Risk Factors for Prolonged Carriage and Reacquisition of Vancomycin-resistant Enterococci

Lee Dongsuk; Suk Park Eun; Yong Dongeun; Yong Choi Jun; Lee Kyungwon; Ha Jee Sun

doi:10.14192/kjnic.2015.20.1.19

Journal List > Korean J Nosocomial Infect Control > v.20(1) > 1098349

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Dongsuk, Eun, Dongeun, Jun, Kyungwon, and Sun: Risk Factors for Prolonged Carriage and Reacquisition of Vancomycin-resistant Enterococci

Original Article

J Nosocomial Infect Control 2013;20(1):19-28.

Published online: 3 May 2013

DOI: https://doi.org/10.14192/kjnic.2015.20.1.19

Risk Factors for Prolonged Carriage and Reacquisition of Vancomycin-resistant Enterococci

Lee Dongsuk, Suk Park Eun, Yong Dongeun, Yong Choi Jun, Lee Kyungwon, Ha Jee Sun

¹Department of Infection Control, Severance Hospital, Seoul, Korea

²Department of Laboratory Medicine, Seoul, Korea

³Division of Infectious Disease, Department of Internal Medicine, Seoul, Korea

⁴Yonsei University College of Medicine, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Korea

Address reprint requests to Sun Ha Jee, Institute for Health Promotion, Graduate School of Public Health, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea Tel: 02-2228-1523, Fax: 02-2227-7871 E-mail: jsunha@yuhs.ac

Received 22 May 2014 Accepted 22 September 2014

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Patients infected with vancomycin-resistant enterococci (VRE) are kept in isolation to prevent the spread of VRE in medical facilities. However, decision-making regarding isolation can be challenging at the time of re-admission of previously VRE-colonized or infected patients who have not been examined for VRE infections for a long time. This study focused on providing guidelines for isolating VRE patients based on the analysis of risk factors for prolonged carriage and reacquisition of VRE.

Methods

A retrospective review was performed on medical records of patients who were diagnosed with VRE infections at a university hospital in 2009. Durations of colonization and negative conversion of VRE were estimated by Kaplan-Meier methods. Prolonged duration of VRE infections and risk factors for reacquisition were analyzed using Cox's proportional hazard model.

Results

Among 220 VRE-colonized patients, 132 were cleared, and 30 reacquired after negative conversion of VRE. The median duration of colonization was 33.1 weeks, and the median clearance period was 19.4 weeks. Patients who were admitted via the emergency department and treated with glycopeptides tended to have prolonged duration of VRE colonization. Prolonged hospitalization and metronidazole therapy increased the risk of reacquisition more rapidly.

Conclusion

Treatment with glycopeptides, metronidazole antibiotic therapy, history of admission via the emergency department, and prolonged hospitalization can affect to prolonged carriage and reacquisition of VRE. Consider carefully the release of isolation of VRE patients with these risk factors.

Keywords: Colonization, Enterococcus, Patient isolation, Vancomycin resistance

References

1. Leclercq R, Derlot E, Duval J, Courvalin P. Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med. 1988; 319:157–61.

2. Uttley AH, Collins CH, Naidoo J, George RC. Vancomycin-resistant enterococci. Lancet. 1988; 1:57–8.

3. Centers for Disease Control and Prevention (CDC).Nosocomial enterococci resistant to vancomycinUnited States, 1989-1993. MMWR Morb Mortal Wkly Rep. 1993; 42:597–9.

4. Patel R. Clinical impact of vancomycin-resistant enterococci. J Antimicrob Chemother. 2003; 51 Suppl 3:iii13–21.

5. Carmeli Y, Eliopoulos G, Mozaffari E, Samore M. Health and economic outcomes of vancomycin-resistant enterococci. Arch Intern Med. 2002; 162:2223–8.

6. Diaz Granados CA, Zimmer SM, Klein M, Jernigan JA. Comparison of mortality associated with vancomycin-resistant and vancomycin- susceptible enterococcal bloodstream infections: a meta-analysis. Clin Infect Dis. 2005; 41:327–33.

7. Cheah AL, Spelman T, Liew D, Peel T, Howden BP, Spelman D, et al. Enterococcal bacteraemia: factors influencing mortality, length of stay and costs of hospitalization. Clin Microbiol Infect. 2013; 19:E181–9.

8. Noble WC, Virani Z, Cree RG. Co-transfer of vancomycin and other resistance genes from Enterococcus faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol Lett. 1992; 72:195–8.

9. Han SH, Chin BS, Lee HS, Jeong SJ, Choi HK, Kim CK, et al. Recovery of both vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus from culture of a single clinical specimen from colonized or infected patients. Infect Control Hosp Epidemiol. 2009; 30:130–8.

10. Lee K, Park KH, Jeong SH, Lim HS, Shin JH, Yong D, et al. Further increase of vancomycin-resistant Enterococcus faecium, amikacin- and fluoroquinolone-resistant Klebsiella pneumoniae, and imipenem-resistant Acinetobacter spp. in Korea: 2003 KONSAR surveillance. Yonsei Med J. 2006; 47:43–54.

