Evidence

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Ostrowsky BE et al.  To assess risk factors  Case-control study and  Among the 30 facilities that participated in all three This study demonstrated how

1 for VRE colonization. point-prevalence survey. years of the point prevalence survey, the overall a comprehensive infection

“Control of vancomycin-  To evaluate the effects  Setting: 32 health care prevalence of VRE colonization decreased from control policy, which includes

resistant Enterococcus of an intervention facilities (including 28 LTC 2.2% in 1997 to 0.5% in 1999 (p < 0.001). ongoing surveillance, patient

in health care facilities program on VRE facilities) located within 50  The number of LTC facilities with screening and screening, and isolation, can

in a region” prevalence. miles of Sioux City, Iowa. infection control policies increased in 1998 and be effective in decreasing the

 Time period: July & 1999 as compared to 1997. prevalence of VRE.

New England Journal of August 1997, October  With respect to specific infection-control practices,

Medicine 1998 & October 1999. 21 of 23 LTC facilities in 1998 and 22 of 25 in 1999 Similar to other studies, this

 Study population: either isolated VRE-positive patients or grouped study identified prior

2001;344(19):1427-33.  Case-Control Study: them together. hospitalization and antibiotic

Cases: N=29.  Within the acute care facilities, significant risk use as predictors for VRE

Controls: N=114. factors for VRE colonization were hospitalization colonization.

 Prevalence surveys: within the past 6 months, prior antibiotic therapy,

1997: N=1,934. diarrhea, and the presence of a urinary catheter. However, there were several

1998: N=1,954.  Within the LTC facilities, hospitalization within the study limitations including the

1999: N=1,820. past 6 months (OR = 5.9, p < 0.05) and prior following:

antibiotic use (OR = 4.6, p < 0.05) were both

significant predictors of VRE colonization. The lack of demographic

information on participants.



Only 30 of the 32 facilities

participated in all three

surveys.



Cultures were obtained from

a smaller proportion of acute

care patients as compared to

LCTF residents.



The use of a single perianal

swab may not have been

sufficient to detect VRE

colonization in some patients.



The authors did not address

the implications of the wide

confidence intervals

associated with some of the

odds ratios.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Tokars JI et al.  To determine the  Prospective prevalence  The prevalence of VRE among hospitalized patients In addition to prior receipt of

2 prevalence of VRE in a study. was 29%. antibiotics, the duration of

“The prevalence of Veterans Affairs facility.  Setting: A Veterans Affairs  Prior receipt of intraveneous ceftriaxone, therapy was also a significant

colonization with  To identify risk factors medical center in Atlanta, ceftazidime, cefuroxime, clindamycin, vancomycin, risk factor for VRE

vancomycin-resistant for VRE. Georgia with an adjoining and ticaricillin-clavulanic acid, either individually or colonization among

Enterococcus at a  To evaluate the utility of LTC facility. in combination, was a significant risk factor for VRE hospitalized patients.

Veteran’s Affairs cultures from recent  Time period: February- colonization.

institution” roommates as a means March 1996.  As the number of antimicrobial days increased from Since the authors found no

of detecting VRE  Study population: zero to 15, VRE prevalence increased from 5% to evidence of clustering, they

Infection Control and colonization.  Hospital: N=147; 78%, respectively (p < 0.001). concluded that obtaining

Hospital Epidemiology median age = 64.  There was no statistically significant clustering of cultures from roommates of

 LTCF: N=77; median VRE-positive patients in multi-bed rooms. VRE-positive patients was

1999;20(3):171-75. age not reported.  None of the LTC residents included in the study not a useful screening tool.

were VRE positive. However, their results may

have been affected by the

small number of patients

included in the analysis.



Surprisingly, the authors did

not find any cases of VRE

among the LTC population.

