Vancomycin-resistant Enterococcus in liver transplant patients.

BACKGROUND: Vancomycin-resistant Enterococcus (VRE) infection is emerging in the transplant population, and there is no effective antibiotic therapy available. The aims of this retrospective review were to (1) investigate the outcome of and (2) identify common characteristics associated with VRE infection and colonization in orthotopic liver transplant (OLTx) candidates. METHODS: From October 1994 through September 1998, 126 isolates of VRE were identified in 42 of 234 OLTx recipients and 5 OLTx candidates who did not proceed to transplantation. Data were collected by patient chart review or from a computerized hospital database. RESULTS: The 1-year mortality rate with VRE infection was 82%, and with VRE colonization, 7%. This mortality rate contrasts with a 14% 1-year mortality for non-VRE transplant patients (P <0.01, infected patients and colonized patients). Characteristics of VRE colonized and infected patients included recent prior vancomycin (87%), coinfection by other microbial pathogens (74%), recent prior susceptible enterococcal infection (72%), concurrent fungal infection (62%), additional post-OLTx laparotomies (47%), and renal failure (Cr >2.5 mg/dL or need for dialysis; 43%). Biliary complications were seen in 52% of post-OLTx VRE-infected or VRE-colonized patients (versus 22% in non-VRE transplant patients, P <0.05). CONCLUSION: VRE infection is associated with a very high mortality rate after liver transplantation. The incidence of biliary complications prior to VRE isolation is very high in VRE-infected and VRE-colonized patients. The most common characteristics of VRE patients were recent prior vancomycin use, recent prior susceptible enterococcal infection, coinfection with other microbial pathogens, and concurrent fungal infection. With no proven effective antimicrobial therapy for VRE, stringent infection control measures, including strict and limited use of vancomycin, must be practiced.     

Impact of Enterococcal Bacteremia in Liver Transplant Recipients

BackgroundEnterococcus species are a common cause of bacteremia in liver transplant recipients. Vancomycin-resistant enterococci (VRE) have become an important cause of nosocomial infection. In this study, we analyzed the incidence, antibiotic resistance, and outcomes of enterococcal bacteremia in living donor liver transplant recipients and the risk factors for VRE.Patients and MethodsThis single-center, retrospective review included 536 patients who underwent liver transplant between January 2008 and December 2017.ResultsAmong 536 patients, 42 (7.8%) experienced a total of 58 enterococcal bacteremic episodes (37 Enterococcus faecium, 17 Enterococcus faecalis, 2 Enterococcus casseliflavus, 1 Enterococcus. avium, and 1 Enterococcus raffinosus). Most cases of enterococcal bacteremia (46/58, 79.3%) occurred within 6 months after transplant; among the 26 cases of VRE bacteremia, 50% occurred within 1 month after transplant. E. faecium isolates had the highest rate of vancomycin resistance (25/37, 67.5%), whereas all E. faecalis isolates were susceptible to vancomycin. According to multivariate analysis, post-transplant dialysis (odds ratio, 3.95; 95% CI, 1.51–10.34; P = .005) and length of post-transplant hospital stay (odds ratio, 1.03; 95% CI, 1.009–1.04; P = .004) were significantly associated with VRE bacteremia. One-year mortality was 31% (13/42) among recipients with enterococcal bacteremia, 5.0% (20/384) among nonbacteremic patients, and 11.1% (10/90) among patients with nonenterococcal bacteremia (P < .001).ConclusionIn this study, enterococcal bacteremia showed high incidence in liver transplant recipients, especially with vancomycin resistance, occurred in early period after transplant, and was associated with increased mortality. High rates of resistance to vancomycin warrant further efforts to manage enterococcal infection in liver transplant recipients at our center.     

