title: Highly resistant microorganisms in a teaching hospital: the role of horizontal spread in a setting of endemicity.
abstract: OBJECTIVE
  To determine the incidence density of highly resistant organisms (HROs) and the relative contribution of horizontal spread in a setting of endemicity.
  
  
  METHODS
  Prospective surveillance was performed among hospitalized patients during an 18-month period. Enterobacteriaceae, nonfermentative gram-negative bacilli, Staphylococcus aureus, Streptococcus pneumoniae, and Enterococcus faecium--all considered highly resistant, according to Dutch guidelines--were included. Epidemiological linkage and nosocomial transmission were determined on the basis of molecular typing and hospital admission data.
  
  
  RESULTS
  From 119 patients, we recovered a total of 170 unique HRO isolates, as follows: Escherichia coli, 96 isolates; Klebsiella species, 11 isolates; Enterobacter species, 8 isolates; Proteus species, 9 isolates; Citrobacter species, 5 isolates; Pseudomonas species, 5 isolates; Acinetobacter species, 3 isolates; Morganella species, 2 isolates; Salmonella species, 1 isolate; Serratia species, 1 isolate; S. pneumoniae, 20 isolates; and S. aureus, 9 isolates. No vancomycin-resistant E. faecium was found. The incidence density was 4.3 HRO isolates per 10,000 patient-days. The majority of HRO isolates were unique, and nosocomial transmission was observed 4 times for highly resistant gram-negative bacilli (case reproduction rate, 0.05) and 4 times for penicillin-nonsusceptible S. pneumoniae (case reproduction rate, 0.29). A stay on the intensive care unit was the main determinant for the recovery of an HRO.
  
  
  CONCLUSIONS
  Nosocomial transmission of HROs was observed 8 times during the 18-month period. The intensive care unit was identified as the main reservoir of horizontal spread of HROs. This study shows that nosocomial transmission of HROs is largely preventable using transmission precautions.
authors.affiliation: Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands. iwillemsen@amphia.nl
authors.forename: Ina
authors.initials: I
authors.lastname: Willemsen
authors.forename: Marlies
authors.initials: M
authors.lastname: Mooij
authors.forename: Marsha
authors.initials: M
authors.lastname: van der Wiel
authors.forename: Diana
authors.initials: D
authors.lastname: Bogaers
authors.forename: Madelon
authors.initials: M
authors.lastname: van der Bijl
authors.forename: Paul
authors.initials: P
authors.lastname: Savelkoul
authors.forename: Jan
authors.initials: J
authors.lastname: Kluytmans
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D002648:Child; D002675:Child, Preschool; D003428:Cross Infection / Q000453:epidemiology*; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006090:Gram-Negative Bacteria / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification / Q000502:physiology*; D016905:Gram-Negative Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000145:classification / Q000302:isolation & purification; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011159:Population Surveillance; D011446:Prospective Studies; D013997:Time Factors; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents