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Enterococcus Faecium Bacteremia Does Vancomycin Resistance Make a Difference?

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Enterococcus Faecium Bacteremia Does Vancomycin Resistance Make a Difference? ORIGINAL INVESTIGATION Enterococcus faecium Bacteremia Does Vancomycin Resistance Make a Difference? Valentina Stosor, MD; Lance R. Peterson, MD; Michael Postelnick, RPh; Gary A. Noskin, MD Background: Enterococcus faecium has received in- eters (P=.01). Fifty-nine percent of the patients with VSE creased attention, primarily due to the emergence of van- bacteremia survived vs 24% with VRE (P=.009), despite comycin resistance. The purpose of this investigation was similar severity-of-illness scores. In 62% of the patients to study the epidemiological characteristics of vancomy- with VRE sepsis, death was related to the bacteremia cin-resistant E faecium (VRE) bacteremia and to deter- (P=.01). Patients infected with VRE had longer hospi- mine the clinical impact of vancomycin resistance on the talizations than those with VSE (34.8 vs 16.7 days, re- outcome of patients with this infection. spectively) (P=.004), were more likely to be on the medi- cal service (P=.03), and on the average, had hospitalization Methods: We retrospectively analyzed the clinical features costs of more than $27 000 per episode than did pa- and outcome of 53 patients with E faecium bacteremia. tients with VSE bloodstream infection ($83 897 vs $56 707, respectively) (P=.04). Results: From January 1992 until December 1995, there were 32 episodes of bacteremia caused by vancomycin- Conclusions: Vancomycin-resistant E faecium bactere- susceptible E faecium (VSE) and 21 caused by VRE. An mia is a complication of prolonged hospitalization in de- intra-abdominal site was the most common source of bac- bilitated patients. Vancomycin resistance has a negative teremia in both groups. All of the VRE and 78% of VSE impact on survival in patients with E faecium bactere- bacteremia cases were nosocomially acquired. Previous mia and leads to higher health care costs. administration of vancomycin was associated with VRE bacteremia (P,.001), as were indwelling bladder cath- Arch Intern Med. 1998;158:522-527 NTEROCOCCUS faecium has In some medical centers, VRE have be- grown in importance as a come endemic.18 Vancomycin-resistant nosocomial pathogen dur- enterococci were first identified at our ing the past decade.1,2 While medical center in 1991, and remain a sig- there once was controversy nificant problem despite attempts to cur- Eregarding the pathogenic role of entero- tail the prevalence by formulary manage- cocci in causing infection, mounting evi- ment strategies19 and the institution of dence has now established E faecium as a increasingly more stringent infection con- cause of significant morbidity and mor- trol practices.20 Since treatment options are tality in hospitalized patients who are in- limited, much attention has been fo- fected with this organism.3-6 Notorious for cused on trying to understand the epide- resistance to multiple antimicrobial agents, miological features of VRE and the im- the acquisition of vancomycin resistance pact that vancomycin resistance has had has made this organism a formidable on the ability to care for patients infected From the Division of Infectious pathogen. with this organism. It is only through this Diseases, Department of Vancomycin-resistant enterococci understanding that more effective means Medicine, and the Clinical (VRE), first described in 1988,7 are a grow- to control further dissemination of VRE Microbiology Section, ing problem as more hospitals throughout will be identified. For these reasons, we Department of Pathology, the United States and Europe report signifi- performed a retrospective comparison of Northwestern University cant outbreaks associated with this organ- vancomycin-susceptible E faecium (VSE) Medical School (Drs Stosor, 8-16 Peterson, and Noskin), and the ism. The National Nosocomial Infec- and VRE bacteremia in our hospital to Department of Pharmacy, tions Surveillance System has reported that study the clinical and epidemiological as- Northwestern Memorial the incidence of VRE increased from 0.3% pects of this infection, as well as to define Hospital (Mr Postelnick), of all enterococci in 1989 to 7.9% in 1993, the clinical and economic significance of Chicago, Ill. with larger increases in intensive care units.17 vancomycin resistance in enterococci. ARCH INTERN MED/ VOL 158, MAR 9, 1998 522 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 PATIENTS AND METHODS indwelling bladder catheters or central venous catheters and hyperalimentation therapy was also recorded. A severity-of-illness score22 was calculated for each pa- PATIENTS tient at the onset of bacteremia. This grading system as- signs points on the following basis: change in mental