Consequences of vancomycin-resistant Enterococcus in liver transplant recipients: a matched control study

BACKGROUND: Liver transplant recipients are at high risk for multi-drug resistant infections because of broad-spectrum antibiotic and immunosuppression. This study evaluates the clinical and financial impact of vancomycin resistant Enterococcus (VRE) in liver transplant recipients. METHODS: Liver transplant recipients with VRE from 1995 to 2002 were identified and matched (age, gender, UNOS status, liver disease and transplant date) to controls. Demographics, clinical factors, co-infections, antibiotic use, length of stay, abdominal surgeries, biliary complications, survival and resource utilization were compared with matched controls. RESULTS: Nineteen patients were found to have 28 VRE infections via evaluation of microbiologic culture results of all liver transplant patients in the transplant registry. Thirty-eight non-VRE patients served as matched controls. The four most common sites VRE was cultured from included blood (35%), peritoneal fluid (35%), bile (20%), and urine (12%). Median time from transplant to infection was 48 d (range of 4-348). No significant differences in demographics were observed. The VRE group had a higher incidence of prior antibiotic use than the non-VRE group (95% vs. 34%; p < 0.05). The VRE group also experienced more abdominal surgery (20/19 vs. 3/38; p = 0.029), biliary complications (9/19 vs. 9/38; p = 0.018) and a longer length of stay (42.5 vs. 21.7 d; p = .005). Survival in the VRE group was lower (52% vs. 82%; p = 0.048). Six of the 19 VRE patients were treated with linezolid for eight infection episodes, and four of six patients survived. Eight patients were treated with quinupristin/dalfopristin for nine infections, and two of eight survived. Increased cost of care was observed in the VRE group. Laboratory costs were higher in the VRE group (6500 dollars vs. 1750; p = 0.02) as well. CONCLUSION: VRE was associated with prior antibiotic use, multiple abdominal surgeries, biliary complications and resulted in decreased survival compared to non-VRE control patients. VRE patients also utilized more hospital resources. Linezolid showed a trend toward improved survival.     

A randomized trial of surgical antimicrobial prophylaxis with and without vancomycin in organ transplant patients

BACKGROUND: Gram-positive organisms, including vancomycin-resistant enterococci (VRE), have emerged as major pathogens on the organ transplant service at our institution. We hypothesized that our use of vancomycin as part of routine surgical prophylaxis increased the risk of VRE colonization and infection; conversely, there was concern that failure to use vancomycin prophylaxis would increase peri-operative morbidity due to gram-positive organisms. METHODS: Renal transplant recipients (n = 88) were randomized to receive either a) vancomycin/ceftriaxone or b) cefazolin; and pancreas transplants (n = 24) to receive either a) vancomycin/gentamicin or b) cefazolin/gentamicin. Stool samples or rectal swabs were obtained for culture for enterococci within 24 h of transplantation and weekly while hospitalized. RESULTS: Enterococci were isolated on stool culture from 38 (34%) of 102 patients at the time of transplantation; 4 (11%) of the isolates were VRE. The percentage of patients who subsequently acquired VRE was low (1-7% per wk) but remained constant during hospitalization. There was no association between new VRE detection and vancomycin use for either prophylactic or therapeutic purposes. Forty-four patients (39%) had a post-operative infection with 46% of these infections due to gram-positive organisms; rates were unaffected by prophylactic vancomycin use. Pancreas transplant patients who did not receive vancomycin prophylaxis had a significantly longer initial hospitalization (p = 0.03); however, differences were not statistically significant when total length of stay (LOS) within the first 90 d of transplantation was compared. CONCLUSIONS: Vancomycin surgical prophylaxis does not appear to have an effect on VRE colonization or infection, or on rates of infection with gram-positive bacteria. Elimination of vancomycin prophylaxis in renal transplant patients may be a reasonable part of an overall program to limit vancomycin usage, although as a single measure, its impact may be minimal. Vancomycin surgical prophylaxis may be of greater importance in pancreas transplants.     

Outpatient vancomycin use and vancomycin-resistant enterococcal colonization in maintenance dialysis patients

BACKGROUND: Although outpatient vancomycin is widely used as empiric therapy for dialysis-associated infections, its relationship with vancomycin-resistant enterococcal (VRE) colonization is not established. METHODS: During a two-year prospective cohort study, rectal swabs obtained from patients at the start and finish of the study period and during interim hospitalizations were cultured for VRE. RESULTS: Ten of 124 patients initially grew VRE. Twenty-four of the remaining patients had no follow-up cultures because of patient death (62%), transfer to another dialysis facility (17%), patient's refusal (7%), and transplantation (4%), and were thus excluded. The remaining patients (N = 90) had a median age of 54.3 years and were 92% African American and 50% male. Fifty-eight percent were treated by hemodialysis. They received 403 g of intravenous vancomycin over 157.2 patient-years of follow-up, 73% as outpatients. Sixteen of 90 patients (17.8%) became colonized with VRE, an incidence rate of one case per 9.8 patient-years of follow-up. None of the 29 patients who did not receive vancomycin developed VRE compared with 26% of those treated with vancomycin (P = 0.001). The odds ratio (95% CI) for the association of outpatient vancomycin (g per year) with VRE colonization was 1.23 (1.05, 1.44, P = 0.008). The association remained significant following adjustment in separate logistic regression analyses for relevant demographic, clinical, antimicrobial (inpatient vancomycin, oral or intravenous cephalosprins, aminoglycosides, quinalones, or antianaerobics), and hospitalization exposures. The unadjusted relative risk of death in patients growing VRE was significantly higher than in those not colonized with VRE (P = 0.005). CONCLUSIONS: VRE colonization is a relatively common and under recognized problem among chronic dialysis patients. It is strongly and independently associated with the outpatient use of vancomycin, which should be avoided whenever possible.     

