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A Population-Based Investigation of Invasive Vancomycin-Resistant Enterococcus Infection in Metropolitan Atlanta, Georgia, and Predictors of Mortality

Published online by Cambridge University Press:  02 January 2015

Bernard C. Camins ,
Monica M. Farley ,
John J. Jernigan ,
Susan M. Ray ,
James P. Steinberg  and
Henry M. Blumberg
Bernard C. Camins*
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
Monica M. Farley
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
John J. Jernigan
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
Susan M. Ray
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia Grady Memorial Hospital, Atlanta, Georgia
James P. Steinberg
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia Emory Crawford Long Hospital, Atlanta, Georgia
Henry M. Blumberg*
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia Grady Memorial Hospital, Atlanta, Georgia
*
Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, Box 8051, St. Louis, MO 63110-1093 (bcamins@im.wustl.edu)
Division of Infectious Diseases, Emory University, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303 (hblumbe@emory.edu)
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Abstract

Background.

Vancomycin-resistant Enterococcus organisms (VRE) have emerged as common nosocomial pathogens, but few population-based data are available on the impact of invasive VRE infections.

Methods.

We assessed the incidence of invasive VRE infections and predictors of mortality among patients identified during prospective, population-based surveillance performed in the metropolitan statistical area (MSA) of Atlanta, Georgia.

Results.

From July 1997 through June 2000, a total of 192 patients who resided in the Atlanta MSA developed an invasive VRE infection, for a rate of 1.57 cases per 100,000 person-years. The incidence of invasive VRE disease significantly increased from 0.91 cases per 100,000 person-years during the first year of the study to 1.73 cases per 100,000 person-years during the third year of the study (P<.001). Rates of invasive VRE infection were significantly higher among African American patients than white patients (2.59 vs 0.70 cases per 100,000 person-years; P < .001). Blood was the most common sterile site from which VRE was recovered (161 [83%] of 193 isolates), followed by deep surgical sites (17 [9%]), peritoneal fluid (10 [5%]), pleural fluid (3 [2%]), and cerebrospinal fluid (1 [0.5%]). In multivariate analysis, a Charlson comorbidity index of 5 or greater, previous receipt of antibiotic therapy, having 2 or more sets of blood cultures positive for VRE, and receipt of central parenteral nutrition were independent predictors of mortality, whereas receipt of an antibiotic with in vitro activity against the VRE isolate was associated with a decreased risk of mortality. Molecular typing revealed 38 different pulsed-field gel electrophoresis patterns, but the 2 most common pulsed-field gel electrophoresis types were found at 3 Emory University-affiliated hospitals.

Conclusions.

The incidence of invasive VRE infection significantly increased in the Atlanta MSA during the 3-year study period, with significant racial disparities detected. Receipt of an antimicrobial agent with in vitro activity against VRE was associated with a lower mortality rate. Molecular typing results demonstrated polyclonal emergence of VRE in Atlanta.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 28 , Issue 8 , August 2007 , pp. 983 - 991
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2007

