Lukšić B, Tonkić M. Vancomycin-resistant Enterococcus faecium COLONIZATION and Clostridium difficile infection in a HEMATOLOGIC patient. Acta Clin Croat 2020; 59:523-528. [PMID: 34177063 PMCID: PMC8212656 DOI: 10.20471/acc.2020.59.03.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Vancomycin-resistant enterococci (VRE), especially Enterococcus faecium, have emerged as significant nosocomial pathogens and patients with impaired host defenses are at a particular risk of VRE infection. The most common occurrence is asymptomatic colonization of the gastrointestinal tract that can persist for a long time and serve as a reservoir for transmission of VRE to other patients. We present a case of a patient who was diagnosed with acute myelogenous leukemia and suffered from bone marrow aplasia following induction therapy. The patient received prolonged broad-spectrum antimicrobial therapy. During hospital stay, the patient developed Clostridium difficile infection (CDI) and was found to be colonized with a strain of Enterococcus faecium resistant to vancomycin during therapy for CDI. This case also highlights the role of risk factors that could contribute to development of resistance, particularly CDI. Early detection of VRE colonization or infection is a crucial component in hospital program designed to prevent transmission of nosocomial infections. Surveillance cultures of such patients should be mandatory.
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Affiliation(s)
| | - Marina Radić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Anita Novak
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Žana Rubić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Nataša Boban
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Boris Lukšić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
| | - Marija Tonkić
- 1Department of Clinical Microbiology, Split University Hospital Centre, Split, Croatia;2University of Split School of Medicine, Split, Croatia; 3Department of Clinical Epidemiology, Split University Hospital Centre, Split, Croatia; 4Department of Infectious Diseases, Split University Hospital Centre, Split, Croatia
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Chiu LM, Domagala BM, Park JM. Management of Opportunistic Infections in Solid-Organ Transplantation. Prog Transplant 2016; 14:114-29. [PMID: 15264456 DOI: 10.1177/152692480401400206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Solid-organ transplantation is often the last alternative in many patients with end-stage organ disease. Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain problematic. Bacterial, fungal, viral, and parasitic infections are implicated after transplantation depending on numerous factors, such as degree of immunosuppression, type of organ transplant, host factors, and period after transplantation. Proper prophylactic and treatment strategies are imperative in the face of chronic immunosuppression, nosocomial and community pathogens, emerging drug resistance, drug-drug interactions, and medication toxicities. This review summarizes the pathophysiology, incidence, prevention, and treatment strategies of common post-transplant infections.
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Affiliation(s)
- Loretta M Chiu
- University of Washington Medical Center, Seattle, Washington, USA
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Lin CK, Hou CC, Guo YY, Cheng WC. Design and Synthesis of Orthogonally Protected d- and l-β-Hydroxyenduracididines from d-lyxono-1,4-Lactone. Org Lett 2016; 18:5216-5219. [DOI: 10.1021/acs.orglett.6b02444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cheng-Kun Lin
- Genomics
Research Center, Academia Sinica, 128, Section 2, Academia Road, Taipei 11529, Taiwan
| | - Chung-Chien Hou
- Genomics
Research Center, Academia Sinica, 128, Section 2, Academia Road, Taipei 11529, Taiwan
| | - Yi-Yong Guo
- Genomics
Research Center, Academia Sinica, 128, Section 2, Academia Road, Taipei 11529, Taiwan
| | - Wei-Chieh Cheng
- Genomics
Research Center, Academia Sinica, 128, Section 2, Academia Road, Taipei 11529, Taiwan
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Lin CK, Yun WY, Lin LT, Cheng WC. A concise approach to the synthesis of the uniqueN-mannosyld-β-hydroxyenduracididine moiety in the mannopeptimycin series of natural products. Org Biomol Chem 2016; 14:4054-60. [DOI: 10.1039/c6ob00644b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The asymmetric synthesis of the orthogonally protectedN-mannosyld-β-hydroxyenduracididine (N-Man-d-βhEnd) is described, starting from enantiopure silylated (S)-serinol.
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Affiliation(s)
| | - Wen-Yi Yun
- Genomics Research Center
- Academia Sinica
- Taipei
- Taiwan
| | - Lin-Ting Lin
- Department of Chemistry
- National Cheng Kung University
- Tainan City
- Taiwan
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Yang T, Chen G, Sang Z, Liu Y, Yang X, Chang Y, Long H, Ang W, Tang J, Wang Z, Li G, Yang S, Zhang J, Wei Y, Luo Y. Discovery of a Teraryl Oxazolidinone Compound (S)-N-((3-(3-Fluoro-4-(4-(pyridin-2-yl)-1H-pyrazol-1-yl)phenyl)-2-oxooxazolidin-5-yl)methyl)acetamide Phosphate as a Novel Antimicrobial Agent with Enhanced Safety Profile and Efficacies. J Med Chem 2015. [PMID: 26212502 DOI: 10.1021/acs.jmedchem.5b00152] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A series of novel teraryl oxazolidinone compounds was designed, synthesized, and evaluated for their antimicrobial activity and toxicities. The compounds with aromatic N-heterocyclic substituents at the 4-position of pyrazolyl ring showed better antibacterial activity against the tested bacteria than other compounds with different patterns of substitution. Among all potent compounds, 10f exhibited promising safety profile in MTT assays and in hERG K(+) channel inhibition test. Furthermore, its phosphate was found to be highly soluble in water (47.1 mg/mL), which is beneficial for the subsequent in vivo test. In MRSA systemic infection mice models, 10f phosphate exerted significantly improved survival protection compared with linezolid. The compound also demonstrated high oral bioavailability (F = 99.1%). Moreover, from the results of in vivo toxicology experiments, 10f phosphate would be predicted to have less bone marrow suppression.
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Affiliation(s)
- Tao Yang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Gong Chen
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Zitai Sang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yuanyuan Liu
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiaoyan Yang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ying Chang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Haiyue Long
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Wei Ang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jianying Tang
- Sichuan Good Doctor Pharmaceutical Co., Ltd. , Chengdu, Sichuan 610031, China
| | - Zhenling Wang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Guobo Li
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shengyong Yang
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jingren Zhang
- Centre for Infectious Diseases Research, School of Medicine, Tsinghua University , Beijing, 100084, China
| | - Yuquan Wei
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
| | - Youfu Luo
- State Key Laboratory of Biotherapy/Collaborative Innovation Center for Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, China
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Comparison of Vancomycin and Cefuroxime for Infection Prophylaxis in Coronary Artery Bypass Surgery. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s0195941700087300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTOBJECTIVE: To investigate clinically significant differences between vancomycin and cefuroxime for perioperative infection prophylaxis in coronary artery bypass surgery.DESIGN: A total of 884 patients were randomized prospectively to receive either cefuroxime (444) or van-comycin (440) and were assessed for infectious complications during hospitalization and 1 month postoperatively.SETTING: A university hospital.RESULTS: The overall immediate surgical-site infection rate was 3.2% in the cefuroxime group and 3.5% in the vancomycin group (difference, −0.3; 95% confidence interval, −2.6-2.1).CONCLUSIONS: The data suggest that vancomycin has no clinically significant advantages over cephalosporin in terms of antimicrobial prophylaxis. We suggest that cefuroxime (or first-generation cephalosporins, which were not studied here) is a good choice for infection prophylaxis in connection with coronary artery bypass surgery in institutions without methicillin-resistantStaphylococcus aureusproblems. In addition to the increasing vancomycin-resistant enterococci problem, the easier administration and usually lower price of cefuroxime make it preferable to vancomycin.