Outcomes of Colonization with MRSA and VRE Among Liver Transplant Candidates and Recipients

Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) infections cause significant morbidity and mortality among liver transplant candidates and recipients. To assess rates of MRSA and VRE colonization, we obtained active surveillance cultures from 706 liver transplant candidates and recipients within 24 h of admission to an 11-bed liver transplant ICU from October 2000 to December 2005. Patients were followed prospectively to determine the cumulative risk of MRSA or VRE infection or death by colonization status. Outcomes were assessed by Kaplan–Meier survival analysis and Cox regression and multivariate logistic regression adjusting for covariates. The prevalence of newly detected MRSA nasal and VRE rectal colonization was 6.7% and 14.6%, respectively. Liver transplant candidates and recipients with MRSA colonization had an increased risk of MRSA infection (adjusted OR = 15.64, 95% CI 6.63–36.89) but not of death (adjusted OR = 1.00, 95% CI 0.43–2.30), whereas those with VRE colonization had an increased risk both of VRE infection (adjusted OR = 3.61, 95% CI 2.01–6.47) and of death (adjusted OR = 2.12, 95% CI 1.27–3.54) compared with noncolonized patients. Prevention and control strategies, including use of active surveillance cultures, should be implemented to reduce the rates of both MRSA and VRE colonization in this high-risk patient population.     

Clinical characteristics and outcomes of surgical patients with vancomycin-resistant enterococcal infections

The purpose of this study is to determine risk factors associated with mortality in surgical patients with vancomycin-resistant enterococcus (VRE) infections. The hospitalizations of surgical patients with VRE infections from January 1998 to December 2001 were reviewed. Statistical analysis was performed using the Student's t test, chi square, and Fisher's exact test. Thirty-one surgical patients (male:female, 14:17) with a mean age of 51.9 years (range, 21-83 years) developed VRE infection. Infections included bacteremia (12), urinary tract (11), surgical site (seven), and soft tissue (five) infections and intra-abdominal abscess (one). Nine (29.0 per cent) patients received recent outpatient antibiotics and 20 (64.5 per cent) were on steroids. Fifteen (48.4 per cent) patients were treated with intravenous vancomycin before infection. Twelve (38.1 per cent) patients died with a trend toward advanced age (60.7 vs 46.5 years; P = 0.06). The incidence of VRE infection in kidney transplant patients was 1.8 per cent. Six transplant patients (five kidney and one kidney/ pancreas) developed VRE infections with four deaths. Hypertension (P = 0.04), coronary artery disease (P = 0.02), and the need for intra-arterial pressure monitoring (P = 0.04) were associated with mortality. Isolate location, gender, diabetes, renal dysfunction, respiratory disease, liver disease, and serum albumin were not associated with mortality. Kidney transplant patients have a high incidence of VRE infection. Surgical patients with VRE infections have a high mortality rate. Hypertension and coronary artery disease are risk factors for mortality.     

