Infection Control & Hospital Epidemiology (2018), 39, 1178–1182 doi:10.1017/ice.2018.178
Original Article
Practical methods for effective vancomycin-resistant enterococci (VRE) surveillance: experience in a liver transplant surgical intensive care unit
Rebecca Y. Linfield MD1, Shelley Campeau PhD2,6, Patil Injean DO3, Aric Gregson MD1, Fady Kaldas MD1, Zachary Rubin MD1, Tae Kim MPH4, Danielle Kunz RPH5, Alfred Chan BS4, Delphine J. Lee MD, PhD4,
Romney M. Humphries PhD2,6 and James A. McKinnell MD1,4,5 1David Geffen School of Medicine at University of California–Los Angeles (UCLA), Los Angeles, California, 2UCLA Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, 3Department of Medicine, Western University of Health Sciences, Pomona, California, 4Infectious Disease Clinical Outcomes Research Unit (ID-CORE), Division of Infectious Disease, Los Angeles Biomedical Research Institute at Harbor—UCLA Medical Center, Torrance, California, 5Expert Stewardship, Newport, California and 6(Present affiliation: Accelerate Diagnostics, 13 Tucson, Arizona [S.C., R.M.H])
Abstract
Objective: We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling. Design: Prospective, patient-level surveillance program of incident VRE colonization. Setting: Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE. Patients: All patients admitted to the SICU from June to August 2015. Methods: We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test. Results: In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001). Conclusions: We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.
(Received 29 April 2018; accepted 3 July 2018; electronically published September 5, 2018)
Vancomycin-resistant Enterococci (VRE) infections can be lethal and costly, resulting in 1.5 times higher cost of hospitalization and 2.5 times higher mortality than non–VRE-infected controls.1 VRE infections affect high-risk patient populations such as liver transplant and hematopoietic stem cell (HSC) transplant recipients.2,3 Among California hospitals in 2016, VRE bloodstream infections (BSIs) were seen in 0.0825 cases per 1,000 patient days in academic medical centers compared to 0.0297 cases per 1,000 patient days in community medical centers.4 Early VRE detection in high-risk patients may have implica- tions for infection prevention and treatment outcomes for VRE
Author for correspondence: James A. McKinnell, 1124 West Carson Street Torrance, CA 90502. E-mail:
dr.mckinnell@
gmail.com
Cite this article: Linfield RY, et al. (2018). Practical methods for effective
vancomycin-resistant enterococci (VRE) surveillance: experience in a liver transplant surgical intensive care unit. Infection Control & Hospital Epidemiology 2018, 39, 1178– 1182. doi: 10.1017/ice.2018.178
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
infection. Contact precautions can be effective at reducing VRE transmission.5 Perencevich et al6 predicted that admission VRE screening with contact precaution isolation would reduce VRE transmission by 39%. Effectiveness of targeted infection prevention programs are dependent on early VRE detection.6 Targeted terminal cleaning7 and endoscope reprocessing8 may also reduce transmission. Early VRE detection may lead to improved outcomes from VRE infections. Patients with VRE colonization are at higher risk for VRE infection,9 and early empiric therapy improves clinical outcomes in large, observational cohort studies.10,11 Despite the potential benefits of early VRE detection, optimal surveillance methods for practical clinical use have not been well defined. D’Agata et al12 found that rectal swabs had a sensitivity of 58% in detecting VRE compared with stool samples. Unfor- tunately, routine collection of stool samples is cumbersome. Moreover, our prior work suggests that admission-only screening
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