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Vancomycin Control Measures at a Tertiary-Care Hospital: Impact of Interventions on Volume and Patterns of use. Infect Control Hosp Epidemiol 2015. [DOI: 10.1017/s0195941700087336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTOBJECTIVE: Evaluate vancomycin prescribing patterns in a tertiary-care hospital before and after interventions to decrease vancomycin utilization.DESIGN: Before/after analysis of interventions to limit vancomycin use.SETTING: 420-bed academic tertiary-care center.INTERVENTIONS: Educational efforts began August 10, 1994, and involved lectures to medical house staff followed by mailings to all physicians and posting of guidelines for vancomycin use on hospital information systems. Active interventions began November 15, 1994, and included automatic stop orders for vancomycin at 72 hours, alerts attached to the medical record, and, for 2 weeks only, computer alerts to physicians following each vancomycin order. Parenteral vancomycin use was estimated from the hospital pharmacy database of all medication orders. Records of a random sample of 344 patients receiving van-comycin between May 1, 1994, and April 30, 1995, were reviewed for an indication meeting published guidelines.RESULTS: Vancomycin prescribing decreased by 22% following interventions, from 8.5 to 6.8 courses per 100 discharges (P<.05). The estimated proportion of van-comycin ordered for an indication meeting published guidelines was 36.6% overall, with no significant change following interventions. However, during the 2 weeks that computer alerts were in place, 60% of vancomycin use was for an approved indication.CONCLUSIONS: Parenteral vancomycin prescribing decreased significantly following interventions, but the majority of orders still were not for an indication meeting published guidelines. Further improvement in the appropriateness of vancomycin prescribing potentially could be accomplished by more aggressive interventions, such as computer alerts, or by targeting specific aspects of prescribing patterns.
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Salgado CD, Farr BM. Outcomes Associated With Vancomycin-Resistant Enterococci: A Meta-Analysis. Infect Control Hosp Epidemiol 2015; 24:690-8. [PMID: 14510253 DOI: 10.1086/502271] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractBackground:Because patients with vancomycin-resistantEnterococcusbacteremia (VREB) usually have a higher severity of illness, it has been unclear whether VREB is worse than vancomycin-susceptibleEnterococcusbacteremia (VSEB).Methods:Data on morbidity and case fatality rates and costs were pooled from studies comparing VREB and VSEB, identified by Medline (January 1986 to April 2002) and meeting abstracts. Heterogeneity across studies was assessed with contingency table chi-square. Multivariate analyses (MVAs) controlling for other predictors were evaluated.Results:Thirteen studies compared case-fatality rates of VREB and VSEB. VREB case fatality was significantly higher (48.9% vs 19%; RR, 2.57; CI95, 2.27 to 2.91; attributable mortality = 30%). Five studies compared VREB with VSEB when bacteremia was the direct cause of death; VREB case fatality was significantly higher (39.1% vs 21.8%; RR, 1.79; CI95, 1.28 to 2.5; attributable mortality = 17%). Four MVAs found significant increases in case-fatality rates (OR 2.10 to 4.0), 3 showed trends toward increase (OR, 1.74 to 3.34 with wide confidence intervals), and 3 with low statistical power found no difference. VREB recurred in 16.9% versus 3.7% with VSEB (P< .0001). Three studies reported significant increases in LOS, costs, or both with VREB.Conclusion:Most studies have had inadequate sample size, inadequate adjustment for other predictors of adverse outcomes, or both, but available data suggest that VREB is associated with higher recurrence, mortality, and excess costs than VSEB including multiple studies adjusting for severity of illness.
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Affiliation(s)
- Cassandra D Salgado
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
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Vancomycin-resistant enterococci: Troublemaker of the 21st century. J Glob Antimicrob Resist 2014; 2:205-212. [PMID: 27873678 DOI: 10.1016/j.jgar.2014.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 04/03/2014] [Accepted: 04/09/2014] [Indexed: 11/22/2022] Open
Abstract
The emergence of multidrug-resistant and vancomycin-resistant enterococci during the last decade has made it difficult to treat nosocomial infections. Although various enterococcal species have been identified, only two (Enterococcus faecalis and Enterococcus faecium) are responsible for the majority of human infections. Vancomycin is an important therapeutic alternative against multidrug-resistant enterococci but is associated with a poor prognosis. Resistance to vancomycin dramatically reduces the therapeutic options for enterococcal infections. The bacterium develops resistance by modifying the C-terminal d-alanine of peptidoglycan to d-lactate, creating a d-Ala-d-Lac sequence that effectively reduces the affinity of vancomycin for the peptidoglycan by 1000-fold. Moreover, the resistance genes can be transferred from enterococci to Staphylococcus aureus, thereby posing a threat to patient safety and also a challenge for treating physicians. Judicious use of vancomycin and broad-spectrum antibiotics must be implemented, but strict infection control measures must also be followed to prevent nosocomial transmission of these organisms. Furthermore, improvements in clinical practice, rotation of antibiotics, herbal drugs, nanoantibiotics and the development of newer antibiotics based on a pharmacogenomic approach may prove helpful to overcome dreadful vancomycin-resistant enterococcal infections.
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Desai NC, Pandya MR, Rajpara KM, Joshi VV, Vaghani HV, Satodiya HM. Synthesis and antimicrobial screening of novel series of imidazo-[1,2-a]pyridine derivatives. Med Chem Res 2012. [DOI: 10.1007/s00044-012-9988-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Yip T, Tse KC, Ng F, Hung I, Lam MF, Tang S, Lui SL, Lai KN, Chan TM, Lo WK. Clinical course and outcomes of single-organism Enterococcus peritonitis in peritoneal dialysis patients. Perit Dial Int 2011; 31:522-8. [PMID: 21532006 DOI: 10.3747/pdi.2009.00260] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Enterococci are part of the normal flora of the gastrointestinal tract. They can cause enteric peritonitis, which is a serious complication of peritoneal dialysis (PD). However, the clinical course and outcome of PD-related Enterococcus peritonitis remains unclear. METHODS We reviewed all Enterococcus peritonitis episodes occurring in our dialysis unit from 1995 to 2009. RESULTS During the study period, 1421 episodes of peritonitis were recorded. Of 29 episodes (2.0%) that were attributable to single-organism Enterococcus, 12 episodes were caused by E. faecalis; 9, by E. faecium; and the remaining 8, by other Enterococcus species. The overall rate of ampicillin resistance was 41.4%. Recent use of antibiotics was associated with the development of ampicillin-resistant Enterococcus (ARE) peritonitis (hazard ratio: 12.53; p = 0.04). The primary response rate of Enterococcus peritonitis was significantly higher than that of Escherichia coli peritonitis (89.7% vs. 69.9%, p = 0.038), but the primary response rate was not significantly lower for ARE peritonitis than for ampicillin-susceptible Enterococcus (ASE) peritonitis (83.3% vs. 94.1%, p = 0.553). However, significantly more patients with ARE had received vancomycin (83.3% vs. 23.5%, p = 0.003), with a longer mean duration of vancomycin treatment (11.8 ± 6.9 days vs. 3.7 ± 6.8 days, p = 0.005). CONCLUSIONS Recent use of antibiotics was a risk factor for the development of ARE peritonitis. Outcomes in ASE and ARE peritonitis were similar, but vancomycin was required during treatment for ARE peritonitis, in turn possibly predisposing the patients to infections caused by vancomycin-resistant organisms.
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Affiliation(s)
- Terence Yip
- Dr. Lee Iu Cheung Memorial Renal Research Centre, Tung Wah Hospital, The University Department of Medicine, The University of Hong Kong, Hong Kong SAR, PR China.
