title: Enterococci resistant to multiple antimicrobial agents, including vancomycin. Establishment of endemicity in a university medical center.
abstract: OBJECTIVE
  To determine the distribution of and risk factors for colonization and infection with vancomycin-resistant enterococci; to evaluate the molecular epidemiology of these strains; and to assess the effect of interventions, including 1) strict adherence to infection control procedures and 2) restricted use of vancomycin.
  
  
  METHODS
  Problem identification based on descriptive studies, point-prevalence surveys, and case-control studies and followed by specific interventions and evaluation of the response to these interventions.
  
  
  METHODS
  University medical center.
  
  
  METHODS
  All patients hospitalized between May 1992 and June 1994 (59,196 admissions).
  
  
  RESULTS
  75 active infections attributed to vancomycin-resistant enterococci were identified. Thirty-one patients (41%) had bloodstream infections and 6 (8%) died. The incidence of active infection was highest in the organ transplantation unit (13.2 infections/1000 admissions). In the point-prevalence studies, vancomycin-resistant enterococci were isolated from 20% of a random sample of hospitalized patients in July, August, and September 1993 (adjusted prevalence, 16.9%). Case-control studies showed significant associations between colonization and infection and 1) receipt of antimicrobial agents, particularly vancomycin, and 2) severity of illness. Although several small case clusters had isolates with identical banding patterns on pulsed field gel electrophoresis, at least 45 different banding patterns were noted among medical center isolates. Interventions took place in November and December 1993. Vancomycin restriction policies resulted in a 59% decrease in intravenous vancomycin use and an 85% decrease in oral vancomycin use. Point-prevalence surveys done in April, May, and June 1994 showed a consistent 20% level of colonization with vancomycin-resistant enterococci strains (adjusted prevalence, 18.7%). No significant changes were seen in rates of vancomycin-resistant enterococci infection.
  
  
  CONCLUSIONS
  Vancomycin-resistant enterococci are an important cause of illness and death in the study institution, particularly among organ transplant recipients and other seriously ill persons; they have also become a common intestinal colonizer among hospitalized patients. The diversity of isolates (based on molecular typing studies) suggests that resistant organisms have been introduced from multiple sources. Interventions that effectively lower the overall level of colonization with vancomycin-resistant enterococci must still be identified.
authors.affiliation: Infectious Diseases Section, Baltimore Veterans Affairs Medical Center, MD 21201, USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Morris
authors.forename: D K
authors.initials: DK
authors.lastname: Shay
authors.forename: J N
authors.initials: JN
authors.lastname: Hebden
authors.forename: R J
authors.initials: RJ
authors.lastname: McCarter
authors.forename: B E
authors.initials: BE
authors.lastname: Perdue
authors.forename: W
authors.initials: W
authors.lastname: Jarvis
authors.forename: J A
authors.initials: JA
authors.lastname: Johnson
authors.forename: T C
authors.initials: TC
authors.lastname: Dowling
authors.forename: L B
authors.initials: LB
authors.lastname: Polish
authors.forename: R S
authors.initials: RS
authors.lastname: Schwalbe
mesh_terms: D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology*; D004352:Drug Resistance, Microbial; D016983:Enterococcus / Q000145:classification / Q000187:drug effects*; D016908:Gram-Positive Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology; D006785:Hospitals, University; D006801:Humans; D008396:Maryland / Q000453:epidemiology; D015995:Prevalence; D012044:Regression Analysis; D014640:Vancomycin / Q000494:pharmacology*
chemical_list: D014640:Vancomycin