They attributed this to a long

median duration since

admission to the LTC facility,

as well as to a very low rate

of antimicrobial use.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Elizaga ML et al.  To determine the  Prospective, observational  Upon admission to the hospital, 45 patients were The authors concluded that

3 prevalence of rectal cohort study. colonized with VRE. almost half of the LTC

“Patients in long-term colonization with VRE  Setting: Two 37-bed  Of the remaining 55 patients, 14 acquired VRE residents were colonized with

care facilities: A among LTC residents medical wards in an while hospitalized. VRE prior to hospital

reservoir for admitted to acute care academic acute care  Univariate analysis revealed that hospitalization in admission. This suggests

vancomycin-resistant hospitals. hospital in Chicago. the past 60 days, admission diagnosis of infections, that VRE is endemic in LTC

Enterococci”  To identify risk factors  Time period: January – inability to ambulate, feeding tubes, urinary facilites.

for colonization. November 1996. catheters, decubitus ulcers, and prior antibiotic use

Clinical Infectious  To assess the  Study population: were all potential risk factors for VRE colonization. While several potential risk

Disease contribution of LTC  Size: N=117.  Using stepwise logistic regression, only prior factors were identified, only

residents to VRE  Predominantly female, antibiotic use (OR = 3.5, p < 0.05) and the presence decubitus ulcers and prior

2002;34(15):441-46. epidemiology in the African-American. of decubitus ulcers (OR = 4.2, p < 0.05) were antibiotic therapy were

acute care setting.  Admitted from 20 identified as significant risk factors. significantly associated with

different LTC facilites.  No significant risk factors for nosocomial acquisition VRE colonization.

 Mean age: 78 years. of VRE were identified.

 Twenty-six patients had both skin and rectal Because of the small sample

colonization with VRE. size, the authors were not

 The mean point prevalence of VRE colonization able to discern if specific

among LTC residents was significantly higher than antimicrobial combinations or

that of all other patients (60% vs. 21%, p < 0.001). durations of therapy

contributed to the overall risk

of VRE acquisition.



Other limitations included the

lack of information regarding

prior hospitalizations and the

assumption of “probable

antibiotic use” in patients with

specific diagnoses.

Additionally, the authors

noted that the study was not

designed to identify cross-

colonization among LTC

residents.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Trick WE et al.  To determine the  Prospective point-  50 (43%) of the 117 residents were colonized with This study identified poor

4 frequency of prevalence survey at least one of the target organisms. functional status and prior

“Colonization of skilled- colonization with MRSA, combined with chart  21% were culture positive for MRSA. antibiotic use as significiant

care facility residents VRE, or extended- review.  33% were culture positive for an ESBL- risk factors for colonization

with antimicrobial- spectrum B-lactamase  Setting: Skilled-care unit producing organism. with antimicrobial resistant

resistant pathogens” (ESBL) producing gram in a 667-bed hospital in  3.5% were culture positive for VRE. organisms.

negative organisms in Illinois.  26% were colonized with two target

Journal of the American residents of a skilled  Time period: June 1998. organisms. There was a surprisingly

Geriatrics Society nursing facility.  Study population:  Of the 50 colonized residents, only 3 were on small number of VRE-positive

 To evaluate risk factors  Size: N=120. contact-isolation precautions. residents identified in this

2001;49(3):270-76. for colonization.  Median age = 60  Prior antibiotic receipt within the previous 6 months study. This may explain the

years. (RR = 6, 95% CI: 1.8-19, p < 0.05) and total wide confidence intervals that

dependence on health care workers for activities of were reported for the VRE

daily living (ADLs) (RR = 3.4, 95% CI: 1.2-10, p < risk factors. A larger sample

0.05) were significantly associated with MRSA size would aid in validating

colonization. these results.

 Total dependence on health care workers for ADLs

was also a significant risk factor for colonization

with ESBL-producing Klebsiella pneumoniae (RR =

3.9, 95% CI: 1.2-13, p < 0.05).

 Residents colonized with VRE were significantly

more likely to have MRSA colonization (RR = 11,

95% CI: 1.2-103, p = 0.029), to have received

antimicrobials (RR = undefined, p = 0.051) or to

have has a shorter length of stay ( 19 vs. 74

months, p = 0.045).

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Brennen C et al.  To describe the  Prospective observational  Of the 36 patients colonized with VREF, 24 (67%) Nosocomially acquired VREF

5 epidemiology of study. were already colonized when they were transferred plays an important role in the

“Vancomycin-resistant colonization with  Setting: 400-bed LTC from an acute care facility. prevalence of VRE

Enterococcus faecium vancomycin-resistant Veterans Affairs facility in  17 of the 36 were also colonized with MRSA and 7 colonization in LTC facilities.

in a long-term care Enterococcus faecium Pittsburgh. had a recent history of C. difficile-associated

facility” (VREF) in a LTC facility.  Time period: June 1993 – diarrhea. The results of this study

December 1994.  Average duration of VRE carriage was 67 days. highlighted several important

Journal of the American  Study population:  Antimicrobial treatment after colonization resulted in points:

Geriatrics Society  Size: N=36. a significantly longer carriage time (p = 0.041).