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Widmer A, Rotter M, Voss A, Nthumba P, Allegranzi B, Boyce J, Pittet D. Surgical hand preparation: state-of-the-art. J Hosp Infect 2010; 74:112-22. [DOI: 10.1016/j.jhin.2009.06.020] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 06/16/2009] [Indexed: 12/01/2022]
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Keely S, Glover LE, Weissmueller T, MacManus CF, Fillon S, Fennimore B, Colgan SP. Hypoxia-inducible factor-dependent regulation of platelet-activating factor receptor as a route for gram-positive bacterial translocation across epithelia. Mol Biol Cell 2009; 21:538-46. [PMID: 20032301 PMCID: PMC2820419 DOI: 10.1091/mbc.e09-07-0573] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Results from these studies reveal that some strains of Gram-positive bacteria exploit hypoxia-inducible factor-regulated platelet-activating factor receptor as a means for translocation through intestinal epithelial cells. Mucosal surfaces, such as the lung and intestine, are lined by a monolayer of epithelia that provides tissue barrier and transport function. It is recently appreciated that a common feature of inflammatory processes within the mucosa is hypoxia (so-called inflammatory hypoxia). Given the strong association between bacterial translocation and mucosal inflammatory disease, we hypothesized that intestinal epithelial hypoxia influences bacterial translocation. Initial studies revealed that exposure of cultured intestinal epithelia to hypoxia (pO2, 20 torr; 24–48 h) resulted in a increase of up to 40-fold in the translocation of some strains of Gram-positive bacteria, independently of epithelial barrier function. A screen of relevant pathway inhibitors identified a prominent role for the platelet-activating factor receptor (PAFr) in hypoxia-associated bacterial translocation, wherein pharmacologic antagonists of PAFr blocked bacterial translocation by as much as 80 ± 6%. Extensions of these studies revealed that hypoxia prominently induces PAFr through a hypoxia-inducible factor (HIF)-dependent mechanism. Indeed, HIF and PAFr loss of function studies (short hairpin RNA) revealed that apically expressed PAFr is central to the induction of translocation for the Gram-positive bacteria Enterococcus faecalis. Together, these findings reveal that some strains of Gram-positive bacteria exploit HIF-regulated PAFr as a means for translocation through intestinal epithelial cells.
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Affiliation(s)
- Simon Keely
- Mucosal Inflammation Program, Department of Medicine, University of Colorado Denver, Aurora, CO 80045, USA.
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18
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Synthesis and Biological Evaluation of Novel Substituted Pyrrolyl and Pyrazolyl Oxazolidinone Analogues. B KOREAN CHEM SOC 2009. [DOI: 10.5012/bkcs.2009.30.8.1895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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19
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Harris AD, McGregor JC, Furuno JP. What Infection Control Interventions Should Be Undertaken to Control Multidrug-Resistant Gram-Negative Bacteria? Clin Infect Dis 2006; 43 Suppl 2:S57-61. [PMID: 16894516 DOI: 10.1086/504479] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Multidrug-resistant gram-negative bacteria are an emerging problem. The present article addresses 2 relevant questions: (1) should active surveillance be performed to identify patients colonized with multidrug-resistant gram-negative bacteria, and (2) should contact isolation precautions be taken with patients colonized or infected with multidrug-resistant gram-negative bacteria? Data and variables that are needed to scientifically answer these questions are reviewed, as are existing data on Pseudomonas aeruginosa, Enterobacteriaceae (Escherichia coli and Klebsiella species in particular), and Acinetobacter baumannii.
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Affiliation(s)
- Anthony D Harris
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Narender P, Srinivas U, Ravinder M, Rao BA, Ramesh C, Harakishore K, Gangadasu B, Murthy USN, Rao VJ. Synthesis of multisubstituted quinolines from Baylis–Hillman adducts obtained from substituted 2-chloronicotinaldehydes and their antimicrobial activity. Bioorg Med Chem 2006; 14:4600-9. [PMID: 16510289 DOI: 10.1016/j.bmc.2006.02.020] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Revised: 02/08/2006] [Accepted: 02/09/2006] [Indexed: 11/18/2022]
Abstract
Baylis-Hillman acetates were synthesized from substituted 2-chloronicotinaldehydes and were conveniently transformed into multisubstituted quinolines and cyclopenta[g]quinolines on reaction with nitroethane or ethyl cyanoacetate via a successive S(N)2'-S(N)Ar elimination strategy. Thus, synthesized quinolines were evaluated for antimicrobial activity and found having substantial antibacterial and antifungal activity.
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Affiliation(s)
- P Narender
- Organic Chemistry Division-II, Indian Institute of Chemical Technology, Tarnaka, Hyderabad
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21
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Bearman GML, Wenzel RP. Bacteremias: a leading cause of death. Arch Med Res 2006; 36:646-59. [PMID: 16216646 DOI: 10.1016/j.arcmed.2005.02.005] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Accepted: 03/03/2005] [Indexed: 10/25/2022]
Abstract
Bloodstream infections (BSIs), recognized to be a major cause of morbidity and mortality globally, are increasing in incidence. The reported rates of crude and attributable mortality vary, possibly due to heterogeneity in patient populations and methodology. Few studies, however, have focused on pathogen-specific attributable mortality. These studies include S. aureus, coagulase-negative staphylococci and enterococcus. Other studies of attributable mortality have been conducted in select populations such as nosocomial and community-acquired cohorts, intensive care units, neutropenic patients, and HIV-positive patients. Regrettably, despite advances in treatment and intensive care facilities, mortality remains high.
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Affiliation(s)
- Gonzalo M L Bearman
- Internal Medicine, Epidemiology and Community Medicine, Division of Quality HealthCare, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0019, USA
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22
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Salgado CD, O'Grady N, Farr BM. Prevention and control of antimicrobial-resistant infections in intensive care patients. Crit Care Med 2005; 33:2373-82. [PMID: 16215395 DOI: 10.1097/01.ccm.0000181727.04501.f3] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To review the literature summarizing important aspects of infection control in the critical care setting and to provide recommendations to reduce infections with resistant bacteria in the intensive care unit. DATA SOURCE Computer searches of MEDLINE, EMBASE, and the Cochrane Library. DATA The frequency of antibiotic-resistant, health care-associated infections has increased every year for the past 2 decades. Infections with antibiotic-resistant organisms have been linked to increases in morbidity, length of hospitalization, increased healthcare costs, and increased mortality. A comprehensive approach is necessary to prevent antimicrobial resistance in ICUs. This includes (1) preventing infections; (2) diagnosing and treating infections appropriately; (3) using antimicrobials wisely; and (4) preventing transmission. CONCLUSIONS The reservoirs for antibiotic-resistant organisms are colonized patients, and the vectors are often healthcare workers. This places an enormous responsibility on healthcare providers to protect their patients. Clinicians must recognize the importance of adhering to the recommendations in the Centers for Disease Control's Campaign to Prevent Antimicrobial Resistance in the healthcare setting.
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23
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McFarland LV. Alternative treatments for Clostridium difficile disease: what really works? J Med Microbiol 2005; 54:101-111. [PMID: 15673502 DOI: 10.1099/jmm.0.45753-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Vancomycin and metronidazole have been used for treating Clostridium difficile-associated disease (CDAD) for the past 25 years, but approximately 20 % of patients develop recurrent disease. The increasing incidence of nosocomial outbreaks, cases of recurrent CDAD and other complications (toxic megacolon, ileus, sepsis) has fuelled the search for different types of treatments. As the understanding of the pathogenesis of this disease has matured, newer treatment strategies that take advantage of these mechanisms have been developed. This review will describe such treatments and examine the evidence for each strategy.
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Affiliation(s)
- Lynne V McFarland
- University of Washington, HSR&D, 1100 Olive Street, #1400, Seattle, WA 98101, USA
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24
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Abstract
Solid-organ transplantation is often the last alternative in many patients with end-stage organ disease. Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain problematic. Bacterial, fungal, viral, and parasitic infections are implicated after transplantation depending on numerous factors, such as degree of immunosuppression, type of organ transplant, host factors, and period after transplantation. Proper prophylactic and treatment strategies are imperative in the face of chronic immunosuppression, nosocomial and community pathogens, emerging drug resistance, drug-drug interactions, and medication toxicities. This review summarizes the pathophysiology, incidence, prevention, and treatment strategies of common posttransplant infections.
