title: Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia. a prospective multicenter study.
abstract: BACKGROUND
  Enterococcus species are major nosocomial pathogens and are exhibiting vancomycin resistance with increasing frequency. Previous studies have not resolved whether vancomycin resistance is an independent risk factor for death in patients with invasive disease due to Enterococcus species or whether antibiotic therapy alters the outcome of enterococcal bacteremia.
  
  
  OBJECTIVE
  To determine whether vancomycin resistance is an independent predictor of death in patients with enterococcal bacteremia and whether appropriate antimicrobial therapy influences outcome.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  Four academic medical centers and a community hospital.
  
  
  METHODS
  All patients with enterococcal bacteremia.
  
  
  METHODS
  Demographic characteristics; underlying disease; Acute Physiology and Chronic Health Evaluation (APACHE) II scores; antibiotic therapy, immunosuppression, and procedures before onset; and antibiotic therapy during the ensuing 6 weeks. The major end point was 14-day survival.
  
  
  RESULTS
  Of 398 episodes, 60% were caused by E. faecalis and 37% were caused by E. faecium. Thirty-seven percent of isolates exhibited resistance or intermediate susceptibility to vancomycin. Twenty-two percent of E. faecium isolates showed reduced susceptibility to quinupristin-dalfopristin. Previous vancomycin use (odds ratio [OR], 5.82 [95% CI, 3.20 to 10.58]; P < 0.001), previous corticosteroid use (OR, 2.43 [CI, 1.22 to 4.86]; P = 0.01), and total APACHE II score (OR, 1.06 per unit change [CI, 1.02 to 1.10 per unit change]; P = 0.003) were associated with vancomycin-resistant enterococcal bacteremia. The mortality rate was 19% at 14 days. Hematologic malignancy (OR, 3.83 [CI, 1.56 to 9.39]; P = 0.003), vancomycin resistance (OR, 2.10 [CI, 1.14 to 3.88]; P = 0.02), and APACHE II score (OR, 1.10 per unit change [CI, 1.05 to 1.14 per unit change]; P < 0.001) were associated with 14-day mortality. Among patients with monomicrobial enterococcal bacteremia, receipt of effective antimicrobial therapy within 48 hours independently predicted survival (OR for death, 0.21 [CI, 0.06 to 0.80]; P = 0.02).
  
  
  CONCLUSIONS
  Vancomycin resistance is an independent predictor of death from enterococcal bacteremia. Early, effective antimicrobial therapy is associated with a significant improvement in survival.
authors.affiliation: Division of Infectious Diseases, University of Pittsburgh, Suite 3A, Falk Medical Building, 3601 Fifth Avenue, Pittsburgh, PA 15213, USA.
authors.forename: E N
authors.initials: EN
authors.lastname: Vergis
authors.forename: M K
authors.initials: MK
authors.lastname: Hayden
authors.forename: J W
authors.initials: JW
authors.lastname: Chow
authors.forename: D R
authors.initials: DR
authors.lastname: Snydman
authors.forename: M J
authors.initials: MJ
authors.lastname: Zervos
authors.forename: P K
authors.initials: PK
authors.lastname: Linden
authors.forename: M M
authors.initials: MM
authors.lastname: Wagener
authors.forename: B
authors.initials: B
authors.lastname: Schmitt
authors.forename: R R
authors.initials: RR
authors.lastname: Muder
mesh_terms: D018806:APACHE; D000328:Adult; D016470:Bacteremia / Q000188:drug therapy / Q000382:microbiology* / Q000401:mortality*; D016983:Enterococcus / Q000187:drug effects*; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy / Q000382:microbiology* / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013223:Statistics as Topic; D016896:Treatment Outcome; D020713:Vancomycin Resistance