 Mean age: 70.3 years.  There was not a significant relationship between Residents with VREF

1998;46(2):157-60.  All patients were male. underlying disease or the presence of indwelling colonization rarely develop

catheters and clearance of VREF. clinical infection.

 None of the patients colonized with VREF

developed clinical infection. Patient-to-patient

transmission can be

prevented with appropriate

control measures.



Inappropriate antimicrobial

use may contribute the

prevalence of VRE

colonization.



Patients colonized with VREF

are often colonized with other

pathogens like MRSA and C.

difficile.



In most patients, VRE

colonization will clear

spontaneously.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Willey BM et al.  To evaluate and  Clinical methodology  The researchers performed broth microdilution and Clinical laboratories should

8 compare the accuracy study. disk diffusion susceptibility tests in accordance with be able to accurately identify

“Detection of of different testing  155 entorococcal isolates National Committee of Clinical Laboratory vancomycin-resistant

vancomycin resistance methods in detecting were collected and Standards (NCCLS) guidelines. The results of both Enteroccus species as well

in Enterococcus vancomycin resistance. subjected to various tests were compared and discrepancies between as their susceptibilities.

species” susceptibility tests. the two tests were categorized as very major errors,

 Setting: Isolates were major errors, or minor errors. This study evaluated different

Journal of the Clinical obtained from the New  Using broth dilution, 98 isolates were testing methods and the

Microbioloogy York City Bureau of resistant, 52 were moderately susceptible, authors concluded that both

Laboratories and the and 5 had intermediate susceptibility to disk diffusion and the agar

Mount Sinai Hospital in vancomycin. screen plate method were

1992;30(7):1621-24. Canada.  Disk diffusion testing resulted in nine (5.8%) reliable tests for vancomycin

 Time period: Isolates were minor errors but no major or very major resistance. The simplicity

collected over an 8 month errors. and low cost of the screen

period in 1991.  The Vitek Gram-Positive Susceptibility card, Pos plate method makes it an

MIC type 6 panel with Walk/Away system, and an attractive alternative to disk

agar screen plate were evaluated for sensitivity and diffusion.

specificity.

 The Vitek card was 72% sensitive and 100% The low sensitivity of the

specific. Vitek system and the need

 The Pos MIC panel was 93% sensitive and for visual inspection with the

98% specific; sensitivity increased to 99% Walk/Away system reduced

when panels were subjected to visual their overall utility.

inspection rather than automated readings.

 The agar screen plate method was A potential limitation of this

determined to be 100% sensitive and specific study was the small number

at all vancomycin concentrations. of isolates, particularly those

 Screen plates containing 6 and 8g of with intermediate

vancomycin per ml were easier to read than susceptibility.

those with higher concentrations.

 74% of the vancomycin-resistant or moderately

susceptible isolates demonstrated high level

resistance to gentamycin and streptomycin.

 70% of the vancomycin-resistant strains were

resistant to teicoplanin.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Swenson JM et al.  To establish optimum  Clinical methodology  In Phase I, BHI agar containing 6 g of This study provided further

9 testing conditions for study conducted in two vancomycin per ml produced the fewest errors in evidence that the agar screen

“Development of the agar screening phases. detecting vancomycin resistance and was selected method is a reliable means of

standardized screening method used in  Phase 1: for further study in Phase 2. confirming vancomycin

method for detection of detecting vancomycin  Compared Mueller-  In Phase 2, the agar screen method demonstrated resistance. Specifically, the

vancomycin-resistant resistance. Hinton (MH) agar and 100% sensitivity. authors recommended using

Enterococci” brain heart infusion  For most Enteroccoci strains, the specificity of the BHI agar, 6g of vancomycin

(BHI) agar based on test ranged from 96% to 99%. However, the per ml, and of inoculum of

5 6

Journal of Clinical their ability to detect specificity was poor (25%) for clinical strains of 10 to 10 CFU per spot.

Microbiology vancomycin Enterococus casseliflavus.

resistance.

1994;32(7):1700-04.  Compared 3

vancomycin

concentrations: 4,

6,and 8g/ml.

