Vancomycin‐resistant Enterococcus in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation address vancomycin‐resistant enterococci (VRE) infections in SOT candidates and recipients. VRE are an important cause of infection and have been named by the CDC as a serious public threat. Typically, a commensal of the gastrointestinal tract, VRE may become pathogenic after abdominal organ manipulation like transplantation. This guideline reviews the microbiology, antimicrobial resistance mechanisms, epidemiology, and clinical manifestations of VRE infection in the context of solid organ transplantation. Treatment regimens including combination therapies and novel investigational agents are also reviewed. Finally, an updated appraisal of infection control measures relevant to VRE infection and colonization is presented.     

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.     

Vancomycin-resistant enterococci peritonitis development after shifting from hemodialysis to peritoneal dialysis

Although hemodialysis (HD) patients could develop vancomycin-resistant enterococci (VRE) infection, limited studies of VRE-related peritoneal dialysis (PD) peritonitis have been reported. Here, we document a patient who developed peritonitis for the first time with VRE infection after shifting from HD to PD over 4 weeks. We suggest that physicians consider VRE a possible cause of PD peritonitis in patients who have recently shifted from HD to PD, especially in cases involving previous vancomycin exposure.     

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.     

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.     

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.     

Vancomycin intermediate and resistant Staphylococcus aureus. What the nephrologist needs to know

Individuals undergoing hemodialysis may be at increased risk for emerging antimicrobial resistance from vancomycin-intermediate Staphylococcus aureus (VISA) and vancomycin-resistant S. aureus (VRSA). The laboratory detection of VISA and VRSA is challenging and requires the use of well-thought-out algorithms. Newly available antimicrobials such as quinipristin/dalfopristin, linezolid, and daptomycin, as well as older drugs such as trimethoprim-sulfamethoxazole appear to be active against recent strains of VISA and VRSA. Prevention of VISA and VRSA necessitates determining the appropriateness of vancomycin use in renal patients and giving priority to infection control precautions in both inpatient and outpatient settings. Because most VISA and all VRSA to date have arisen from endemic methicillin-resistant S. aureus (MRSA), and in the case of VRSA have acquired genes from vancomycin-resistant enterococci (VRE), the emergence of VISA and VRSA should provide renewed motivation for the containment of MRSA and VRE transmission in the hemodialysis population.     

Overview of resistant gram-positive pathogens in the surgical patient

Staphylococci and enterococci are the most common pathogens in surgical-site and bloodstream infections. The emergence of drug resistance among these gram-positive bacteria thus poses a substantial threat to patients with surgical infections. Resistance to methicillin/oxacillin is frequently observed in Staphylococcus aureus isolates and is often accompanied by multidrug resistance. Vancomycin is usually the treatment of choice for infections caused by methicillin-resistant S. aureus (MRSA), so the recent appearance of S. aureus isolated with intermediate sensitivity to vancomycin is cause for concern. Vancomycin resistance has already appeared in most species of enterococci. Infections caused by vancomycin-resistant enterococci (VRE) are associated with increased mortality compared to infections caused by vancomycin-sensitive isolates. Measures for preventing vancomycin resistance include reducing the use of vancomycin and other agents that appear to be associated with VRE, including third-generation cephalosporins and anti-anaerobic drugs. Third-generation cephalosporins have also been implicated in the increased prevalence of MRSA infections. Prudent use of existing antibiotics is an essential strategy for combating the rising tide of drug-resistant gram-positive pathogens.     

Peritonitis due to Leuconostoc species in a child receiving peritoneal dialysis

Leuconostoc species are rarely pathogenic in humans, but may cause infection in patients at risk. A 7-year-old girl with p-ANCA-positive crescentic glomerulonephritis, treated with peritoneal dialysis, developed peritonitis due to Leuconostoc species. She had a history of treatment with vancomycin and a brief course of immunosuppressive therapy. The peritonitis responded well to ampicillin therapy. To date, only 47 cases of Leuconostoc infection, including our patient, have been reported in the medical literature; 25 of the cases occurred in children. Only 1 prior case has been reported in the setting of peritoneal dialysis. The risk factors for Leuconostoc infections are not clear, but commonly associated conditions include immunocompromised status and indwelling medical devices. Leuconostoc species are easily misidentified as streptococci in culture, but they possess inherent resistance to vancomycin despite sensitivity to most other antibiotics. In patients with gram-positive peritonitis, Leuconostoc should be considered as a possible etiological agent, particularly if vancomycin resistance is noted in an organism thought to be a Streptococcus species.     