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Affiliation(s)
- Loretta M Chiu
- University of Washington Medical Center, Seattle, Washington, USA
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25
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Harris AD, Nemoy L, Johnson JA, Martin-Carnahan A, Smith DL, Standiford H, Perencevich EN. Co-carriage rates of vancomycin-resistant Enterococcus and extended-spectrum beta-lactamase-producing bacteria among a cohort of intensive care unit patients: implications for an active surveillance program. Infect Control Hosp Epidemiol 2004; 25:105-8. [PMID: 14994933 DOI: 10.1086/502358] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the co-colonization rates of extended-spectrum beta-lactamase (ESBL)-producing bacteria and vancomycin-resistant Enterococcus (VRE) obtained on active surveillance cultures. DESIGN Prospective cohort study. SETTING Medical and surgical intensive care units (ICUs) of a tertiary-care hospital. PATIENTS Patients admitted between September 2001 and November 2002 to the medical and surgical ICUs at the University of Maryland Medical System had active surveillance perirectal cultures performed. Samples were concurrently processed for VRE and ESBL-producing bacteria. RESULTS Of 1,362 patients who had active surveillance cultures on admission, 136 (10%) were colonized with VRE. Among these, 15 (positive predictive value, 11%) were co-colonized with ESBL. Among the 1,226 who were VRE negative, 1,209 were also ESBL negative (negative predictive value, 99%). Among the 1,362 who had active surveillance cultures on admission, 32 (2%) were colonized with ESBL. Among these, 15 (47%) were co-colonized with VRE. Of the 32 patients colonized with ESBL, 10 (31%) had positive clinical cultures for ESBL on the same hospital admission. For these 10 patients, the surveillance cultures were positive an average of 2.7 days earlier than the clinical cultures. CONCLUSIONS Patients who are colonized with VRE can also be co-colonized with other antibiotic-resistant bacteria such as ESBL-producing bacteria. Our study is the first to measure co-colonization rates of VRE and ESBL-producing bacteria. Isolating VRE-colonized patients would isolate 47% of the ESBL-colonized patients without the need for further testing. Hence, active surveillance for VRE should also theoretically diminish the amount of patient-to-patient transmission of ESBL-producing bacteria.
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Affiliation(s)
- Anthony D Harris
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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26
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Campanile F, Bartoloni A, Bartalesi F, Borbone S, Mangani V, Mantella A, Nicoletti G, Paradisi F, Russo G, Strohmeyer M, Stefani S. Molecular alterations of VanA element in vancomycin-resistant enterococci isolated during a survey of colonized patients in an Italian intensive care unit. Microb Drug Resist 2004; 9:191-9. [PMID: 12820805 DOI: 10.1089/107662903765826796] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To screen for vancomycin-resistant enterococci (VRE) colonization in hospitalized patients and to study molecular evolution and alterations of Tn1546-like elements in VRE among potentially at-risk patients, a 3-year surveillance protocol in an Intensive Care Unit was performed. A total of 397 patients were screened in the period June, 1997-June, 2000, and VRE were isolated from rectal swabs taken at admission, weekly, and when clinically indicated. The susceptibility of the enterococci was determined by the disk diffusion and broth dilution methods. The presence of vancomycin-resistance genes (vanA, vanB, and vanC) was assessed by polymerase chain reaction (PCR); genetic clonality of isolates was assessed by pulsed-field gel electrophoresis (PFGE); Tn1546 types were obtained by restriction fragment length polymorphism (RFLP) analysis of Tn1546 PCR fragments. Thirty-four strains, 31 identified as Enterococcus faecium and 3 strains as E. faecalis, were isolated from 12 of the 397 patients (3.0%); all strains were VanA as assessed by PCR and were resistant to the other antibiotics tested and showed high-level resistance to aminoglycosides. Enterococci isolated during the study period showed that different genetic backgrounds of strains, determined by PFGE combined with RFLP of Tn1546, are present in all the strains isolated in the study. PFGE type B was predominant in 1998 and 1999, and insertion sequence movements were found to have a role in the evolution of VanA resistance elements found in all strains. This study demonstrates that single patients may be colonized by closely related VRE with several PFGE types containing a wide variety of VanA elements. Moreover, isolates with identical PFGE types may contain different VanA elements reflecting rearrangements mediated by insertion sequences in VRE strains during their stay in the gastrointestinal tract.
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Affiliation(s)
- Floriana Campanile
- Department of Microbiological and Gynecological Sciences, University of Catania, 95124 Catania, Italy
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27
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Calfee DP, Giannetta ET, Durbin LJ, Germanson TP, Farr BM. Control of endemic vancomycin-resistant Enterococcus among inpatients at a university hospital. Clin Infect Dis 2003; 37:326-32. [PMID: 12884155 DOI: 10.1086/376624] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2002] [Accepted: 03/20/2003] [Indexed: 11/03/2022] Open
Abstract
We sought to determine the ability of surveillance cultures and isolation of vancomycin-resistant Enterococcus (VRE)-colonized patients to control nosocomial VRE infection and colonization during a 5-year period (November 1994 through October 1999). During this period, VRE colonization was limited to 0.82% of admissions. The incidence of VRE infection was 0.12 cases per 1000 patient-days (attack rate, 0.07%). Colonized patients were first identified by surveillance (95%) or routine clinical cultures (5%); 14% of colonized patients had a positive clinical culture a median of 15 days after a positive surveillance culture. Ten percent of colonized patients were identified by surveillance at the time of transfer from another health care facility. Identification of these colonized patients was associated with reduction from a peak incidence rate of 2.07% to a rate of 1.25% and stabilization at this lower level. The use of surveillance cultures to identify and isolate patients with asymptomatic colonization can provide sustained control of the spread of VRE within a health care facility.
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Affiliation(s)
- David P Calfee
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
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28
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Chavers LS, Moser SA, Benjamin WH, Banks SE, Steinhauer JR, Smith AM, Johnson CN, Funkhouser E, Chavers LP, Stamm AM, Waites KB. Vancomycin-resistant enterococci: 15 years and counting. J Hosp Infect 2003; 53:159-71. [PMID: 12623315 DOI: 10.1053/jhin.2002.1375] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We review the history of vancomycin-resistant enterococci (VRE) and propose a causal model illustrating the roles of exposure to VRE reservoirs, patient characteristics, antimicrobial exposure, and prevalence of VRE in the progression from potential VRE reservoirs to active disease in hospitalized patients. Differences in VRE colonization and VRE infection are discussed with respect to hospital surveillance methodology and implications for interventions. We further document clonal transmission of VRE in a large, urban, teaching hospital and demonstrate VRE susceptibility to a wide array of antimicrobial agents. This model can guide the identification of mutable factors that are focal points for intervention.
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Affiliation(s)
- L S Chavers
- Department of Epidemiology and International Health, School of Public Health, University of Alabama at Birmingham, Alabama 35249, USA
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29
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Abstract
Vancomycin-resistant enterococcus first was described in 1988, and has become a major problem in nosocomial infections. This is a retrospective review of 10 patients, seen at the authors' hospital during a 2-year period, with confirmed vancomycin-resistant enterococcal osteomyelitis: four patients had total joint arthroplasty infections, one patient had an infected tibial nail, three patients had infections associated with external fixators, and two patients had osteomyelitis of the femur. Four of the 10 patients had underlying medical illnesses (diabetes mellitus, systemic lupus erythematosus, human immunodeficiency virus infection); four of the 10 patients were intravenous drug users. Two patients had vancomycin-resistant enterococci on admission, and the other eight patients were admitted to the hospital for a mean of 21.3 days (range, 3-73 days) before vancomycin-resistant enterococci were identified in the bone. Eight of the 10 patients had monomicrobial infections with vancomycin-resistant enterococci. Patients were treated by surgical debridement, removal of hardware, and antibiotics (chloramphenicol in eight patients, quinupristin and dalfopristin (Synercid) in two patients). All patients initially improved with therapy, but one patient had a recurrence of vancomycin-resistant enterococcal osteomyelitis and died of bacteremia. Bone infections with vancomycin-resistant enterococcus still may be uncommon, but with time and selective antibiotic pressures, vancomycin-resistant enterococci may become a more prominent entity in orthopaedic infections.