 N = 100 isolates.

 Phase 2:

 Evaluated screen test

in 8 laboratories

across the US.

 N = 157 isolates.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Landman D et al.  To examine the  Clinical methodology  VRE were isolated from 101 of the 189 perianal The authors concluded that

10 sensitivity of five study. cultures. the Enterococcul broth

“Comparison of five different media for  Setting: Veterans Affairs  Methods 1, 2, and 3 were the least sensitive, medium (method 5) was the

selective media for detecting VRE from Medical Center in detecting less than half of the positive isolates. most sensitive in detecting

identifying fecal perianal cultures. Brooklyn, NY.  Method 3 was the simplest test to perform. VRE resistance.

carriage of vancomycin-  Time period: January  Method 4 was significantly better than the first three

resistant Enterococci” 1995. methods with a sensitivity of 69%. They also suggested that the

 N = 189 isolates.  Method 5 demonstrated the highest sensitivity at bile esculin azide agar

Journal of Clinical  The five culture media 87%. (method 3) might be an

Microbiology were as follows:  Final identification of VRE required one day for inexpensive alternative for

method 4, two days for methods 2 and 3, and three some laboratories. However,

1996;34(3):751-52. Method 1: tryptic soy broth days for methods 1 and 5. considering the sensitivity of

with vancomycin 64g/ml that medium was less that

and aztreonam 60g/ml. 50%, one might question the

validity of that

Method 2: Mueller-Hinton recommendation.

(MH) agar with

vancomycin 20g/ml,

polymixin 100g/ml, and

streptomycin 100g/ml.



Method 3: bile esculin

azide agar with a 30mg

vancomycin disk.



Method 4: Campylobacter

blood agar plate with

clindamycin 75g/ml.



Method 5: Enterococcul

broth with vancomycin

64g/ml and aztreonam

60g/ml.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Weinstein JW et al.  To determine the  Clinical methodology  Both rectal and perirectal swabs demonstrated The results of this study

11 sensitivity of rectal and study. 79% sensitivity and 83% positive predictive value. indicate that rectal and

“Comparison of rectal perirectal swabs for  Setting: Tertiary care  The specificities of rectal and perirectal swabs were perirectal swabs are equally

and perirectal swabs for VRE detection. medical center in 87% and 86%, respectively. sensitive and may be used

detection of  To evaluate the Connecticut.  The negative predictive values were 83.3% and interchangeably for VRE

colonization with concordance of results  N = 13 patients; 82 paired 82.6%, respectively. detection.

vancomycin-resistant between rectal swabs, swabs.  There was 100% concordance between the two

Enterococci” perirectal swabs and types of swabs and there was 91% concordance The perirectal swabs may be

stool cultures. when the swabs were compared to stool cultures. particularly useful in patients

Journal of Clinical who refuse rectal swabs or in

Microbiology neutropenic patients in whom

rectal swabs are

116;34(1):210-12. contraindicated.



The authors were unable to

determine the relative

sensitivity of the stool

cultures because they were

obtained in only 11 of the 13

patients.



The primary limitation of this

study was the small sample

size. Additionally, the

authors indicated that the

sensitivities and specificities

may have been

underestimated due to the

strict definitions used.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Tenorio AR et al.  To assess the  Prospective observational  16 of the 50 (32%) healthcare workers had VRE on The use of gloves reduced

12 effectiveness of routine study. their hands prior to patient contact. the risk of VRE hand

“Effectiveness of gloves gloving in the  Setting: 824-bed teaching  Of those, 6 had a patient’s VRE strain on their hand contamination by 71%.

in the prevention of prevention of hand hospital in Chicago. and were excluded from further evaluation. However, since the gloves

hand carriage of carriage of VRE by  Study population:  The 44 remaining workers wore non-sterile did not provide complete

vancomycin-resistant health care workers.  Patients: N=10. powdered latex examination gloves while protection, this study

Enterococcus species  Caregivers: N=50. performing patient care. supports the practice of hand

by health care workers  17 (39%) workers acquired VRE on their gloves washing before and after

after patient care” after patient contact, and 5 of those workers also wearing gloves.

had VRE contamination on their hands after glove

Clinical Infectious removal. Furthermore, the authors

Disease  Three workers who did not have any direct patient recommend a universal

contact but who performed manipulations in the gloving policy for health care

2001;31(5):826-29. patient rooms were among those with glove workers at institutions with a

contamination. high prevalence of VRE

 Univariate analysis revealed several risk factors for colonization.