Association of fungal infection and increased mortality in liver transplant recipients

BACKGROUND: Invasive fungal infection is associated with increased morbidity and mortality following orthotopic liver transplantation (OLTx). Understanding the risk factors associated with fungal infection may facilitate identification of high-risk patients and guide appropriate initiation of antifungal therapy. OBJECTIVES: The aim of this study was to determine the incidence of fungal infections, identify the most common fungal pathogens, and determine the risk factors associated with fungal infections and mortality in OLTx recipients. METHODS: Medical records from 96 consecutive OLTx in 90 American veterans (88 males, 2 females; mean age 48 years, range 32 to 67) performed from January 1994 to December 1997 were retrospectively reviewed for fungal infection in the first 120 days after transplantation. Infection was defined by positive cultures from either blood, urine (<105 CFU/mL), cerebrospinal or peritoneal fluid, and/or deep tissue specimens. Superficial fungal infection and asymptomatic colonization were excluded from study. All patients received cyclosporine, azathioprine, and prednisone as maintenance immunosuppressive therapy. Fungal prophylaxis consisted of oral clotrimazole (10 mg) troches, five times per day during the study period. RESULTS: Thirty-five patients (38%) had documented infection with one or more fungal pathogens, including Candida albicans (25 of 35; 71%), C torulopsis (7 of 35; 20%), C tropicalis (2 of 35; 6%), non-C albicans (2 of 35; 6%), Aspergillus fumigatus (4 of 35; 11%), and Cryptococcus neoformans (1 of 35; 3%). The crude survival for cases with or without fungal infection was 68% and 87%, respectively (P <0.0001). The median intensive care unit stay and overall duration of hospitalization were significantly longer for patients with fungal infection (P <0.01). The mean time interval from transplantation to the development of fungal infection was 15 days (range 4 to 77) with a mean survival time from fungal infection to death of 21 days (range 3 to 64). Fungal infections occurred significantly more often in patients with renal insufficiency (serum creatinine >2.5 mg/dL), biliary/vascular complications, and retransplantation. CONCLUSIONS: Fungal infections were associated with increased morbidity and mortality following OLTx, with Candida albicans being the most common pathogen. Treatment strategies involving antifungal prophylaxis for high-risk patients and earlier initiation of antifungal therapy in cases of presumed infection are warranted.     

The clinical and molecular epidemiology of pre‐transplant vancomycin‐resistant enterococci colonization among liver transplant recipients

Vancomycin‐resistant enterococci (VRE) infections cause significant morbidity in liver transplant recipients. The epidemiology and impact of pre‐transplant colonization with VRE among patients who undergo liver transplantation are poorly understood. We conducted an observational cohort study to identify risk factors and outcomes associated with pre‐transplant VRE colonization and described the molecular diversity among VRE strains colonizing patients who undergo liver transplantation. Perirectal VRE surveillance cultures were performed prior to transplantation. Repetitive sequence‐based polymerase chain reaction (rep‐PCR) testing was used to identify clonality among VRE isolates. Of 61 patients who underwent pre‐transplant VRE surveillance and subsequent liver transplantation, 27 (44%) were colonized with VRE. In multivariate analysis, pre‐transplant VRE colonization was associated with central venous catheterization (OR 9.4, 95% confidence interval [CI]= 1.3–70.2, p = 0.03) and rifaximin use (OR 15.4, 95% CI 1.5–159.7, p = 0.02). Pre‐transplant VRE colonization was associated with more hospital days post‐transplant (26.6 vs. 16.1 d, p = 0.04). Of VRE‐colonized patients analyzed with rep‐PCR, 68% were colonized with the same strain as another patient in the cohort. Active surveillance identifies VRE‐colonized patients who may benefit from targeted antimicrobial prophylaxis and enhanced infection prevention measures to prevent VRE spread. The relationship between rifaximin receipt and VRE colonization warrants further study. The identification of similar VRE isolates may suggest linked transmission during pre‐transplant hospitalizations, which should be further investigated in prospective studies.     

Clinical outcomes of intestinal transplant recipients colonized with multidrug‐resistant organisms: a retrospective study

Rates of multidrug‐resistant organisms (MDRO) colonization among intestinal transplant (ITx) recipients have not been reported. Colonization rates with vancomycin‐resistant Enterococcus (VRE), carbapenem‐resistant Gram‐negative bacteria (CR‐GNB), and methicillin‐resistant Staphylococcus aureus (MRSA) were obtained retrospectively in adults undergoing ITx (isolated or multivisceral) from 1/2009 to 12/2015. We assessed for VRE, CR‐GNB, and MRSA bacteremia during the first year post‐transplant for patients colonized with VRE, CR‐GNB, and MRSA, respectively, and for those who were not colonized. We evaluated whether the number of hospitalization days and one year post‐transplant survival were different in MDRO‐colonized patients. Forty‐five ITx recipients were identified. Twenty‐eight (62%) were colonized with MDRO [VRE in 22 (50%) patients, MRSA in seven (16%), and CR‐GNB in six (15%)]. VRE and CR‐GNB‐colonized patients were more likely to develop VRE and CR‐GNB bacteremia, respectively, than noncolonized patients [8/22 (36%) vs. 1/23 (4%), and 4/6 (67%) vs. 2/39 (5%), P < 0.05 for both]. There was no difference in one‐year survival between MDRO‐colonized and noncolonized patients. However, survival was lower among MDRO‐colonized patients who developed VRE, CR‐GNB, or MRSA bacteremia (P < 0.001). MDRO colonization was common among our ITx recipients. VRE and CR‐GNB bacteremia was more common among colonized patients, and survival was lower among MDRO‐colonized patients who developed bacteremia.     