Vancomycin-resistant enterococci in livertransplant recipients

BackgroundVancomycin-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.MethodsFromOctober 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.ResultsThe 1-year mortalityrate 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). 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).ConclusionVREinfection 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, coninfection 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.     

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.     

Emerging bacterial pathogens: a consensus of the scientific data and the risk for development of multiple organ dysfunction syndrome

Antibiotic resistance in the hospital setting is continuing to increase, particularly in intensive care units (ICUs) and other areas of the hospital such as oncology units, where the use of empiric broad-spectrum antibiotics is common. The problem of antibiotic resistance is also compounded in the immunocompromised patient. Multi-drug resistance is common among both Gram-positive and -negative bacteria, and becoming more prevalent among fungi (yeast). Two major antibiotic-resistant pathogens include extended-spectrum beta-lactamase producing Klebsiella pneumoniae (ESBL-KP) and vancomycin-resistant enterococci (VRE). When infections occur with ESBL-KP, a carbapenem antibiotic is usually the drug of choice. When infection occurs with VRE, specific therapy is bacteriostatic, and the clinician may have to rely on empirically selected antibiotics or combinations of antibiotics to achieve a positive outcome. Two newly-approved agents, linezolid and quinupristin/dalfopristin can be used to treat infections caused by resistant gram-positive cocci, but the latter is approved for use against VR-E. faecium. Risk factors for the development of ESBL-KP include the use of extended-spectrum cephalosporins such as ceftazidime. Risk factors for the development of VRE include inappropriate use of vancomycin, extended-spectrum cephalosporins, and antianaerobic drug therapy such as clindamycin. Several institutions have documented a reduction in one or both of these resistant pathogens following a decrease in the use of extended-spectrum cephalosporins combined with the increased use of extended-spectrum penicillins/beta-lactamase inhibitor combinations, such as piperacillin/tazobactam, for the empiric therapy of infections. For VRE, a reduction in the inappropriate use of vancomycin is also an important interventional strategy along with improved infection control practice.     

The effect of topical vancomycin applied to sternotomy incisions on postoperative serum vancomycin levels

Abstract Background and Aim: Topical vancomycin has been shown to reduce the incidence of sternal wound infections but concerns have been raised that persistent serum levels of vancomycin may contribute to the emergence of drug‐resistant infections. This study was undertaken to determine: (1) whether serum levels of vancomycin remain elevated when applied topically to the sternum and (2) whether the use of topical vancomycin can potentiate postoperative drug‐resistant infections. Methods: Serum vancomycin levels were measured on the evening of surgery and the sixth postoperative day in 36 patients in which topical vancomycin was applied to the cut edges of the sternum during their cardiac surgical procedures. Data are presented as a mean ± standard deviation and statistical significance was tested using paired t‐test analyses. Results: There was a significant decrease in serum vancomycin levels from the night of surgery to the sixth postoperative day (11.5 ± 1.9 μg/mL to 2.12 ± 0.79 μg/mL; p <0.0001). The incidence of sternal infections was 0% and no patient developed any infection or had renal toxicity during the 12‐month follow‐up. Conclusions: The use of topical vancomycin applied to the sternotomy incision does not result in persistently elevated levels of serum vancomycin following cardiac surgical procedures. Furthermore, topical vancomycin does not potentiate the emergence of drug‐resistant infections or contribute to postoperative renal toxicity. (J Card Surg 2011;26:461‐465)     

Treatment of multifocal vancomycin-resistant Enterococcus faecium osteomyelitis in sickle cell disease: a preliminary report

Repeat episodes of musculoskeletal infarction coupled with immunosuppression predispose sickle cell patients to infectious complications throughout their lives. Osteomyelitis is a familiar complication of sickle cell disease, and it may result in significant morbidity, especially when occurring in multiple sites. Staphylococcus and Salmonella remain the most common causes of osteomyelitis in sickle cell patients. Vancomycin-resistant enterococcus (VRE) infections have been reported mainly in connection with bacteremias and infections outside of the musculoskeletal system. To our knowledge, only a few cases of VRE long bone osteomyelitis have been reported in the literature. A few antimicrobial agents are available to treat VRE infections. The occurrence of VRE osteomyelitis is a major clinical concern, especially in an immunocompromised host, such as a sickle cell patient. We present a case of multiple long bone vancomycin-resistant Enterococcus faecium (mixed organisms) osteomyelitis in a sickle cell patient, and we report on a new method of using quinupristin-dalfopristin as part of the management plan to treat a complicated VRE infection successfully. We discuss the mechanism of action of anti-VRE drugs and the future direction to combat VRE in orthopedic infections.     