VRE contamination during patient care including:

duration of contact, contact with patient body fluids, An important observation was

presence of diarrhea in a patient, mean VRE colony that the prevalence of VRE

counts on a patient’s skin, and the number of body colonization among

sites colonized with VRE. healthcare workers may

contribute to the horizontal

transmission of VRE.

According to the authors,

“this helps maintain a high

endemic level of patient

colonization.”



There were several

drawbacks to this study

design, most notably the

absence of a control group.

Additionally, the authors were

unable to distinguish between

internal and external

contamination of the glove

surfaces. This prevented

them from assessing the

mechanism of glove to hand

transmission.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Bonilla HF et al.  To compare the  Prospective, point  Patients in the LTC unit were more likely to have This study identified a high

13 epidemiology of VRE in prevalence survey. VRE colonization than those in the acute-care level of environmental

“Colonization with a LTC unit and an  Setting: 200-bed hospital (OR = 2.64, p = 0.023). contamination and hand

vancomycin-resistant acute-care hospital. Veterans Affairs Medical  Transmission of VRE strains between roommates carriage of VRE in the LTC

Enterococcus faecium: Center with an attached was uncommon. unit. The authors

Comparison of a long- 90-bed LTC unit in  VRE was more likely to be identified from recommended further studies

term care unit with an Michigan. environmental cultures obtained from the LTC unit to evaluate the role that these

acute-care hospital”  Time period: December than those obtained from the acute-care hospital factors may play in the

1994 to August 1996. (OR = 4.14, p = 0.001). transmission of VRE.

Infection Control and  Study population:  In the LTC unit, bed rails and bedside tables were

Epidemiology  Patients: N=34. most frequently positive for VRE. It is possible that the higher

 Health care workers:  Health care workers in the LTC unit were more rate of endemicity of VRE in

1997;18(5):333-39. total number of unique likely to have VRE contamination on their hands the LTC unit as compared to

subjects not specified. compared to those in the acute-care setting (OR = the acute care setting may be

4.09, p = 0.004). related to the longer length of

 Hand washing was effective in eliminating VRE stay in LTC units.

carriage in 12 of 14 workers.

Of note was the fact that

despite the high rate of VRE

colonization and

environmental contamination

in the LTC unit, infection

rates in that population were

relatively low.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Goetz AM et al.  To quantify the  Prospective observational  VRE was isolated from 210 patients during the In this study, VRE

14 incidence of VRE study. study period. colonization rates exceeded

“Infection and infection versus  Setting: Veterans Affairs  Forty (19%) of those patients developed 47 infection rates by a ratio of

colonization with colonization. Medical Center in infections; 1/3 of which were urinary tract infections. 4:1.

vancomycin-resistant  To identify risk factors Pittsburgh.  Twenty-five (17%) patients cleared VRE during their

Enterocooccus faecium for VRE infection.  Time period: 27-month hospital stay. The authors identified

in an acute care  To define the natural period between January  Univariate analysis revealed that liver specific risk factors

Veteran’s Affairs history of VRE 1994 and March 1996. transplantation, chemotherapy, TPN, and associated with VRE

Medical Center: A 2- colonization.  Study population: corticosteroid use were significantly associated with infection, but postulated that

year survey”  N=210. VRE infection. those risk factors may have

 98% males.  Multivariate analysis revealed that only TPN (OR = been indicative of the severity

American Journal of  Mean age = 65 years. 4.3, CI95 1.9-9.8 p < 0.01) and chemotherapy (OR = of illness and not necessarily

Infection Control 6.9, CI95 1.7-27.3, p < 0.01) were significantly causative factors.

associated with VRE infection.

1998;26(6):558-62.  94% of VRE positive patients had received prior Contrary to several other

antibiotic therapy. studies, this study failed to

 Twenty environmental cultures were collected and identify any environmental

all were negative for VRE. contamination with VRE.



The authors concluded that

an “appropriate isolation

policy, ongoing staff

education, and regular

surveillance were not

sufficient to control the

dissemination of VRE.”