Incidence, predisposing factors, and results of surgical treatment of incisional hernia after orthotopic liver transplantation

The literature provides little data about incisional herniae (IH) developing after orthotopic liver transplantation (OLTx). We evaluated the incidence, predisposing factors, and results of surgical treatment of this pathological condition. We reviewed the records of 718 consecutive OLTx performed in 623 patients between April 1986 and May 2002. Patients whose IH developed after transplantation were included in the study. We identified 31 patients (incidence, 4.9%) whose IH developed from 2 to 140 months after the transplantation. This complication was significantly more frequent in men. Important predisposing factors included: virus-correlated cirrhosis, body mass index >25, severe ascites, incision type for OLTx (bilateral subcostal extended upper midline to xiphoid), and post-OLTx complications. In 17 patients, repair of hernia was performed using direct fascial approximation, in 20 patients, it required a prosthesis. After hernia treatment, we observed no deaths but a morbidity rate of 6.4%, a mean postoperative hospital stay of 8 days and a recurrence rate of 6.4%. IH post-OLTx need surgical treatment.     

Late mortality after orthotopic liver transplantation.

BACKGROUND: Mortality within the first year after orthotopic liver transplantation (OLTx) is usually due to infection or allograft failure. Late complications leading to death after OLTx have not been extensively evaluated. The aim of this study was to determine the incidence of late mortality and to identify the most common causes and risk factors associated with late mortality after OLTx. METHODS: A total of 479 OLTx were performed in 459 patients (320 males, 139 females; mean age 47 years, range 13 to 69) between September 1991 and April 2000. All patient deaths among liver transplant recipients who survived more than 1 year after transplantation (follow-up mean 3.4 years, median 3, range 1 to 8.6) were reviewed. RESULTS: In all, 122 allografts (24%) were lost in 109 patients during the study period (24%). Seventy-five allografts were lost in 69 patients by 1 year (15%). Forty-seven allografts were lost in 40 patients who survived at least 1 year (9.6%). Actuarial survivals at 2 years, 5 years, and 9 years were 95%, 85%, and 80%, respectively (based on 100% survival at 1 year). The causes of the late mortality were malignancy (9 patients), disease recurrence (8), late infection (6), renal failure complications (5), cardiovascular complications (4), chronic rejection (3), gastrointestinal hemorrhage (2), medication noncompliance (1), and unknown (2). CONCLUSIONS: Malignancy and disease recurrence are the major causes of late mortality among adult OLTx recipients. Pharmacologic immunosuppression is associated with many of the causes of late mortality. Advances in immunosuppression with less toxicity may improve long-term survival after OLTx.     

Immunosuppression impact on long-term cardiovascular complications after liver transplantation

BACKGROUND: With current early transplant patient and allograft survivals nearly optimized, long-term medical complications have become a significant focus for potential improvement in patient outcomes. Cardiovascular disease and associated risk factors have been shown in renal transplant patients to be related to the pharmacologic immunosuppression employed.OBJECTIVE: The objective of this study is to investigate at 3 years postliver transplant (OLTx) the incidence of hypertension (HTN), hyperlipidemia (HLIP), diabetes mellitus (DM), nephrotoxicity (NTX), and cardiovascular disease (MI, angioplasty, CHF, CVA, and seborth) as well as rejection in two cohorts of liver transplant recipients who received either tacrolimus (FK-506) or cyclosporine (CSA) and to analyze the consequences of these complications on mortality following transplantation.METHODS: Eighty-seven sequential patients (CSA: n = 50, mean age 48 years, M/F 32/18; and FK-506: n = 37, mean age 45 years, M/F 22/15) who underwent OLTx between 1994 and 1998, were >/=18 years, and had a minimum of 3 years of complete follow-up were included in the analysis. All OLTx candidates over age 50, who had a history of alcoholic cirrhosis, or had a history of cardiac conditions/events underwent complete cardiac consultation including an echocardiogram with additional cardiac investigation as indicated prior to OLTx.RESULTS: At 3 years following OLTx, the incidence of acute rejection (40% versus 19%, P < 0.05), HTN (62% versus 38%, P < 0.05), HLIP (14% versus 5%, P = 0.08), and cardiovascular disease (18% versus 0%, P < 0.001), were significantly greater for the CSA patients compared with the FK-506 patients. Eight (20%) of the CSA patients who died before 3 years had their death attributed to cardiovascular events versus none in the FK-506 group.CONCLUSION: Compared with CSA, FK-506 was associated with significantly less rejection and a reduced incidence of HTN and cardiovascular disease.     