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Affiliation(s)
- Paul D Holtom
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
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30
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Harbarth S, Cosgrove S, Carmeli Y. Effects of antibiotics on nosocomial epidemiology of vancomycin-resistant enterococci. Antimicrob Agents Chemother 2002; 46:1619-28. [PMID: 12019066 PMCID: PMC127216 DOI: 10.1128/aac.46.6.1619-1628.2002] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Stephan Harbarth
- Division of Infectious Diseases, Children's Hospital, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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31
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Byers KE, Anglim AM, Anneski CJ, Farr BM. Duration of colonization with vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol 2002; 23:207-11. [PMID: 12002235 DOI: 10.1086/502036] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the duration of colonization with vancomycin-resistant Enterococcus (VRE) and the adequacy of 3 consecutive negative cultures to determine clearance. DESIGN Retrospective cohort study. SETTING A university hospital. POPULATION Patients identified by perirectal cultures as VRE carriers who had follow-up cultures. METHODS Follow-up perirectal cultures were collected in inpatient and outpatient settings, at least 1 week apart, when patients were not receiving antibiotics with activity against VRE. The likelihood of culture positivity was analyzed given prior culture results and time from the initial positive culture. RESULTS A total of 116 patients colonized with VRE had 423 follow-up cultures, a mean of 204 days (range, 4 to 709 days) after their initial isolate. The first follow-up culture, collected a mean of 125 days after the initial positive isolate, was negative in 64%. After 1 negative follow-up culture, the next one was negative in 92% of the patients. After 2 negative cultures, 95% remained culture-negative. After 3 sequential negative cultures, 35 (95%) of 37 patients remained culture-negative. As the interval between the initial and the follow-up isolates increased, the probability that a subsequent culture would be positive decreased (P < .001, chi square for trend). Prolonged hospitalization, intensive care, and antibiotic use each decreased the likelihood of clearing VRE. CONCLUSION These data support the Centers for Disease Control and Prevention criterion of 3 sequential negative cultures, at least 1 week apart, to remove patients from VRE isolation. Nevertheless, this may reflect a decrease in the quantity of VRE to an undetectable level and these patients should be observed for relapse, especially when re-treated with antibiotics.
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Affiliation(s)
- Karin E Byers
- University of Virginia Health System, Charlottesville 22908, USA
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Floret N, Thalamy B, Estavoyer J, Thouverez M, Talon D. Évaluation rétrospective des prescriptions de vancomycine dans un hôpital universitaire de l'Est de la France en 1999. Med Mal Infect 2002. [DOI: 10.1016/s0399-077x(02)00349-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Timmers GJ, van der Zwet WC, Simoons-Smit IM, Savelkoul PHM, Meester HHM, Vandenbroucke-Grauls CMJE, Huijgens PC. Outbreak of vancomycin-resistant Enterococcus faecium in a haematology unit: risk factor assessment and successful control of the epidemic. Br J Haematol 2002; 116:826-33. [PMID: 11886387 DOI: 10.1046/j.0007-1048.2002.03339.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe an outbreak of vancomycin-resistant Enterococcus faecium (VRE) on the haematology ward of a Dutch university hospital. After the occurrence of three consecutive cases of bacteraemia with VRE, strains were genotyped and found to be identical. During the next 4 months an intensive surveillance programme identified 21 additional patients to be colonized with VRE, while two more patients developed bacteraemia. A case-control study was carried out to identify risk factors for VRE acquisition. In comparison with VRE-negative control patients (n=49), cases (n=24) had a longer stay on the ward during the year preceding the outbreak (25.8 versus 10.1 d, P=0.02), more cases with acute myeloid leukaemia [11 versus 4, odds ratio (OR) 9.5, 95% confidence interval (CI95) 2.4-32.2] and higher grades of mucositis (P=0.03). Logistic regression analysis identified antibiotic use within 1 month before admission (OR 13.0, CI95 2.1-80.5, P=0.006) and low albumin levels at baseline (OR 1.2, CI95 1.1-1.3, P=0.02) to be independent risk factors. Four patients with VRE-bacteraemia were successfully treated with quinupristin/dalfopristin (Synercid). Control of the outbreak was achieved by step-wise implementation of intensive infection control measures, which included the cohorting of patients, allocation of nurses and reinforcement of hand hygiene.
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Affiliation(s)
- Gert Jan Timmers
- Department of Haematology, VU University Medical Centre, Amsterdam, the Netherlands.
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Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol 2002; 23:27-31. [PMID: 11868889 DOI: 10.1086/501964] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the additional direct costs of hospitalization attributable to catheter-associated urinary tract infection (CAUTI) in 1,497 newly catheterized patients. DESIGN Prospective observational and laboratory study. SETTING University hospital. METHODS Data were collected on risk factors for CAUTI (defined as > 10(3) colony-forming units [CFU]/mL), severity of illness, and diagnostic and therapeutic interventions in consenting newly catheterized patients. Daily urine cultures were obtained from each newly catheterized patient, but the results of these cultures were not revealed to his or her physician. During the study, one of the investigators (DGM) reviewed each patient's record and made a judgment as to which of the diagnostic tests and treatments ordered and what incremental length of stay could reasonably be ascribed to his or her CAUTI. The total hospital costs for each patient were also obtained. RESULTS Overall, 235 patients acquired CAUTIs during the study; most of the CAUTIs were completely asymptomatic, and only 52% were diagnosed by the patients' physicians using the hospital laboratory. Only 1 patient with a CAUTI had a secondary bloodstream infection. Thirty-three (13%) of the CAUTIs were caused by Escherichia coli; 63 (25%) by Klebsiella, Enterobacter, Citrobacter, Pseudomonas aeruginosa, or other antibiotic-resistant, gram-negative bacilli; 87 (35%) by enterococci or staphylococci; and 67 (27%) by Candida species. The 123 CAUTIs diagnosed by the hospital laboratory were judged to have been responsible for an additional $20,662 in extra costs of diagnostic tests and $35,872 in extra medication costs, a mean of $589 (median, $356) per CAUTI. CAUTIs caused by E. coli cost considerably less than infections caused by other gram-negative bacilli ($363.3 +/- $228.2 vs $690.4 +/- $783.7; P = .02) or yeasts ($821.2 +/- $2,169.9). There were less striking differences in the costs per CAUTI caused by staphylococci or enterococci ($387.1 +/- $434.8). CONCLUSIONS The extra direct costs associated with nosocomial CAUTI found in this prospective study, which was done in the era of managed care during the late 1990s, are substantially lower than those reported in the largest comparable studies done more than 15 years ago, most of which were retrospective, reflecting the powerful impact of cost-containment measures that are now implemented in managed care.
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Affiliation(s)
- Paul A Tambyah
- Department of Medicine, University of Wisconsin Medical School, University of Wisconsin, Madison, USA
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35
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Linden PK, Moellering RC, Wood CA, Rehm SJ, Flaherty J, Bompart F, Talbot GH. Treatment of vancomycin-resistant Enterococcus faecium infections with quinupristin/dalfopristin. Clin Infect Dis 2001; 33:1816-23. [PMID: 11668430 DOI: 10.1086/323899] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2001] [Revised: 06/08/2001] [Indexed: 11/03/2022] Open
Abstract
Clinicians caring for patients with vancomycin-resistant Enterococcus faecium (VREF) infections face severe constraints in the selection of treatment. Quinupristin/dalfopristin (Synercid) is active in vitro against VREF, with a MIC(90) of 1.0 microg/mL. We investigated the clinical efficacy and safety of this agent in a multicenter, prospective, noncomparative, emergency-use study of 396 patients. Patients were included if they had signs and symptoms of active infection, including bacteremia of unknown origin, intra-abdominal infection, and skin and skin-structure infection, with no alternative antibiotic therapy available. The mean duration of treatment was 20 days (range, 4-40 days). The clinical response rate was 68.8% in the evaluable subset, and the overall response rate was 65.6%. The most common adverse events related to quinupristin/dalfopristin were arthralgias and myalgias. Related laboratory abnormalities were rare. In this severely ill patient population, quinupristin/dalfopristin was efficacious and demonstrated an acceptable safety profile in the treatment of VREF infection.