The lack of a control group

and specific information on

incidence rates (e.g., if/how

they changed over the 27-

month period) prevents

accurate assessment of the

overall results.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Armstrong-Evans M et  To describe the  Prospective surveillance  VRE was isolated from the urine of one of the LTC This study described a case

16 al. investigation and study. residents following admission to an acute care in which infection control

control of transmission  Setting: 254-bed facility. measures were successful in

“Control of transmission of VRE in a residential residential LTC facility in  Based on this case, the authors decided to screen preventing the spread of VRE

of vancomycin-resistant LTC setting. Canada. rectal swabs from all of its 235 residents for the in a LTC facility.

Enterococcus faecium  Time period: 1996. presence of VRE.

in a long-term care  Study population:  In addition to the index case, 4 additional residents The authors suggested that

facility”  Size: N=235. were colonized with the same strain of VRE. their infection control

 Mean age: 82 years.  None of the cases were roommates and there were measures may have been

Infection Control and no signs of clustering. easier to implement than

Hospital Epidemiology  Infection control measures were instituted for the most cases because all of the

colonized residents at a cost of $12,061.* colonized residents were in

1999;20(5):312-17.  No further cases were detected following the wheelchairs and relatively

implementation of infection control measures. easy to confine.

 Bacitracin therapy (75,000 units four times daily for

2 weeks) was only successful in clearing VRE The greatest cost associated

carriage in one of the colonized residents. with the control measures

was due to the collection and

screening of specimens.

This highlights the extent of

*Infection control measures included educational laboratory resources needed

programs, cohorting colonized patients, VRE to control VRE transmission.

precautions, treatment to eradicate VRE carriage, and

environmental cleaning.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Katz KC et al  To compare an  Retrospective, cost-  The authors compared two different screening The authors proposed a

17 intensive VRE effectiveness study. strategies. One involved intensive screening of focused screening strategy

“A comparison of screening strategy to  Setting: 1,000-bed tertiary high risk patients, select patients on low risk wards that limits VRE screening to

multifaceted versus one focused on the care center in Canada. as well as all samples sent for C. difficile testing. stool samples submitted for

Clostridium difficile- screening of  Costs: labor costs The other “focused screening strategy” only C. difficile assays. Rectal

focused VRE Clostridium difficile associated with specimen screened samples sent for C. difficile testing and swab screening would be

surveillance strategies samples. collection, laboratory rectal swabs from patients on wards where new limited to those patients on

in a low-prevalence costs. VRE cases were detected. wards with new VRE cases

setting”  Outcome: detection of  Overall, 66 VRE cases were identified by the detected from the C. difficile

new VRE cases. intensive screening strategy. samples.

Infection Control and  Time period: April 1996 to  48 (73%) of those cases would have been detected This type of strategy has the

Hospital Epidemiology July 1999. by the focused screening strategy. potential for significant cost

 Study Sample:  Focused ward screening was significantly more savings.

2001;22(4):219-21.  3,660 rectal swabs. likely to detect new VRE cases compared to

 7,831 C. difficile nonfocused ward screening (11/667 vs. 18/2,993, p However, as many as 23% of

specimens. = 0.01). the VRE cases may be

 There was no association between VRE missed by this type of

colonization and C. difficile toxin positivity. strategy. The authors did not

 The focused screening strategy would have cost attempt to quantify the cost of

32% less than the current program with an not detecting these cases.

estimated cost savings of $60,668.

A prospective study would

provide a more accurate

analysis of the proposed

screening strategy.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Leber AL et al.  To study VRE  Prospective prevalence  525 specimens submitted for C. difficile toxin assay The quarterly surveillance of

18 gastrointestinal and cost anlaysis. were tested for VRE via quarterly surveillance. stool samples submitted for

“Laboratory-based colonization prevalence  Setting: Large university  104 (19.8%) of the 526 specimens were positive for C. difficile assay combined

surveillance for in high-risk hospitals. teaching hospital in VRE stool colonization. with screening C. difficile

vancomycin-resistant  To assess the cost and California.  10 (9.6%) of the 104 patients with VRE colonization positive specimens for VRE

enterococci: Utility of utility of laboratory-  Time period: October subsequently developed VRE infection. may be a cost effective

screening stool based surveillance. 1996 to June 1999.  Patients with positive C. difficile assays were more strategy for detecting VRE

specimens submitted  Study sample: likely to be colonized with VRE (OR = 2.3, 95% CI: colonization among high risk

for Clostridium difficile  Quarterly prevalence 1.2-4.5). hospitalized patients.

