Reporting of vancomycin-resistant enterococci in Connecticut: implementation and validation of a state-based surveillance system

OBJECTIVE

To assess state-based surveillance for isolation from a sterile site of vancomycin-resistant enterococci (VRE) in Connecticut.

DESIGN

Clinical laboratory reporting (passive surveillance) of VRE isolates to the Connecticut Department of Public Health (CDPH) was followed by state-initiated validation, laboratory proficiency testing, and review of hospital demographic characteristics.

SETTINGS

All 45 clinical laboratories and all 37 (36 for 1995 and 1996) acute-care hospitals in Connecticut were included in the study.

MAIN OUTCOME MEASURES

The outcome measures included determination of the statewide incidence of VRE and the accuracy of passive reporting, determination of clinical laboratory proficiency in detecting VRE, and analysis of hospital characteristics that might be associated with an increased incidence of VRE.

RESULTS

During 1994 through 1996, 29 (78%) of 37 hospital-affiliated clinical laboratories and 1 (11%) of 9 commercial or other laboratories in Connecticut reported to the CDPH the isolation of VRE from sterile sites; 158 isolates were reported for these 3 years. Based on verification, we discovered that these laboratories actually detected 58 VRE isolates in 1994, 104 in 1995, and 104 in 1996 (total, 266). The age-standardized incidence rate of VRE was 14.1 cases per million population in 1994 and 26.8 cases per million population for both 1995 and 1996. Laboratory proficiency testing revealed that high-level vancomycin resistance was identified accurately and that low- and moderate-level resistance was not detected. The incidence of VRE isolates was three times greater in hospitals with over 300 beds compared with categories of hospitals with fewer beds. Increases in the number of VRE isolates were at least twice as likely in hospitals located in areas with a higher population density, or with a residency program or trauma center in the hospital.

CONCLUSIONS

Passive reporting of VRE isolates from sterile sites markedly underestimated the actual number of iso lates, as determined in a statewide reporting system. Statewide passive surveillance systems for routine or emerging pathogens must be validated and laboratory proficiency ensured if results are to be accurate and substantial underreporting is to be corrected.

Energy intake and glycemia in lactating women with type 1 diabetes

OBJECTIVE

To describe glycemia and insulin administration in lactating women with type 1 diabetes and compare their energy intake, lactation onset, and postpartum weight to lactating women without diabetes.

DESIGN

A prospective observational study conducted at 2, 3, 6, 14, 42, and 84 days postpartum. Insulin dosage and glucose levels after fasting and at 80 and 110 minutes after eating (by measuring capillary blood glucose concentrations and glycated hemoglobin [HbA1c] values) are described for women with type 1 diabetes. Dietary intake, weight, and lactation onset for women with type 1 diabetes are compared with those without the disease.

SUBJECTS/SETTING

Fourteen lactating women with type 1 diabetes and 25 women without diabetes (control subjects) were recruited from private obstetrician offices and high-risk prenatal clinics at 3 major medical centers.

STATISTICAL ANALYSES

A repeated-measures 2-factor analysis of variance was used to determine group, time, and interaction effects between women with type 1 diabetes and the control group at 2, 3, 7, 14, 42, and 84 days postpartum.

RESULTS

Seven women with type 1 diabetes breast-fed through 84 days postpartum, although they perceived later onset of milk and had fasting and postprandial hyperglycemia. Their HbA1c levels increased by 20%, confirming relative hyperglycemia. After adjustment for prepregnancy weight, women with type 1 diabetes consumed 7 kcal fewer per kilogram per day than control subjects. Average insulin dose was returned to prepregnancy levels of 45.3 +/- 3.6 U/d (least square means +/- standard error of the mean) by 1 week.

APPLICATION

Achieving desired metabolic control during the establishment of lactation is difficult. A better understanding of energy and insulin needs and their relationship to lactation in women with type 1 diabetes is needed.

Vitamin E in plasma and milk of lactating women with insulin-dependent diabetes mellitus

We measured levels of plasma and milk alpha-tocopherol in women with insulin-dependent diabetes mellitus (IDDM), women without IDDM, and healthy reference women. Milk collections were made at 7, 14, 42, and 84 days postpartum; blood was collected at 3, 14, and 42 days. Postprandial glucose at 80 min was used to describe metabolic control of women with IDDM postpartum. There was no difference between the groups for plasma alpha-tocopherol, which was within normal reported levels. Tocopherol (micrograms/g lipid) decreased by approximately 50% in all groups between 7 and 14 days. The trend for milk tocopherol was similar when expressed as micrograms/dl. Metabolic control did not have a significant effect on mean milk or plasma alpha-tocopherol. We have shown that this group of women with IDDM produced a milk with vitamin E content similar to control and reference women. We conclude that the infant of the breast-feeding woman with IDDM who is in good metabolic control during pregnancy and who receives good prenatal counseling most likely receives adequate vitamin E from the mother's milk.