11. Korean Centers for Disease Control and Prevention, Korean National Institute of Health.Korean Antimicrobial Resistance Monitoring System 2009 Annual Report. 2011.

12. Hospital Infection Control Practices Advisory Committee (HICPAC).Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol. 1995; 16:105–13.

13. Montecalvo MA, de Lencastre H, Carraher M, Gedris C, Chung M, VanHorn K, et al. Natural history of colonization with vancomycin-resistant Enterococcus faecium. Infect Control Hosp Epidemiol. 1995; 16:680–5.

14. Henning KJ, Delencastre H, Eagan J, Boone N, Brown A, Chung M, et al. Vancomycin-resistant Enterococcus faecium on a pediatric oncology ward: duration of stool shedding and incidence of clinical infection. Pediatr Infect Dis J. 1996; 15:848–54.

15. Nourse C, Murphy H, Byrne C, O’Meara A, Breatnach F, Kaufmann M, et al. Control of a nosocomial outbreak of vancomycin resistant Enterococcus faecium in a paediatric oncology unit: risk factors for colonisation. Eur J Pediatr. 1998; 157:20–7.

16. Patel R, Allen SL, Manahan JM, Wright AJ, Krom RA, Wiesner RH, et al. Natural history of vancomycin-resistant enterococcal colonization in liver and kidney transplant recipients. Liver Transpl. 2001; 7:27–31.

17. Byers KE, Anglim AM, Anneski CJ, Farr BM. Duration of colonization with vancomycin-resistant Enterococcus. Infect Control Hosp Epidemiol. 2002; 23:207–11.

18. Yoon YK, Lee SE, Lee J, Kim HJ, Kim JY, Park DW, et al. Risk factors for prolonged carriage of vancomycin-resistant Enterococcus faecium among patients in intensive care units: a case-control study. J Antimicrob Chemother. 2011; 66:1831–8.

19. Park I, Park RW, Lim SK, Lee W, Shin JS, Yu S, et al. Rectal culture screening for vancomycin-resistant enterococcus in chronic haemodialysis patients: false-negative rates and duration of colonisation. J Hosp Infect. 2011; 79:147–50.

20. Sohn KM, Peck KR, Joo EJ, Ha YE, Kang CI, Chung DR, et al. Duration of colonization and risk factors for prolonged carriage of vancomycin-resistant enterococci after discharge from the hospital. Int J Infect Dis. 2013; 17:e240–6.

21. Pacio GA, Visintainer P, Maguire G, Wormser GP, Raffalli J, Montecalvo MA. Natural history of colonization with vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and resistant gram-negative bacilli among long-term-care facility residents. Infect Control Hosp Epidemiol. 2003; 24:246–50.

22. Shenoy ES, Paras ML, Noubary F, Walensky RP, Hooper DC. Natural history of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE): a systematic review. BMC Infect Dis. 2014; 14:177.

23. Roghmann MC, Qaiyumi S, Schwalbe R, Morris JG Jr. Natural history of colonization with vancomycin-resistant Enterococcus faecium. Infect Control Hosp Epidemiol. 1997; 18:679–80.

24. Henard S, Lozniewski A, Aissa N, Jouzeau N, Rabaud C. Evaluation of the duration of vanA vancomycin-resistant Enterococcus faecium carriage and clearance during a large-scale outbreak in a region of eastern France. Am J Infect Control. 2011; 39:169–71.

25. Tacconelli E. Antimicrobial use: risk driver of multidrug resistant microorganisms in healthcare settings. Curr Opin Infect Dis. 2009; 22:352–8.

26. Gordts B, Van Landuyt H, Ieven M, Vandamme P, Goossens H. Vancomycin-resistant enterococci colonizing the intestinal tracts of hospitalized patients. J Clin Microbiol. 1995; 33:2842–6.

27. Bonten MJ, Slaughter S, Ambergen AW, Hayden MK, van Voorhis J, Nathan C, et al. The role of “colonization pressure” in the spread of vancomycin-resistant enterococci: an important infection control variable. Arch Intern Med. 1998; 158:1127–32.

28. Tokars JI, Gehr T, Jarvis WR, Anderson J, Armistead N, Miller ER, et al. Vancomycin-resistant enterococci colonization in patients at seven hemodialysis centers. Kidney Int. 2001; 60:1511–6.

29. Elizaga ML, Weinstein RA, Hayden MK. Patients in long-term care facilities: a reservoir for vancomycin-resistant enterococci. Clin Infect Dis. 2002; 34:441–6.

30. Tacconelli E, Karchmer AW, Yokoe D, D’Agata EM. Preventing the influx of vancomycin-resistant enterococci into health care institutions, by use of a simple validated prediction rule. Clin Infect Dis. 2004; 39:964–70.

31. D’Agata EM, Gautam S, Green WK, Tang YW. High rate of false-negative results of the rectal swab culture method in detection of gastrointestinal colonization with vancomycin-resistant enterococci. Clin Infect Dis. 2002; 34:167–72.