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References

1. Treitman, AN, Yarnold, PR, Warren, J, Noskin, GA. Emerging incidence of Enterococcus faecium among hospital isolates (1993 to 2002). J Clin Microbiol 2005;43:462–463.CrossRefGoogle ScholarPubMed
2. Lai, KK, Fontecchio, SA, Kelley, AL, Baker, S, Melvin, ZS. The changing epidemiology of vancomycin-resistant enterococci. Infect Control Hosp Epidemiol 2003;24:264–268.CrossRefGoogle ScholarPubMed
3. Murray, BE. Vancomycin-resistant enterococcal infections. N Engl J Med 2000;342:710–721.CrossRefGoogle ScholarPubMed
4. Carmeli, Y, Eliopoulos, G, Mozaffari, E, Samore, M. Health and economic outcomes of vancomycin-resistant enterococci. Arch Intern Med 2002;162:2223–2228.CrossRefGoogle ScholarPubMed
5. Pelz, RK, Lipsett, PA, Swoboda, SM, et al. Vancomycin-sensitive and vancomycin-resistant enterococcal infections in the ICU: attributable costs and outcomes. Intensive Care Med 2002;28:692–697.CrossRefGoogle ScholarPubMed
6. Song, X, Srinivasan, A, Plaut, D, Perl, TM. Effect of nosocomial vancomycin-resistant enterococcal bacteremia on mortality, length of stay, and costs. Infect Control Hosp Epidemiol 2003;24:251–256.CrossRefGoogle ScholarPubMed
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;36:145–158.CrossRefGoogle ScholarPubMed
8. Muto, CA, Jernigan, JA, Ostrowsky, BE, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus . Infect Control Hosp Epidemiol 2003;24:362–386.CrossRefGoogle ScholarPubMed
9. Stosor, V, Kruszynski, J, Suriano, T, Noskin, GA, Peterson, LR. Molecular epidemiology of vancomycin-resistant enterococci: a 2-year perspective. Infect Control Hosp Epidemiol 1999;20:653–659.CrossRefGoogle ScholarPubMed
10. 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;135:484–492.CrossRefGoogle ScholarPubMed
11. Shay, DK, Goldmann, DA, Jarvis, WR. Reducing the spread of antimicrobial-resistant microorganisms: control of vancomycin-resistant enterococci. Pediatr Clin North Am 1995;42:703–716.CrossRefGoogle ScholarPubMed
12. Moreno, F, Grota, P, Crisp, C, et al. Clinical and molecular epidemiology of vancomycin-resistant Enterococcus faecium during its emergence in a city in southern Texas. Clin Infect Dis 1995;21:1234–1237.CrossRefGoogle Scholar
13. Morris, JG Jr, Shay, DK, Hebden, JN, et al. Enterococci resistant to multiple antimicrobial agents, including vancomycin: establishment of endemicity in a university medical center. Ann Intern Med 1995;123:250–259.CrossRefGoogle Scholar
14. Karanfil, LV, Murphy, M, Josephson, A, et al. A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol 1992;13:195–200.CrossRefGoogle Scholar
15. Boyle, JF, Soumakis, SA, Rendo, A, et al. Epidemiologic analysis and genotypic characterization of a nosocomial outbreak of vancomycin-resistant enterococci. J Clin Microbiol 1993;31:1280–1285.CrossRefGoogle ScholarPubMed
16. Dever, LL, China, C, Eng, RH, O'Donovan, C, Johanson, WG Jr. Vancomycin-resistant Enterococcus faecium in a Veterans Affairs medical center: association with antibiotic usage. Am J Infect Control 1998;26:40–46.CrossRefGoogle Scholar
17. Edmond, MB, Ober, JF, Dawson, JD, Weinbaum, DL, Wenzel, RP. Vancomycin-resistant enterococcal bacteremia: natural history and attributable mortality. Clin Infect Dis 1996;23:1234–1239.CrossRefGoogle ScholarPubMed
18. Lucas, GM, Lechtzin, N, Puryear, DW, Yau, LL, Flexner, CW, Moore, RD. Vancomycin-resistant and vancomycin-susceptible enterococcal bacteremia: comparison of clinical features and outcomes. Clin Infect Dis 1998;26:1127–1133.CrossRefGoogle ScholarPubMed
19. Carmeli, Y, Eliopoulos, GM, Samore, MH. Antecedent treatment with different antibiotic agents as a risk factor for vancomycin-resistant Enterococcus . Emerg Infect Dis 2002;8:802–807.CrossRefGoogle ScholarPubMed
