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Longitudinal Multicenter Analysis of Outcomes After Cessation of Control Measures for Vancomycin-Resistant Enterococci

  • Camille Lemieux (a1) (a2), Michael Gardam (a1) (a3), Gerald Evans (a4), Michael John (a5), Kathryn N. Suh (a6) (a7), Carl vanWalraven (a8), Elisa Vicencio (a1), Cameron Coulby (a1), Virginia Roth (a6) (a7) and Susy Hota (a1) (a3)...

Abstract

OBJECTIVE

To assess clinically relevant outcomes after complete cessation of control measures for vancomycin-resistant enterococci (VRE).

DESIGN

Quasi-experimental ecological study over 3.5 years.

METHODS

All VRE screening and isolation practices at 4 large academic hospitals in Ontario, Canada, were stopped on July 1, 2012. In total, 618 anonymized abstracted charts of patients with VRE-positive clinical isolates identified between July 1, 2010, and December 31, 2013, were reviewed to determine whether the case was a true VRE infection, a VRE colonization or contaminant, or a true VRE bacteremia. All deaths within 30 days of the last VRE infection were also reviewed to determine whether the death was fully or partially attributable to VRE. All-cause mortality was evaluated over the study period. Generalized estimating equation methods were used to cluster outcome rates within hospitals, and negative binomial models were created for each outcome.

RESULTS

The incidence rate ratio (IRR) for VRE infections was 0.59 and the associated P value was .34. For VRE bacteremias, the IRR was 0.54 and P=.38; for all-cause mortality the IRR was 0.70 and P=.66; and for VRE attributable death, the IRR was 0.35 and P=.49. VRE control measures were not significantly associated with any of the outcomes. Rates of all outcomes appeared to increase during the 18-month period after cessation of VRE control measures, but none reached statistical significance.

CONCLUSION

Clinically significant VRE outcomes remain rare. Cessation of all control measures for VRE had no significant attributable adverse clinical impact.

Infect Control Hosp Epidemiol 2016;1–7

Copyright

Corresponding author

Address correspondence to Camille Lemieux, 200 Elizabeth Street, Toronto, ON M5T 2S8, (camille.lemieux@uhn.ca).