32. Donskey CJ, Hoyen CK, Das SM, Helfand MS, Hecker MT. Recurrence of vancomycin-resistant Enterococcus stool colonization during antibiotic therapy. Infect Control Hosp Epidemiol. 2002; 23:436–40.

Table 1.

Characteristics of patients, N=220

Characteristics	meanSD / n (%)
Age, years	59.813.3
Gender, male	89 (40.5)
Department
Medical	156 (70.9)
Surgical	64 (29.1)
Admission route*
ER	101 (46.1)
OPD	118 (53.9)
Transferred from other hospitals	40 (18.2)
Prior admission frequency	1.82.8
0	92 (41.8)
1-2	74 (33.6)
≥3	54 (24.5)
Prior hospital stay, days*	29.035.2
≥30 days	71 (32.4)
Hospital stay after VRE identification, days*	43.954.4
≥30 days	106 (48.4)
Readmission frequency after VRE identification	3.44.7
0	70 (31.8)
1-2	66 (30.0)
≥3	84 (38.2)
Underlying disease^†
Solid organ cancer	100 (45.5)
Hematologic cancer	55 (25.0)
Solid organ transplant	19 (8.6)
Diabetes	61 (27.7)
Cardiovascular	122 (55.5)
Liver cirrhosis	10 (4.5)
Dialysis	36 (16.4)
Others^‡	125 (56.8)
Colonization of other MDROs before VRE identification	101 (45.9)
Prior invasive procedure or operation^†	204 (92.7)
Prior antibiotics use^†	216 (98.2)
Antibiotics use after discharge^†,§	104 (55.0)
Antibiotics use at readmission^†,‖	134 (87.6)
Prior ICU care	96 (43.6)
Final visit to hospital before reacquisition of VRE^¶
Admission	64 (48.5)
OPD	68 (51.5)
Invasive procedure or operation before reacquisition of VRE^†,¶	62 (47.0)
Antibiotics use before reacquisition of VRE^†,¶	73 (55.3)
Frequency of stool VRE test	10.49.3
VRE positive on first stool test	187 (85.0)

*N=219, One paitient identified VRE at OPD prior to admission; ^†Includes one or more underlying disease or procedure or antibiotics use; ^‡Includes connective tissue, chronic pulmonary, neurologic and gastrointestinal disorder and major trauma; ^§N=189, 31 paitients died before discharge; ^‖N=153; ^¶N=132.

Abbreviations: SD, standard deviation; VRE, vancomycin-resistant enterococci; ER, emergency room; OPD, outpatient department; MDROs, multidrug-resistant organisms; ICU, intensive care unit.

Fig. 1.

Clearance and reacquisition of VRE. *124 clearance and 29 reacquisition, when culture used to ChromID VRE media performed. 8 clearance and 1 reacquisition, when PCR assay performed. The difference of VRE reacquisition due to the VRE test method was not significant (P=1.000); ^†Condition1 is basic condition of VRE clearance and condition2 is modified condition; The difference of VRE reacquisition due to the clearance condition of VRE was not significant (P=0.538).

Fig. 2.

Kaplan-Meier curve: Estimated duration of VRE colonization. Abbreviation: CI, confidence interval.

Fig. 3.

Kaplan-Meier curve: Estimated duration of free VRE. Abbreviation: See Fig. 2.

Table 2.

Factors associated with prolonged carriage of VRE, N=220

Variable	n (%)	Log Rank P-value	Cox proportional hazard model
Variable	n (%)	Log Rank P-value	HR (95% CI)	P-value
Age ≥60 years*	123 (55.9)	0.873
Admission route, ER^{†, ‡}	113 (45.2)	0.028	1.5 (1.1-2.1)	0.044
Prior antibiotics use^†
Glycopeptide	42 (19.4)	0.053	1.7 (1.0-3.0)	0.037
3rd, 4th generation cephalosporins	167 (76.3)	0.148
Carbapenem	68 (31.1)	0.109
Colonization of other MDROs before	101 (45.9)	0.096
VRE identification

*Reference, age 20-59 years; ^†N=219; ^‡Reference, outpatient department.

Abbreviations: HR, hazard ratio; CI, confidence interval; ER, emergency room; MDROs, multidrug-resistant organisms.

Table 3.

Factors associated with the reacquisition of VRE, N=132

Variable	n (%)	Log Rank P-value	Cox proportional hazard model
Variable	n (%)	Log Rank P-value	HR (95% CI)	P-value
Age ≥60 years	69 (52.3)	0.203
Hospital stay after VRE identification ≥30 days	50 (37.9)	0.008	2.5 (1.1-5.4)	0.023
Prior antibiotics use^† Vancomycin	52 (39.4)	0.037
Final visit to hospital before reacquisition of VRE, Admission^‡	64 (48.5)	0.131
Antibiotics use before reacquisition of VRE Metronidazole	14 (10.6)	0.001	3.9 (1.5-10.0)	0.005
Invasive procedure before reacquisition of VRE Operation	8 (6.1)	0.009

*Reference, age 20-59 years; ^†N=131; ^‡Reference, outpatient department.

Abbreviations: See Table 2.

TOOLS

Similar articles