20. Shay, DK, Maloney, SA, Montecalvo, M, et al. Epidemiology and mortality risk of vancomycin-resistant enterococcal bloodstream infections. J Infect Dis 1995;172:993–1000.CrossRefGoogle ScholarPubMed
21. Zaas, AK, Song, X, Tucker, P, Perl, TM. Risk factors for development of vancomycin-resistant enterococcal bloodstream infection in patients with cancer who are colonized with vancomycin-resistant enterococci. Clin Infect Dis 2002;35:1139–1146.CrossRefGoogle ScholarPubMed
22. Lodise, TP, McKinnon, PS, Tam, VH, Rybak, MJ. Clinical outcomes for patients with bacteremia caused by vancomycin-resistant Enterococcus in a level 1 trauma center. Clin Infect Dis 2002;34:922–929.CrossRefGoogle ScholarPubMed
23. Stroud, L, Edwards, J, Danzing, L, Culver, D, Gaynes, R. Risk factors for mortality associated with enterococcal bloodstream infections. Infect Control Hosp Epidemiol 1996;17:576–580.CrossRefGoogle ScholarPubMed
24. 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;30:466–472.CrossRefGoogle ScholarPubMed
25. Lautenbach, E, Bilker, WB, Brennan, PJ. Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality. Infect Control Hosp Epidemiol 1999;20:318–323.CrossRefGoogle ScholarPubMed
26. Stosor, V, Kruszynski, J, Suriano, T, Noskin, GA, Peterson, LR. Molecular epidemiology of vancomycin-resistant enterococci: a 2-year perspective. Infect Control Hosp Epidemiol 1999;20:653–659.CrossRefGoogle ScholarPubMed
27. Lai, KK, Fontecchio, SA, Kelley, AL, Baker, S, Melvin, ZS. The changing epidemiology of vancomycin-resistant enterococci. Infect Control Hosp Epidemiol 2003;24:264–268.CrossRefGoogle ScholarPubMed
28. Lautenbach, E, Schuster, MG, Bilker, WB, Brennan, PJ. The role of chloramphenicol in the treatment of bloodstream infection due to vancomycin-resistant Enterococcus . Clin Infect Dis 1998;27:1259–1265.CrossRefGoogle ScholarPubMed
29. Lautenbach, E, Brennan, PJ. Vancomycin resistance and mortality associated with enterococcal bacteremia. Clin Infect Dis 1997;24:530–531.CrossRefGoogle ScholarPubMed
30. Linden, PK, Pasculle, AW, Manez, R, et al. Differences in outcomes for patients with bacteremia due to vancomycin-resistant Enterococcus faecium or vancomycin-susceptible E. faecium . Clin Infect Dis 1996;22:663–670.CrossRefGoogle ScholarPubMed
31. Warren, DK, Kollef, MH, Seiler, SM, Fridkin, SK, Fraser, VJ. The epidemiology of vancomycin-resistant Enterococcus colonization in a medical intensive care unit. Infect Control Hosp Epidemiol 2003;24:257–263.CrossRefGoogle Scholar
32. Farley, MM, Stephens, DS, Harvey, RC, Sikes, RK, Wenger, JD. Incidence and clinical characteristics of invasive Haemophilus influenzae disease in adults. CDC Meningitis Surveillance Group. J Infect Dis 1992;165(suppl 1):S42–S43.CrossRefGoogle ScholarPubMed
33. Farley, MM, Harvey, RC, Stull, T, et al. A population-based assessment of invasive disease due to group B Streptococcus in nonpregnant adults. N Engl J Med 1993;328:1807–1811.CrossRefGoogle ScholarPubMed
34. Farley, MM, Stephens, DS, Brachman, PS Jr, Harvey, RC, Smith, JD, Wenger, JD. Invasive Haemophilus influenzae disease in adults: a prospective, population-based surveillance. CDC Meningitis Surveillance Group. Ann Intern Med 1992;116:806–812.CrossRefGoogle ScholarPubMed
35. Charlson, ME, Pompei, P, Ales, KL, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–383.CrossRefGoogle ScholarPubMed
36. Friedman, ND, Kaye, KS, Stout, IE, et al. Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 2002;137:791–797.CrossRefGoogle ScholarPubMed
37. Bannerman, TL, Hancock, GA, Tenover, FC, Miller, JM. Pulsed-field gel electrophoresis as a replacement for bacteriophage typing of Staphylococcus aureus . J Clin Microbiol 1995;33:551–555.CrossRefGoogle ScholarPubMed