toxin assay” survey: N=526.  Patients with VRE-positive specimens were

 Screening culture significantly older than those with VRE-negative The disadvantage of only

Infection Control and survey: N=140. specimens (median, 66 vs. 51 years, p < 0.001). screening C. difficile positive

Hospital Epidemiology  Costs: laboratory based  Beginning in July 1998, C. difficile-positive stool specimens is that some VRE

surveillance, cost per specimens were routinely screened for VRE. positive patients may go

2001;22(3):160-64. VRE-positive patient,  Between July 1998 and June 1999, 41% of patients undetected. The authors

annual cost of screening with positive C. difficile assays were also colonized estimated that they may have

specimens. with VRE. missed as many as four VRE

positive patients for every

 Outcomes: detection of  The cost of quarterly surveillance of stool

one patient identified via a

VRE colonization. specimens submitted for C. difficile assays

positive C. difficile screen.

combined with routine screening of all C. difficile

positive specimens was $5,800 per year and $62

Unfortunately, the cost of

per VRE-positive patient identified. This was based

routinely screening every

on a screening rate of 50 specimens per quarter.

stool specimen submitted for

a C. difficile assay may limit

the feasibility of such a

strategy.

Vancomycin-resistent Enterococcus

Table 1: Detailed description of each study

# Article Objectives Study Design Main Findings Discussion

Silverblatt FJ et al.  To test the  Prospective point  Residents were cultured before transfer to the acute Rapid identification and

20 effectiveness of an prevalence study. care facility and upon their return. If a positive VRE isolation of VRE-positive

“Preventing the spread infection control  Setting: A 252-bed, state- culture was obtained, the patient would be isolated patients transferred from

of vancomycin-resistant program in preventing supported veterans and treated with oral bacitracin. acute care facilities is an

Enterococci in a long- the spread of VRE from nursing home and an  During the study period, a total of 170 patients at effective means of preventing

term care facility” an acute care setting to acute care veterans the acute care facility were colonized with VRE. the spread of VRE to

a LTC facility. hospital in Rhode Island.  90 residents were identified as VRE positive upon noncolonized LTC residents.

Journal of the American  Time period: May 1996 to transfer to the LTC facility. These patients were

Geriatrics Society January 1999. isolated or cohorted and colonization usually Although the authors treated

 Study population: resolved within a month. VRE-positive patients with

2000;48(10):1211-15.  1996: N=69.  In the prevalence surveys, none of the LTC oral bacitracin, they

 1998: N=120. residents who were cultured were VRE positive. acknowledged that the utility

of this practice is debatable

and requires further study.



The use of a convenience

sample raises the possibility

that selection bias may have

influenced the overall results.

However, when the authors

compared the demographic

characteristics of those

residents who were cultured

and those who were not, they

found no significant

differences between the two

groups.

Table 2: Guideline, Recommendation, or Review – VRE

# Article Guidelines or Recommendations

“Recommendations for preventing the spread of  This report from the CDC and HICPAC

6 vancomycin resistance. Recommendations of the provides guidelines for the prevention and

Hospital Infection Control Practices Advisory control of vancomycin resistance with

Committee (HICPAC)” specific focus on VRE. These

recommendations were aimed specifically at

Morbidity and Mortality Weekly Report hospitals and not necessarily directly

applicable to the LTC setting.

1995;44(RR12):1-13.



Centers for Disease Control and Prevention  This fact sheet covers main points related to

7 the isolation, molecular typing, and

“Fact Sheet: Vancomycin-resistant enterococci screening of VRE in the clinical laboratory.

(VRE) and the clinical laboratory”



Available at:

http://www.cdc.gov/ncidod/hip/Lab/FactSheet/vre.htm



1999.



Crossley K  This paper was designed to supplement

15 HICPAC recommendations and provide

“SHEA Position Paper: Vancomycin-resistant realistic infection control guidelines for use

enterococci in long-term care facilities” in the LTC setting.



Infection Control and Hospital Epidemiology



1998;19(7):521-25.



Dever L  This article provides a review of the

19 epidemiology of VRE as well as commonly

“Vancomycin-resistant enterococcal infections: employed treatment options. It also

Epidemiology and treatment” describes some novel antibiotics that are

currently under investigation.

Annals of Long-Term Care



1999;7(10):375-80.