Low Prevalence of Colonization with Vancomycin-Resistant Enterococcus in Patients Awaiting Liver Transplantation

The orthotopic liver transplant (OLT) population has been particularly affected by the increase in vancomycin-resistant enterococcus (VRE) infections in recent years. Pre-transplant colonization prevalence, the role of spontaneous bacterial peritonitis (SBP) antimicrobial prophylaxis as a risk factor, and the risk of post-OLT infection in colonized patients are all unknowns. We prospectively evaluated OLT candidates at our center with the aim of answering these questions. Vancomycin-resistant enterococcus colonization status was determined by rectal culture. Data collected included illness severity, antibiotic use (including SBP prophylaxis), waiting time, previous hospitalizations, and invasive procedures. Eighty-eight patients (31 female, 57 male, median age 52 years) were enrolled. The most common diagnoses were hepatitis C (49%), primary sclerosing cholangitis (13.6%), and alcoholic liver disease. Median MELD score was 11.5 (range 7-24), and median waiting time was 551 days (range 1-2224). Vancomycin-resistant enterococcus risk factors were common in our patients: recent hospitalization in 16%, recent antibiotic exposure in 39%, and renal insufficiency in 7%. Seventeen percent were receiving SBP prophylaxis. Despite the presence of established risk factors, VRE colonization prevalence was 3.4%. Preliminary limited data showed poor correlation between screening rectal cultures and operative/peri-operative cultures. Vancomycin-resistant enterococcus colonization prevalence in an OLT candidate population with mid-level MELD scores was low, and SBP prophylaxis was not a significant risk factor.     

Incidence and risk factors of vancomycin-resistant enterococcus colonization in burn unit patients

This study was aimed to identify the incidence of vancomycin-resistant enterococcus (VRE) colonization in burn patients, to collate risk factors for colonization and to determine the VRE resistance profile to different antimicrobial agents. This prospective study was carried out on the burn unit, during the period from September 2008 to January 2010, in 128 patients who were hospitalized at least 3 weeks or more. Periodic swabs were taken from burn wound, rectal, axillary, umblicaly and throat regions of the patients on admission and 7th, 14th, 21st days of hospitalization. Demographics and known risk factors were retrieved and assessed by statistical methods. Only 20 patients (15.6%) were colonized with enterococci on admission and these strains isolated from rectal, umblical and throat samples were sensitive to vancomycin. Initial VRE isolation was made in the first samples from the rectum of two patients on the 7th day. The rates of rectal, umblical, throat and axillary colonization increased to 21.9%, 3.1%, 3.1% and 3.1% at 28th day, respectively. VRE strains were the first isolated from burn wounds of only one patient (0.8%) on the 14th day and the colonization rate increased to 7.0% at the 28th day. Our study indicated that rectal colonization was seen more than other sites of colonization and was strictly correlate to colonizing enterococci between burn wound and other body regions. Multivariate analyses showed that glycopeptide use, burn depth and total burn surface area were independent risk factors for acquisition of VRE. All VSE strains were susceptible to teicoplanin, tigecycline and linezolid. VSE strains were more resistant to gentamicin and streptomycin, and VRE strains were more resistant to penicillin and ampicillin. The present study showed tigecycline and linezolid to be most active agents against VRE strains. The determined VRE colonization and risk factors of VRE acquisition are expected to be useful in establishing guidelines for preventing VRE infection in burn unit.     