38. Tenover, FC, Arbeit, RD, Goering, RV, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol 1995;33:2233–2239.CrossRefGoogle ScholarPubMed
39. Stosor, V, Kruszynski, J, Suriano, T, Noskin, GA, Peterson, LR. Molecular epidemiology of vancomycin-resistant enterococci: a 2-year perspective. Infect Control Hosp Epidemiol 1999;20:653–659.CrossRefGoogle ScholarPubMed
40. Lai, KK, Fontecchio, SA, Kelley, AL, Baker, S, Melvin, ZS. The changing epidemiology of vancomycin-resistant enterococci. Infect Control Hosp Epidemiol 2003;24:264–268.CrossRefGoogle ScholarPubMed
41. Warren, DK, Kollef, MH, Seiler, SM, Fridkin, SK, Fraser, VJ. The epidemiology of vancomycin-resistant Enterococcus colonization in a medical intensive care unit. Infect Control Hosp Epidemiol 2003;24:257–263.CrossRefGoogle Scholar
42. Dembek, ZF, Kellerman, SE, Ganley, L, et al. Reporting of vancomycinresistant enterococci in Connecticut: implementation and validation of a state-based surveillance system. Infect Control Hosp Epidemiol 1999;20:671–675.CrossRefGoogle ScholarPubMed
43. Robinson, KA, Baughman, W, Rothrock, G, et al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: opportunities for prevention in the conjugate vaccine era. JAMA 2001;285:1729–1735.CrossRefGoogle ScholarPubMed
44. US Renal Data System: 2004 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases 2005. Available at: http://www.usrds.org/2004/pdf/02_incid_prev_04.pdf. Accessed July 25, 2005.Google Scholar
45. Krop, JS, Coresh, J, Chambless, LE, et al. A community-based study of explanatory factors for the excess risk for early renal function decline in blacks vs whites with diabetes: the Atherosclerosis Risk in Communities study. Arch Intern Med 1999;159:1777–1783.CrossRefGoogle ScholarPubMed
46. Richards, MJ, Edwards, IR, Culver, DH, Gaynes, RP. Nosocomial infections in coronary care units in the United States: National Nosocomial Infections Surveillance System. Am J Cardiol 1998;82:789–793.CrossRefGoogle ScholarPubMed
47. Richards, MJ, Edwards, JR, Culver, DH, Gaynes, RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21:510–515.CrossRefGoogle ScholarPubMed
48. Stosor, V, Kruszynski, J, Suriano, T, Noskin, GA, Peterson, LR. Molecular epidemiology of vancomycin-resistant enterococci: a 2-year perspective. Infect Control Hosp Epidemiol 1999;20:653–659.CrossRefGoogle ScholarPubMed
49. Blumberg, HM, Jarvis, WR, Soucie, JM, et al. Risk factors for candidal bloodstream infections in surgical intensive care unit patients: the NEMIS prospective multicenter study. Clin Infect Dis 2001;33:177–186.CrossRefGoogle Scholar
50. Warren, DK, Kollef, MH, Seiler, SM, Fridkin, SK, Fraser, VI. The epidemiology of vancomycin-resistant Enterococcus colonization in a medical intensive care unit. Infect Control Hosp Epidemiol 2003;24:257–263.CrossRefGoogle Scholar
51. Lesens, O, Methlin, C, Hansmann, Y, et al. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Infect Control Hosp Epidemiol 2003;24:890–896.CrossRefGoogle ScholarPubMed
52. DiazGranados, CA, Jernigan, JA. Impact of vancomycin resistance on mortality among patients with neutropenia and enterococcal bloodstream infection. J Infect Dis 2005;191:588–595.CrossRefGoogle ScholarPubMed
53. Coque, TM, Willems, RJ, Fortun, J, et al. Population structure of Enterococcus faecium causing bacteremia in a Spanish university hospital: setting the scene for a future increase in vancomycin resistance? Antimicrob Agents Chemother 2005;49:2693–2700.CrossRefGoogle Scholar
54. Boyce, JM, Opal, SM, Chow, JW, et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol 1994;32:1148–1153.CrossRefGoogle ScholarPubMed