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Affiliation(s)
- P K Linden
- University of Pittsburgh Medical Center, Division of Critical Care Medicine, Pittsburgh, PA 15213, USA.
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36
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Chamberland S, Blais J, Hoang M, Dinh C, Cotter D, Bond E, Gannon C, Park C, Malouin F, Dudley MN. In vitro activities of RWJ-54428 (MC-02,479) against multiresistant gram-positive bacteria. Antimicrob Agents Chemother 2001; 45:1422-30. [PMID: 11302805 PMCID: PMC90483 DOI: 10.1128/aac.45.5.1422-1430.2001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RWJ-54428 (MC-02,479) is a new cephalosporin with a high level of activity against gram-positive bacteria. In a broth microdilution susceptibility test against methicillin-resistant Staphylococcus aureus (MRSA), RWJ-54428 was as active as vancomycin, with an MIC at which 90% of isolates are inhibited (MIC(90)) of 2 microg/ml. For coagulase-negative staphylococci, RWJ-54428 was 32 times more active than imipenem, with an MIC(90) of 2 microg/ml. RWJ-54428 was active against S. aureus, Staphylococcus epidermidis, and Staphylococcus haemolyticus isolates with reduced susceptibility to glycopeptides (RWJ-54428 MIC range, < or = 0.0625 to 1 microg/ml). RWJ-54428 was eight times more potent than methicillin and cefotaxime against methicillin-susceptible S. aureus (MIC(90), 0.5 microg/ml). For ampicillin-susceptible Enterococcus faecalis (including vancomycin-resistant and high-level aminoglycoside-resistant strains), RWJ-54428 had an MIC(90) of 0.125 microg/ml. RWJ-54428 was also active against Enterococcus faecium, including vancomycin-, gentamicin-, and ciprofloxacin-resistant strains. The potency against enterococci correlated with ampicillin susceptibility; RWJ-54428 MICs ranged between < or = 0.0625 and 1 microg/ml for ampicillin-susceptible strains and 0.125 and 8 microg/ml for ampicillin-resistant strains. RWJ-54428 was more active than penicillin G and cefotaxime against penicillin-resistant, -intermediate, and -susceptible strains of Streptococcus pneumoniae (MIC(90)s, 0.25, 0.125, and < or = 0.0625 microg/ml, respectively). RWJ-54428 was only marginally active against most gram-negative bacteria; however, significant activity was observed against Haemophilus influenzae and Moraxella catarrhalis (MIC(90)s, 0.25 and 0.5 microg/ml, respectively). This survey of the susceptibilities of more than 1,000 multidrug-resistant gram-positive isolates to RWJ-54428 indicates that this new cephalosporin has the potential to be useful in the treatment of infections due to gram-positive bacteria, including strains resistant to currently available antimicrobials.
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Affiliation(s)
- S Chamberland
- Microcide Pharmaceuticals Inc, Mountain View, California 94043, USA
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37
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Abstract
After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.
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Abstract
After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.
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Affiliation(s)
- Y Cetinkaya
- Department of Healthcare Epidemiology and Division of Infectious Diseases, University of Texas Medical Branch at Galveston, Galveston, Texas 77555-0835, USA
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Chen DK, Pearce L, McGeer A, Low DE, Willey BM. Evaluation of D-xylose and 1% methyl-alpha-D-glucopyranoside fermentation tests for distinguishing Enterococcus gallinarum from Enterococcus faecium. J Clin Microbiol 2000; 38:3652-5. [PMID: 11015378 PMCID: PMC87451 DOI: 10.1128/jcm.38.10.3652-3655.2000] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To determine the validity of the rapid xylose and methyl-alpha-D-glucopyranoside (MDG) fermentation tests in distinguishing Enterococcus gallinarum from Enterococcus faecium, 156 well-characterized clinical isolates of enterococci (55 E. gallinarum, 91 E. faecium, and 10 Enterococcus faecalis isolates) known to be of different clones were examined in a blinded fashion. Species identification was confirmed by PCR of the ddl ligase genes of E. faecium and E. faecalis and the vanC1 gene of E. gallinarum. Xylose tests were performed with D-xylose tablets by using a heavy bacterial suspension and were interpreted after 2 h of incubation. Standard MDG fermentation tests were read after 24 h of incubation. The xylose fermentation test had a sensitivity of 98% (54 of 55) and a specificity of 99% (100 of 101) in distinguishing E. gallinarum from E. faecium and E. faecalis. The standard MDG test had a sensitivity of 100% (55 of 55) and a specificity of 95% (96 of 101) after 24 h. The xylose fermentation test is a simple method, easily incorporated into laboratory protocols, that distinguishes E. gallinarum from E. faecium with high sensitivity and specificity in 2 h. The standard MDG test has high sensitivity and can be useful in ruling out the presence of E. gallinarum but requires overnight incubation.
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Affiliation(s)
- D K Chen
- Department of Microbiology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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40
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Silverblatt FJ, Tibert C, Mikolich D, Blazek-D'Arezzo J, Alves J, Tack M, Agatiello P. Preventing the spread of vancomycin-resistant enterococci in a long-term care facility. J Am Geriatr Soc 2000; 48:1211-5. [PMID: 11037006 DOI: 10.1111/j.1532-5415.2000.tb02592.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To test the hypothesis that infection control practices can prevent the spread of vancomycin-resistant enterococci (VRE) to residents of a long-term care facility (LCF) from an affiliated acute care facility with a high endemic rate of colonization. DESIGN Point prevalence study of the rate of rectal colonization. SETTING A state-supported veterans nursing home and an acute care veterans hospital. PARTICIPANTS Residents in a state veterans home. INTERVENTIONS Identification of patients with rectal colonization by VRE before transfer to the state veterans home, contact isolation for colonized veterans, use of oral bacitracin to eliminate colonization. MEASUREMENTS Rectal swab and culture for VRE, review of clinical records and recording of presumptive risk factors for VRE colonization. The risk factors were age, gender, length of stay at nursing home, treatment with vancomycin or oral antibiotics, prior hospitalization at the acute care facility during the prior year, use of indwelling urethral catheters, presence of diarrhea, and fecal or urinary incontinence. RESULTS Sixty-nine of 200 residents were cultured in the first study (1996) and 130 of 230 residents were cultured in the second study (1998). Residents who consented to culture differed from those who did not only with regards to gender (2 vs 7, P = .012). In neither study were any residents found to be colonized with VRE who had not already been identified as positive on admission. CONCLUSIONS Adherence to infection control practices by the patient care staff of the LTCF was associated with the absence of transmission of VRE colonization among its residents. The presence of rectal colonization with VRE in an acute care patient should not be a barrier to acceptance in a nursing home.