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.     

Efficacy of prophylactic application of vancomycin powder in preventing surgical site infections after instrumented spinal surgery: A retrospective analysis of patients with high-risk conditions

ObjectiveThis study aimed to determine the efficacy of prophylactic use of vancomycin powder against surgical site infections in patients with high-risk conditions who underwent posterior spinal instrumentation.MethodsData obtained from 209 patients who underwent posterior spinal instrumentation at a single institution from 2014 to 2017 were retrospectively reviewed. Patients were then divided into two groups: control group, including 107 patients (61 females, 46 males; mean age=54 years; age range=16–85 years), and treatment group, including 102 patients (63 females, 39 males; mean age=53 years; age range=14–90 years). All patients received the same standard prophylactic antibiotic regimen. In addition to the prophylactic antibiotic, vancomycin powder was applied locally to the surgical site in the treatment group. All patients were followed up for at least 90 days postoperatively. Infections were categorized as superficial and deep infections. Subgroup analysis of high-risk patients (Syrian refugees) was also performed.ResultsThe infection rates were 1.96% (two patients) in the treatment group and 6.54% (seven patients) in the control group. A significant decrease in the infection rates was observed with local vancomycin powder application. Advanced age (>46 years) and prolonged surgical duration (>140 min) were found to be the main risk factors for surgical site infections (p=0.004 and p=0.028, respectively). The infection rates were 3.22% and 8.11% in the treatment and control groups of refugees, respectively. There were three superficial and four deep infections in the control group and one superficial and one deep infection in the treatment group. A dominance of staphylococcus infections was observed in the control group, whereas no significant dominance was observed in the treatment group. Three patients in the control group and one patient in the treatment group received implant removal.ConclusionEvidence from this study has revealed that local application of vancomycin powder reduces the rate of surgical site infections after instrumented spinal surgery. The benefit of vancomycin application may be most appreciated in higher risk populations or in clinics with high baseline rates of infection.Level of EvidenceLevel III, Therapeutic Study     

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.     

The use of linezolid in the treatment of vancomycin-resistant enterococcal septicaemia in two patients with burn injuries

Vancomycin-resistant enterococci (VRE) are multi-resistant micro-organisms that have emerged as important nosocomial pathogens during the last decade. Emergence of this organism has been blamed mainly on the increased and inappropriate use of antibiotics, in particular, the cephalosporins and the glycopeptide, vancomycin. Burns patients are highly vulnerable to acquiring VRE infections, being both debilitated and immunocompromised, and often receiving antibiotics that further diminish their intrinsic microbial flora.We report on two patients with large burn injuries who acquired vancomycin-resistant enterococcal septicaemia during their in-patient stay. Both patients were successfully treated using the antibiotic, linezolid.Linezolid is the first in a new class of antibiotics known as the oxazolidinones whose mode of action inhibits early bacterial protein synthesis. Linezolid has a spectrum of activity against Gram-positive micro-organisms including methicillin-resistant Staphylococcus aureus (MRSA) and VRE, and can provide a useful treatment alternative to the glycopeptides.     

Antibiotic-Resistant Gram-Positive Cocci: Implications for Surgical Practice

Enterococcus and Staphylococcus . Methicillin-resistant strains of Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) emerged during the 1970s, leading to a marked increase in the use of vancomycin as the treatment of choice. Vancomycin use, in turn, has been implicated (along with widespread cephalosporin use) in the emergence of vancomycin-resistant enterococci (VRE) during the 1990s. Of great concern is the likely emergence of vancomycin-resistant staphylococci, which would constitute a public health emergency. Vancomycin remains the treatment of choice for infections caused by MRSA/MRSE, but rampant inappropriate use (e.g., prophylaxis in non-penicillin-allergic patients, treatment of methicillin-sensitive strains) must be curtailed. Chloramphenicol is increasingly the treatment of choice for serious VRE infections. Infection control policy must also minimize the possibility of transmission. All infected or colonized patients should be isolated and all environmental surfaces considered contaminated. Disposable gloves are mandatory for all patient contact, even incidental contact, and must be disposed of after each patient encounter. Hand-washing (the single most effective infection control measure) is mandatory after glove disposal. Gowns should be worn for direct contact with infected patients and masks used when aerosolization or splashing of secretions is likely.     

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.