References

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1. Lior, L, Litt, M, Hockin, J, et al. Vancomycin-resistant enterococci on a renal ward in an Ontario hospital. Can Communicable Dis Rept 1996;22:125128.
2. Simner, PJ, Adam, H, Baxter, M, et al. Epidemiology of vancomycin-resistant enterococci (VRE) in Canadian hospitals: CANWARD 2007–2013. Antimicrob Agents Chemother 2015;59:43154317.
3. Proportion of vancomycin-resistant enterococcus faecalis isolates in participating countries in 2014. European Centre for Disease Control and Prevention website. http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/map_reports.aspx. Published 2014. Accessed February 11, 2016.
4. Ziakas, PD, Thapa, R, Rice, LB, Mylonakis, E. Trends and significance of VRE colonization in the ICU: a meta-analysis of published studies. PloS One 2013;8:e75658.
5. Muto, CA, Jernigan, JA, Ostrowsky, BE, et al. SHEA guideline for preventing nosocomial transmission of multi-drug resistant strains of Staphylococcus aureus and enterococcus . Infect Control Hosp Epidemiol 2003;24:362386.
6. Limbago, BM, Kallen, AJ, Zhu, W, et al. Report of the 13th vancomycin-resistant Staphylococcus aureus isolate in the United States. J Clin Microbiol 2014;52:9981002.
7. Bhavnani, SM, Drake, JA, Forrest, A, et al. A nationwide, multicenter, case-control study comparing risk factors, treatment, and outcome for vancomycin-resistant and -susceptible enterococcal bacteremia. Diagn Microbiol Infect Dis 2000;36:145158.
8. Cheah, AL, Peel, T, Howden, BP, et al. Case-case-control study on factors associated with vanB vancomycin-resistant and vancomycin-susceptible enterococcal bacteraemia. BMC Infect Dis 2014;14:353.
9. Da Silva, NS, Muniz, VD, Estofolete, CF, Furtado, GH, Rubio, FG. Identification of temporal clusters and risk factors of bacteremia by nosocomial vancomycin-resistant enterococci. Am J Infect Control 2014;42:389392.
10. DiazGranados, 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;41:327333.
11. Hurley, J. C. Mortality due to vancomycin-resistant enterococcal bacteremia versus vancomycin-susceptible enterococcal bacteremia: an ecological analysis. Clin Infect Dis 2005;41:15411542.
12. Garbutt, JM, Ventrapragada, M, Littenberg, B, Mundy, LM. Association between resistance to vancomycin and death in cases of Enterococcus faecium bacteremia. Clin Infect Dis 2000;30:466472.
13. Krcmery, V, Bilikova, E, Svetlansky, I, Kovacicova, G. Is vancomycin resistance in enterococci predictive of inferior outcome of enterococcal bacteremia? Clin Infect Dis 2001;32:11101112.
14. Mikulska, M, Del Bono, V, Raiola, AM, et al. Enterococcal bloodstream infection after hematopoietic stem cell transplant: experience of a center with a low prevalence of vancomycin-resistant enterococci. Clin Infect Dis 2012;55:1744.
15. Salgado, CD, Farr, BM. Outcomes associated with vancomycin-resistant enterococci: a meta-analysis. Infect Control Hosp Epidemiol 2003;24:690698.
16. Vergis, EN, Hayden, MK, Chow, JW, et al. Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia: a prospective multicenter study. Ann Intern Med 2001;135:484492.
17. Vydra, J, Shanley, RM, George, I, et al. Enterococcal bacteremia is associated with increased risk of mortality in recipients of allogeneic hematopoietic stem cell transplantation. Clin Infect Dis 2012;55:764770.
18. Prematunge, C, MacDougall, C, Johnstone, J, et al. VRE and VSE bacteremia outcomes in the era of effective VRE therapy: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2015;00:110.
19. Huskins, WC, Huckabee, CM, O’Grady, NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011;364:14071418.
20. Derde, LP, Cooper, BS, Goossens, H, et al. Interventions to reduce colonization and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomized trial. Lancet Infect Dis 2014;14:3139.
21. Karki, S, Leder, K, Cheng, AC. Patients under contact precautions have an increased risk of injuries and medication errors: a retrospective cohort study. Infect Control Hosp Epidemiol 2013;34:11181120.
22. Morgan, DJ, Pineles, L, Shardell, M, et al. The effect of contact precautions on healthcare worker activity in acute care hospitals. Infect Control Hosp Epidemiol 2013;34:6973.
23. Masse, V, Valiquette, L, Boukhoudmi, S, et al. Impact of methicillin-resistant Staphylococcus aureus contact isolation units on medical care. PLoS One 2013;8:e57057.
24. Gandra, S, Barysauskas, CM, Mack, DA, Barton, B, Finberg, R, Ellison, RT. Impact of contact precautions on falls, pressure ulcers and transmission of MRSA and VRE in hospitalized patients. J Hosp Infect 2014;88:170176.
25. Day, HR, Perencevich, EN, Harris, AD, et al. Depression, anxiety, and moods of hospitalized patients under contact precautions. Infect Control Hosp Epidemiol 2013;34:251258.
26. Public Health Agency of Canada. Antimicrobial resistant organisms (ARO) surveillance summary report for data from January 1, 2009 to December 31, 2014, updated July 2015. Ottawa: Centre for Communicable Diseases and Infection Control; 2015.
27. Chapter 15: Generalized Estimating Equations. In: Stokes ME, Davis CS, Kock GG. Categorical Data Analysis using the SAS System. 2nd ed. Cary, NC: SAS Institute Inc.; 2000: 471–550.
28. Ballinger, GA. Using generalized estimating equations for longitudinal analysis. Org Res Methods 2004;7:127150.
29. Cook, A. Small sample robust variance correction for generalized estimating equations for use in cluster randomized clinical trials. NIH Health Care Systems Research Collaboratory report. http://sites.duke.edu/rethinkingclinicaltrials/biostatistical-guidance-documents/. Published 2015. Accessed April 11, 2016.
30. Popiel, KY, Miller, MA. Evaluation of vancomycin-resistant enterococci (VRE)-associated morbidity following relaxation of VRE screening and isolation precautions in a tertiary care hospital. Infect Control Hosp Epidemiol 2014;35:818825.
31. Almyroudis, NG, Osawa, R, Samonis, G, et al. Discontinuation of systematic surveillance and contact precautions for vancomycin-resistant enterococcus (VRE) and its impact on the incidence of VRE faecium bacteremia in patients with hematologic malignancies. Infect Control Hosp Epidemiol 2016;37:398403.
32. Cheah, AL, Spelman, T, Liew, D, et al. Enterococcal bacteraemia: factors influencing mortality, length of stay and costs of hospitalization. Clin Microbiol Infect 2013;19:E181E189.
33. Peel, T, Cheng, AC, Spelman, T, Huysmans, M, Spelman, D. Differing risk factors for vancomycin-resistant and vancomycin sensitive enterococcal bacteraemia. Clin Microbiol Infect 2012;18:388394.
34. Bossaer, JB, Hall, PD, Garrett-Mayer, E. Incidence of vancomycin-resistant enterococci (VRE) infection in high-risk febrile neutropenic patients colonized with VRE. Support Care Cancer 2010;19:231237.
35. Matar, MJ, Tarrand, J, Raad, I, Rolston, KV. Colonization and infection with vancomycin-resistant Enterococcus among patients with cancer. Am J Infect Control 2006;34:534536.
36. Theilacker, C, Jonas, D, Huebner, J, Bertz, H, Kern, WV. Outcomes of invasive infection due to vancomycin-resistant Enterococcus faecium during a recent outbreak. Infection 2009;6:540543.

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