Epidemiology and control of vancomycin-resistant enterococci in an adult and childrenʹs hospital

Background: The incidence of vancomycin-resistant enterococci (VRE) has reached endemic proportions in many medical centers. To initiate an effective infection control program, an understanding of the epidemiologic attributes of the genus in medical facilities is imperative. Methods: We studied 138 consecutive cases of VRE from April through December 1995. We created a database to analyze the risk factors for patients in both an adult hospital and a childrenʹs hospital and screened all specimens, submitted for routine microbiologic analysis, for VRE. Results: One hundred twenty-three cases (89%) occurred in the adult acute care hospital, and 15 (11%) occurred in the childrenʹs hospital. Eight patients (58%) were colonized with VRE, and 58 (42%) had an infection with VRE. Eighty-three percent of all the cases of VRE were nosocomially acquired. The majority of cases occurred in the medical service. Urine was the most important clinical specimen infected or colonized. Prior use of an antibiotic, other than vancomycin, was the most important risk factor for all nosocomial cases, followed by prior vancomycin use for surgical patients and residence in a unit with other patients infected with VRE for the medical service. Direct admission from another hospital was the most important risk factor for community-acquired cases. Special microbiologic screening of cultures yielded 48% of all VRE identified. Enterococcus faecium was the predominant resistant isolate recovered. Conclusions: The control of VRE in the hospital setting is difficult for several reasons. Almost half of all patients carrying VRE would not have been identified without special microbiologic screening efforts, as would patients, admitted from the community, who are already colonized with VRE. Controlling antibiotic use both in the hospital and the community is basic for controlling these organisms. Continuous education of all staff about VRE and other nosocomially significant organisms is the key to controlling the spread of these bacteria.