sta- Northwestern Memorial Hospital in Chicago, Ill, is a 588- tus with disorientation, 1 point; change in mental status bed, university-affiliated, tertiary care hospital with active with stupor, 2 points; change in mental status with coma, surgical, trauma, solid organ transplantation, and bone mar- 4 points; body temperature of 37.8°C or higher, 1 point; row transplantation units. Medical records were reviewed body temperature of 40°C or higher, 2 points; body tem- for all patients who had a blood culture positive for E fae- perature of 35.6°C or lower, 2 points; hypotension (sys- cium during the 4-year period from January 1992 through tolic blood pressure #90 mm Hg, decrease in systolic blood December 1995, as identified by the Clinical Microbiology pressure by $20 mm Hg, or use of intravenous pressor Laboratory of Northwestern Memorial Hospital. Seventy-two agents), 2 points; use of mechanical ventilation, 2 points; cases of E faecium bacteremia were identified; of these, com- and cardiac arrest, 4 points. This index has previously been plete medical records were available for 59 patients. Four shown to be predictive of outcome for patients with bac- of these bacteremias were only identified from autopsy speci- teremia. mens and were not included in the final analysis. Two cases were excluded because the patients were neonates and fi- MICROBIOLOGICAL DETERMINATIONS nal outcomes were unknown due to patient transfer to other hospitals. Overall, 53 patients with bacteremia were included From January 1992 through March 1993, blood was cul- in the final analysis: 32 patients with VSE and 21 patients with tured aerobically with the use of a processing system (Iso- VRE bacteremia. Clinically significant bacteremia was defined lator system, Wampole Laboratories, Cranberry, NJ) and as the presence of 2 or more blood cultures positive for E fae- anaerobically in broth (Thiol, Difco Laboratories, Detroit, cium, or a single positive blood culture coupled with a clini- Mich). Throughout the remainder of the study period, the cally evident, or culture-positive, other site of infection.3 Isolator processing system and an automated system (ESP, Difco Laboratories) were used to culture blood aerobi- CLINICAL DATA COLLECTION cally and anaerobically. Identification of E faecium was based on standard methods, including the ability of the organ- Clinical information obtained for each patient included the ism to hydrolyze esculin in the presence of bile and grow following: age, sex, length of hospital stay prior to the on- in 6.5% sodium chloride, demonstration of a lack of pig- set of bacteremia, and hospital unit where the patient was mentation and motility, and fermentation of arabinose.23 admitted. A determination was also made regarding Susceptibility testing was performed by agar dilution on community vs nosocomial acquisition of the bacteremia. Mueller-Hinton agar according to reference methods.24 Nosocomial acquisition was defined as those patients whose first positive blood culture occurred more than 72 hours TREATMENT DATA after admission to the hospital, or when the patient was transferred from another hospital or chronic care facility. Therapy recorded for E faecium bacteremia included in- The source of bacteremia was identified from a culture- formation on the dosage and duration of all antimicrobial positive site or a clinically apparent site of infection. If an- agents used. Documentation was made if single, dual, or other site of infection was not evident, the source was con- no drug therapy was attempted. Data were also collected sidered unknown and the bacteremia primary in origin. If if other interventions (such as central venous catheter re- E faecium was isolated from multiple body sites, this was moval or surgical drainage of infected tissues) were made documented. Information regarding previous antimicro- in attempt to treat the infection and/or bacteremia. bial agent therapy was also obtained for each patient, as well as data pertaining to the management of the infection. OUTCOME DATA All medical records were reviewed for potential un- derlying risk factors or predisposing conditions for the ac- Outcome determinations were based on mortality: death quisition of E faecium bacteremia. This information in- was considered directly caused by the E faecium bactere- cluded liver disease, renal dysfunction, neutropenia, mia if the patient died following a positive blood culture significant corticosteroid therapy, infection with the hu- with a clinical picture consistent with sepsis; death was in- man immunodeficiency virus, malignant neoplasms, bone directly caused by the bacteremia if the patient died of mul- marrow transplantation, solid organ transplantation, dia- tifactorial causes, including further organ compromise by betes mellitus, pulmonary disease, debilitating neurologic the
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