Prediction of poorer prognosis by infection with antibiotic-resistant gram-positive cocci than by infection with antibiotic-sensitive strains.

HYPOTHESES: Surgical patients with antibiotic-resistant gram-positive coccal (GPC) infections have a poorer prognosis than those with antibiotic-sensitive GPC infections, and colonization with resistant GPC predisposes to the development of resistant GPC infections. DESIGN: All infections among surgical patients from December 1, 1996, to December 1, 1998, were followed up prospectively. Patients with antibiotic-sensitive and antibiotic-resistant GPC infections were compared. Cohorts were also subdivided on the basis of GPC species, colonization status, and immunosuppression. SETTING: The surgical wards and intensive care units of a tertiary care, university hospital. MAIN OUTCOME MEASURES: In-hospital mortality, inhospital mortality during antibiotic therapy, length of stay, and length of stay from the time of initiation of antibiotics to discharge. RESULTS: Antibiotic-resistant GPC infection compared ki4th antibiotic-sensitive GPC infection was associated with a higher mortality and previous colonization rate (25.8% and 31.0% vs 17.6% and 8.8%, respectively; P = .04 and P<.001, respectively) and a markedly longer length of stay (55.0 +/- 3.3 vs 31.0 +/- 2.0 days; P<.001). Length of stay and treatment to discharge times were longer after resistant Staphylococcus aureus infections than after resistant Staphylococcus epidermidis infections. The mortality and length of stay of patients with gentamicin-resistant or vancomycin-resistant enterococcal infections were equivalently higher than those with antibiotic-sensitive enterococcal infections. Transplant recipients with resistant enterococcal infection had the highest mortality (41.9%). CONCLUSIONS: Surgical patients who develop antibiotic-resistant GPC infections have a significantly higher mortality rate, longer length of stay, and longer treatment to discharge time than patients with antibiotic-sensitive GPC infections. Colonization with resistant GPC predisposes to resistant GPC infection. Gentamicin-resistant enterococcus appears to be as virulent as vancomycin-resistant enterococcus.     

Epidemiology and clinical consequences of vancomycin-resistant enterococci in liver transplant patients

BACKGROUND: Vancomycin-resistant enterococci (VRE) are increasingly important as pathogens in liver transplant patients. To guide control efforts, we conducted an epidemiological study of the frequency, source, and modes of transmission of VRE at our center. METHODS: During September 1998 through August 1999, we obtained weekly surveillance cultures from consenting liver transplant patients and surfaces in their rooms. Pooled handwash specimens from personnel also were obtained. Specimens were processed on selective media to detect VRE, and isolates were typed by pulsed field gel electrophoresis. Information was collected from patient records concerning in-hospital treatment and clinical course. RESULTS: Serial cultures were obtained during 33 admissions of 29 patients. VRE were detected in initial specimens from 6 admissions, and nosocomial acquisition of VRE occurred in 12 (44%) of the remaining 27 admissions. Seven different strain types of VRE were detected. The initial site of acquisition was stool in all cases; bile became culture-positive in only two patients. Overall, 16 (55%) of the 29 patients became colonized, usually after transplantation. VRE were detected in environmental cultures during 10 admissions and in 2 of 21 pooled handwashes. No statistically significant differences in clinical status or treatment were found when colonized patients were compared to noncolonized controls. The only VRE infection resulted from a choledochojejunostomy anastomotic leak. CONCLUSION: Alimentary tract colonization by VRE occurred commonly in liver transplant patients, probably by cross-transmission. The clinical consequences were modest in the patients studied, but colonized transplant patients provide a substantial reservoir for continued VRE transmission in hospitals.     

Why is an infection control program needed in the hemodialysis setting?

Infections account for the second leading cause of mortality among patients with end-stage renal disease. Many of these infections are due to sepsis, primarily arising from the vascular access site. Septicemia alone accounts for almost 11% of mortality in hemodialysis patients. Hemodialysis patients are also a sentinel population for the emergence of antimicrobial resistance, especially with regards to gram-positive cocci (vancomycin-resistant enterococci (VRE), methicillin resistant S. aureus (MRSA), Staphylococcus aureus with reduced susceptibility to vancomycin (VISA), and vancomycin resistant S. aureus [VRSA]). It is extremely important to follow infection control recommendations designed to prevent these types of adverse events from occurring in the hemodialysis population. The campaign to prevent antimicrobial resistance in dialysis includes four strategies: Prevent infection; diagnose and treat infection; use antimicrobials wisely; and prevent transmission. In addition, efforts to prevent infection should include avoiding use of hemodialysis catheters, whenever possible, and meticulous care of hemodialysis catheters and other vascular access sites. These efforts would improve patient outcomes and quality-of-life issues by reducing hospitalizations and mortality due to infection and vascular access complications.     