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Affiliation(s)
- F J Silverblatt
- Department of Veterans Affairs Medical Center, Providence, Rhode Island 02908, USA
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41
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Klaassen RJ, Allen U, Doyle JJ. Randomized placebo-controlled trial of oral antibiotics in pediatric oncology patients at low-risk with fever and neutropenia. J Pediatr Hematol Oncol 2000; 22:405-11. [PMID: 11037850 DOI: 10.1097/00043426-200009000-00004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Fever combined with neutropenia in pediatric oncology patients has traditionally been managed in the hospital with broad-spectrum intravenous antibiotics until there is documented neutrophil recovery. Recent evidence has suggested that patients at "low-risk" can be discharged from the hospital before neutrophil recovery. Whether oral antibiotics are required at the time of discharge is not known. PATIENTS AND METHODS Using a randomized, double-blind, placebo-controlled study design, 73 patients at low-risk with episodes of fever and neutropenia were discharged home while still neutropenic: 37 administered with oral cloxacillin and cefixime and 36 administered with corresponding placebos. Low-risk criteria included: afebrile for more than 24 hours, negative blood culture results at 48 hours, absence of clinical sepsis, cancer in bone marrow remission, and absence of comorbid conditions. RESULTS Five patients (14%; 95% confidence interval [CI]; 2%-25%) in the antibiotic arm and two patients (6%; 95% CI; 0%-13%) in the placebo arm were readmitted to the hospital with recurrent fever while still neutropenic (P = 0.43). One patient randomized to the placebo arm had a positive blood culture result on readmission, which responded to appropriate intravenous antibiotics. All of the readmissions were uneventful and there were no fatalities. The average cost per episode of fever and neutropenia was $1,821 Canadian dollars with only minimal incremental cost to the antibiotic arm. CONCLUSION This study supports the discontinuation of antibiotics in pediatric oncology patients at low-risk who still have neutropenia at the time of discharge from the hospital.
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Affiliation(s)
- R J Klaassen
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.
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42
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Catalano OA, Hahn PF, Hooper DC, Mueller PR. Efficacy of percutaneous abscess drainage in patients with vancomycin-resistant enterococci. AJR Am J Roentgenol 2000; 175:533-6. [PMID: 10915709 DOI: 10.2214/ajr.175.2.1750533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We reviewed a 4-year experience draining fluid collections infected with vancomycin-resistant enterococci to determine the outcome of percutaneous intervention in patients with this highly resistant and increasingly common organism. MATERIALS AND METHODS Charts of patients from whom vancomycin-resistant enterococci had been isolated during percutaneous drainage were reviewed to determine patient response to drainage, catheter management, and outcome of treatment. RESULTS Twenty-one patients underwent percutaneous drainage of 28 fluid collections from which vancomycin-resistant enterococci were isolated, including 16 intraabdominal abscesses, seven biliary or urinary obstructions, and five empyemas. The drainage of 27 (96%) of 28 collections were technically successful. In seven patients, drainage provided the first isolation of vancomycin-resistant enterococci from the patient. Five patients also had blood cultures with positive findings for vancomycin-resistant enterococci, and 14 collections were coinfected with other bacteria or with fungi. Twenty collections (71%) or obstructions were successfully treated with percutaneous drainage. Drainage was unsuccessful in treating eight collections in seven patients. CONCLUSION Despite high-level antibiotic resistance, fluid collections infected with vancomycin-resistant enterococci can be successfully drained percutaneously, resulting in a favorable likelihood of recovery for patients.
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Affiliation(s)
- O A Catalano
- Department of Radiology, Massachusetts General Hospital, Boston 02114, USA
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43
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Surawicz CM, McFarland LV. Pseudomembranous Colitis Caused by C. difficile. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2000; 3:203-210. [PMID: 11097737 DOI: 10.1007/s11938-000-0023-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Pseudomembranous colitis (PMC) is a considerable clinical concern for several reasons, including disease severity, increasing frequency, complications, and development of antibiotic-resistant organisms. C. difficile infection should be considered in anyone who develops diarrhea during or after antibiotic therapy; PMC is the most serious manifestation of C. difficile disease. PMC is effectively treated with either metronidazole or vancomycin. Metronidazole should be first-line therapy, reserving vancomycin for those who are very ill or who do not respond to metronidazole or cannot take it (ie, first trimester pregnancy, side effects). Recurrent C. difficile disease (which occurs in approximately 20% of C. difficile cases) is best treated with an antibiotic in combination with a biotherapeutic agent. Prevention of epidemics of C. difficile requires careful hand washing and cleaning of environmental surfaces. Antibiotic restriction may be necessary in some cases.
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Affiliation(s)
- CM Surawicz
- Division of Gastroenterology, Box 359773, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA
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44
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Abstract
Concern frequently is voiced about individuals not complying with guidelines intended to prevent spread of antibiotic-resistant pathogens from patient to patient, but institutional decisions to ignore Centers for Disease Control and Prevention guidelines recommending detection and isolation of colonized patients also have contributed greatly to the increasing rate of infections due to these pathogens. This is so because colonized patients are the main reservoir for spread, and barrier precautions prevent spread much more effectively than Standard Precautions. Providing effective leadership and changing this culture of noncompliance must begin with the infection control team believing that spread is both important and preventable.
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Affiliation(s)
- B M Farr
- University of Virginia Health System, Charlottesville, USA
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45
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Winston DJ, Emmanouilides C, Kroeber A, Hindler J, Bruckner DA, Territo MC, Busuttil RW. Quinupristin/Dalfopristin therapy for infections due to vancomycin-resistant Enterococcus faecium. Clin Infect Dis 2000; 30:790-7. [PMID: 10817685 DOI: 10.1086/313766] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/1999] [Revised: 12/06/1999] [Indexed: 11/03/2022] Open
Abstract
The efficacy and safety of quinupristin/dalfopristin for treatment of infections due to vancomycin-resistant Enterococcus faecium were evaluated in 24 hospitalized patients with documented infections (19 bacteremias, 5 localized infections) caused by vancomycin-resistant E. faecium that was susceptible to quinupristin/dalfopristin in vitro. Patients received iv quinupristin/dalfopristin at a dosage of either 7.5 mg/kg every 8 h or 5 mg/kg every 8 h. A favorable clinical response (cure or improvement) occurred in 19 (83%) of 23 evaluable patients; bacteriologic eradication occurred in 17 (74%) of 23 evaluable patients. A favorable clinical response was observed in 12 (80%) of 15 patients who were treated with 7.5 mg/kg of quinupristin/dalfopristin every 8 h and in 7 (88%) of 8 patients treated with 5 mg/kg of quinupristin/dalfopristin every 8 h. Two of four treatment failures were associated with a decrease in the in vitro susceptibility of vancomycin-resistant E. faecium to quinupristin/dalfopristin. Superinfections developed in 6 patients (26%), but only one was caused by Enterococcus faecalis that was resistant to quinupristin/dalfopristin. Myalgias and arthralgias were the only adverse events related to quinupristin/dalfopristin. These conditions occurred in 8 (33%) of 24 patients and were dose-related (8 cases in 16 patients treated with 7.5 mg/kg of quinupristin/dalfopristin every 8 h, no cases in 8 patients treated with 5 mg/kg every 8 h). Mortality associated with vancomycin-resistant E. faecium infection was 17% (4 of 23 patients), whereas mortality from other causes was 52% (12 of 23 patients). These results suggest that quinupristin/dalfopristin is effective as treatment for vancomycin-resistant E. faecium infections in critically ill patients with serious underlying conditions. Except for myalgias and arthralgias at higher dosages, the drug is well-tolerated.
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Affiliation(s)
- D J Winston
- Department of Medicine, Division of Hematology-Oncology, UCLA Medical Center, Los Angeles, CA 90095, USA
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46
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Abstract
Vancomycin resistant enterococci (VRE) are increasingly important nosocomial pathogens. This paper describes our experience of the epidemiology and clinical impact of VRE in the two years since the occurrence of our first case of VRE infection. Following introduction of surveillance, gastrointestinal colonization with VRE was detected in 38.3% of Haematology/Oncology and 11.1% of Hepatology/Gastroenterology patients, but in only 2.3% of children in the Paediatric Intensive Care and 1.5% of children in the Renal Unit. Only five patients with gastrointestinal colonization subsequently developed clinical infection with VRE, giving an annual incidence of 7.5%. A further six children were colonized at extra-intestinal sites. Twelve children had clinical infections with VRE, of whom three (25%) died. Contamination of bedspaces was found in association with 2/3 (66.7%) children with extraintestinal colonization and 5/7 (71.4%) children with clinical infections, compared with 6/28 (21.4%) cases of gastrointestinal colonization. In the latter group, bedspace contamination was usually associated with widespread contamination of the ward with VRE and may have been the cause rather than the result of patients acquiring VRE. Originally we employed control measures based closely on the North American HICPAC guidelines, but our control strategy has since evolved in response to epidemiological and clinical observations.
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Affiliation(s)
- J W Gray
- Department of Microbiology, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH.
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47
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Klaassen RJ, Goodman TR, Pham B, Doyle JJ. "Low-risk" prediction rule for pediatric oncology patients presenting with fever and neutropenia. J Clin Oncol 2000; 18:1012-9. [PMID: 10694551 DOI: 10.1200/jco.2000.18.5.1012] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To prospectively derive and validate a clinical prediction rule to allow a more tailored approach to the management of pediatric oncology outpatients presenting with fever and neutropenia. PATIENTS AND METHODS The clinical prediction rule was derived over a 1-year period and then validated over the following 8 months in a new set of fever and neutropenia episodes. Patients were excluded if they presented with comorbidity or an abnormal chest x-ray (CXR). RESULTS Significant bacterial infection (SBI; defined as any blood or urine culture positive for bacteria, interstitial or lobar consolidation on CXR, or unexpected death from infection) was documented in 43 of the 227 episodes. Multivariate analysis found four significant factors: bone marrow disease, general appearance unwell on initial examination, monocyte count less than 0.1 x 10(9)/L, and peak oral or oral equivalent temperature greater than 39 degrees C. Only the monocyte count contributed to determining a low-risk group, excluding SBI with 84% sensitivity (95% confidence interval [CI], 61% to 100%), 42% specificity (95% CI, 38% to 46%), and a negative predictive value of 92% (95% CI, 76% to 100%). If the monocyte count was >/= 0.1 x 10(9)/L at the time of presentation (low risk), the incidences of SBI and bacteremia were 8% and 5%, respectively, versus 25% and 17% in the high-risk group. When validated in a new population of 136 episodes of fever and neutropenia, the incidences of SBI and bacteremia in the low-risk group were 12% and 5%, respectively, and 25% and 19% in the high-risk group. CONCLUSION Pediatric oncology outpatients with fever and neutropenia who present with an initial monocyte count of >/= 0.1 x 10(9)/L and do not have comorbidity or an abnormal CXR at the time of presentation are at lower risk for SBI and can be considered for less aggressive initial therapy.
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Affiliation(s)
- R J Klaassen
- Department of Pediatrics, Children's Hospital of Eastern Ontario and Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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48
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Bhavnani SM, Drake JA, Forrest A, Deinhart JA, Jones RN, Biedenbach DJ, Ballow CH. A nationwide, multicenter, case-control study comparing risk factors, treatment, and outcome for vancomycin-resistant and -susceptible enterococcal bacteremia. Diagn Microbiol Infect Dis 2000; 36:145-58. [PMID: 10729656 DOI: 10.1016/s0732-8893(99)00136-4] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
National Nosocomial Resistance Surveillance Group participants from 22 hospitals across the United States reviewed medical records for hospitalized patients with vancomycin-resistant enterococcal (VRE) or vancomycin-susceptible enterococcal (VSE) bacteremia to identify risk factors associated with the acquisition of VRE bacteremia, describe genetic traits of VRE strains, and identify factors predictive of clinical outcome. VRE cases were matched to VSE controls within each institution. Multiple logistic regression (LR) and classification and regression tree (CART) analysis were used to probe for factors associated with VRE bacteremia and clinical outcome. A total of 150 matched-pairs of VRE cases and VSE controls were collected from 1995 to 1997. Using LR, the following were found to be highly associated with VRE bacteremia: history of AIDS, positive HIV status, or drug abuse (OR 9.58); prior exposure with parenteral vancomycin (OR 8.37); and liver transplant history (OR 6. 75). CART analysis revealed that isolation of Enterococcus faecium, prior vancomycin exposure, and serum creatinine values > or = 1.1 mg/dl were predictors of VRE bacteremia. Greater proportions of clinical failure (60% versus 40%, P < 0.001) and all-cause mortality (52% versus 27%, P < 0.001) were seen in patients with VRE versus VSE bacteremia. Results from both LR and CART indicated that patients with persisting enterococcal bacteremia, intubation at baseline, higher APACHE II scores, and VRE bacteremia were at greater risk for poor outcome.
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Affiliation(s)
- S M Bhavnani
- The Clinical Pharmacokinetics Laboratory, Millard Fillmore Hospital/Kaleida Health, Buffalo, New York, USA.
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49
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Garbutt JM, Littenberg B, Evanoff BA, Sahm D, Mundy LM. Enteric carriage of vancomycin-resistant Enterococcus faecium in patients tested for Clostridium difficile. Infect Control Hosp Epidemiol 1999; 20:664-70. [PMID: 10530643 DOI: 10.1086/501562] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify independent risk factors for enteric carriage of vancomycin-resistant Enterococcus faecium (VREF) in hospitalized patients tested for Clostridium difficile toxin. DESIGN Retrospective case-cohort study. SETTING Tertiary-care teaching hospital. PATIENTS Convenience sample of 215 adult inpatients who had stool tested for C difficile between January 29 and February 25, 1996. RESULTS 41 (19%) of 215 patients had enteric carriage of VREE Five independent risk factors for enteric VREF were identified: history of prior C difficile (odds ratio [OR], 15.21; 95% confidence interval [CI95], 3.30-70.10; P < .001), parenteral treatment with vancomycin for > or = 5 days (OR, 4.06; CI95, 1.54-10.73; P = .005), treatment with antimicrobials effective against gram-negative organisms (OR, 3.44; CI95, 1.20-9.87; P = .021), admission from another institution (OR, 2.95; CI95, 1.21-7.18; P =.017), and age > 60 years (OR 2.57; CI95, 1.13-5.82; P = .024). These risk factors for enteric VREF were independent of the patient's current C difficile status. CONCLUSIONS Antimicrobial exposures are the most important modifiable independent risk factors for enteric carriage of VREF in hospitalized patients tested for C difficile.
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Affiliation(s)
- J M Garbutt
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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50
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Taylor ME, Oppenheim BA, Chadwick PR, Weston D, Palepou MF, Woodford N, Bellis M. Detection of glycopeptide-resistant enterococci in routine diagnostic faeces specimens. J Hosp Infect 1999; 43:25-32. [PMID: 10462636 DOI: 10.1053/jhin.1999.0630] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Faeces received in a diagnostic laboratory were screened for glycopeptide-resistant enterococci (GRE) on modified Lewisham medium, with and without enrichment in Enterococcosel broth. Colonization by GRE was detected in 102/838 patients (12.2%). In 74 (73%) of colonized patients GRE were detected by both methods and in 28 (27%) they were detected only after enrichment. The carriage rate in hospitalized patients was 32% (93/289) compared with 2.3% (11/425) in the community (GP patients and food-handlers). Carriage of GRE increased with age. Clostridium difficile isolation was associated with GRE colonization, odds ratio 6.76 (P<0.001). Fifty-nine percent (60/102) of the GRE had the VanA phenotype and 41% (42/102) had the VanB phenotype. In the community VanA predominated (91%), whereas 64% (57/89) of the isolates from hospitalised patients were of the VanB phenotype.
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Affiliation(s)
- M E Taylor
- Manchester PHL, Withington Hospital, West Didsbury, Manchester, M20 2LR
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