Reduction in rates of methicillin-resistant Staphylococcus aureus infection after introduction of quarterly linezolid-vancomycin cycling in a surgical intensive care unit

ABSTRACT Background: The burden of infection with antibiotic-resistant gram-positive cocci, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), continues to increase, leading to substantial morbidity and high mortality rates, particularly in intensive care units (ICUs). Creative interventions may be required to reverse or stabilize this trend. Methods: The efficacy of empiric cycling of antibiotics active against gram-positive organisms was tested in a before-after intervention in a single surgical ICU. Four years of baseline data were compared with two years of data compiled after the implementation of a strategy where the empiric antibiotic of choice for the treatment of gram-positive infections (linezolid or vancomycin) was changed every three months. Whatever the initial choice of drug, if possible, the antibiotic was de-escalated after final culture results were obtained. The rates of all gram-positive infections were analyzed, with a particular focus on MRSA and VRE. Concurrently, similar outcomes were followed for patients treated on the same services but outside the ICU, where cycling was not practiced. Results: During the four years prior to cycling, 543 infections with gram-positive organisms were acquired in the ICU (45.3/1,000 patient-days), including 105 caused by MRSA (8.8/1,000 patient days) and 21 by VRE (1.8/1,000 patient-days). In the two years after implementation of cycling, 169 gram-positive infections were documented (28.1/1,000 patient-days; p < 0.0001 vs. non-cycling period), including 11 caused by MRSA (1.8/1,000 patient-days; p < 0.0001 vs. non-cycling period). The percentage of S. aureus infections caused by MRSA declined from 67% to 36%. The rate of infection with VRE was unchanged. Outside the ICU, the yearly numbers of infections with both MRSA and VRE increased over time. Conclusion: Quarterly cycling of linezolid and vancomycin in the ICU is a promising method to reduce infections with MRSA.     

Vancomycin-resistant enterococcus in end-stage renal disease

The percentage of nosocomial vancomycin-resistant enterococci (VRE) has been increasing rapidly in the United States. This has recently resulted in recommendations to reserve vancomycin use for cases with proven resistance to other antimicrobials. We prospectively investigated the incidence of VRE in our dialysis population and compared it with a control group of 40 clinic patients with chronic renal insufficiency (CRI) who had a serum creatinine level greater than 1.5 mg/dL, but were not undergoing dialysis. The incidence of VRE on our campus is almost 10%, which is similar to US data. We studied 50 chronic hemodialysis (HD) patients and 50 peritoneal dialysis (PD) patients. Each patient had a rectal swab test performed and cultured for the presence of enterococci. Antimicrobial exposures over the 6 months before the initial swab test were reviewed in each patient. At least one repeated swab test was performed in 30 CRI, 45 HD, and 37 PD patients. From the initial swab culture, vancomycin-sensitive enterococci (VSE) were isolated in 65% of CRI, 54% of HD, and 70% of PD patients. No CRI or HD patients had VRE isolated and 2% (1 of 50) of PD patients had VRE isolated. The remaining patients had no enterococci isolated. Review of antimicrobial exposures in the 6 months before the initial swab test showed 0% of CRI, 32% of HD, and 36% of PD patients received vancomycin. Other antimicrobials were administered to 40% of CRI, 46% of HD, and 78% of PD patients in the same time period. In the month immediately preceding the initial swab test, 0% of CRI, 12% of HD, and 22% of PD patients received vancomycin and 18% of CRI, 20% of HD, and 36% of PD patients received other antimicrobials. Results from repeated cultures showed that 57% of CRI, 40% of HD, and 38% of PD patients changed their culture status related to VSE, VRE, or no enterococci present. Cultures of 342 swabs from 140 patients yielded three VRE isolates in two patients. We conclude that despite the frequent use of vancomycin and other antimicrobials, the incidence of VRE in our renal population is less than the reported incidence. Given this lack of VRE isolates, we recommend the continued judicious use of vancomycin in treating renal patients and continued enterococcal sensitivity surveillance.