RESUMEN
OBJECTIVE: To determine risk factors for vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak and to evaluate Centers for Disease Control and Prevention (CDC)-recommended control measures. DESIGN: Epidemiological study involving prospective identification of colonization and a case-control study. SETTING: A university hospital. PARTICIPANTS: Patients on eight wards involved in outbreak from late 1994 through early 1995. METHODS: Cases were matched by ward and culture date with up to two controls. Risk factors were evaluated with four multivariate models using conditional logistic regression. The first evaluated proximity to other VRE patients and isolation status. The second evaluated proximity to unisolated VRE cases and three variables independently predictive after adjustment for proximity. The third evaluated seven significant univariate predictors in addition to proximity to unisolated VRE in backward, stepwise logistic regression. The fourth assessed proximity to VRE with all other variables collected, clustered in a principal components analysis. Pulsed-field gel electrophoresis was performed to assess clonality of two outbreak strains. RESULTS: The incidence of transmission declined significantly after CDC guidelines were implemented. Proximity to unisolated VRE cases during the prior week was a significant predictor of acquisition in each of four multivariate models. Other significant risk factors in multivariate models included a history of major trauma and treatment with metronidazole. Pulsed-field gel electrophoresis confirmed the clonality of two outbreak strains. CONCLUSIONS: VRE was transmitted between patients during a hospital epidemic, with proximity to previously unisolated VRE patients being an important risk factor. Weekly surveillance cultures and contact isolation of colonized patients significantly reduced spread
Asunto(s)
Brotes de Enfermedades/prevención & control , Enterococcus faecalis/aislamiento & purificación , Enterococcus faecium/aislamiento & purificación , Infecciones por Bacterias Grampositivas/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Niño , Preescolar , Enterococcus faecalis/efectos de los fármacos , Enterococcus faecium/efectos de los fármacos , Femenino , Hospitales Universitarios , Humanos , Incidencia , Lactante , Unidades de Cuidados Intensivos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Resistencia a la Vancomicina , Virginia/epidemiologíaRESUMEN
Sixteen percent of hospital room surfaces remained colonized by vancomycin-resistant enterococci (VRE) after routine terminal disinfection. Disinfection with a new "bucket method" resulted in uniformly negative cultures. Conventional cleaning took an average of 2.8 disinfections to eradicate VRE from a hospital room, while only one cleaning was required with the bucket method.
Asunto(s)
Antibacterianos/farmacología , Infección Hospitalaria/prevención & control , Desinfección , Enterococcus faecium/efectos de los fármacos , Infecciones por Bacterias Grampositivas/prevención & control , Vancomicina/farmacología , Desinfección/economía , Desinfección/métodos , Farmacorresistencia Microbiana , Humanos , Habitaciones de Pacientes , Estados UnidosRESUMEN
BACKGROUND: With the development of nosocomial pathogens that are resistant to multiple antimicrobial agents, reasonable restriction of antibiotic use has become a priority. METHODS: During an outbreak of vancomycin-resistant enterococcal infections, an audit of vancomycin hydrochloride use was conducted during October 3 through 21, 1994, and January 24 through February 2, 1995. During these periods, all orders for vancomycin were reviewed by clinical pharmacists. Use was classified as either appropriate or inappropriate based on recommendations by the Hospital Infection Control Practice Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention, Atlanta, Ga. A policy restricting the use of vancomycin was adopted in November 1994. RESULTS: During the first audit in October 1994, 61% of vancomycin orders were considered inappropriate according to HICPAC criteria. At the time of this audit, the first cases of an outbreak of nosocomial vancomycin-resistant Enterococcus faecium had been detected. The follow-up audit showed that 30% of vancomycin orders were inappropriate by HICPAC criteria (P < .001). Overall use of vancomycin decreased by 50% and remained at this lower level for the following year. CONCLUSION: The institution of a vancomycin restriction policy was associated with a reduction of both inappropriate drug orders and total use.
Asunto(s)
Antibacterianos/uso terapéutico , Infección Hospitalaria/tratamiento farmacológico , Brotes de Enfermedades , Prescripciones de Medicamentos , Enterococcus faecium , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Administración Hospitalaria , Formulación de Políticas , Pautas de la Práctica en Medicina , Vancomicina/uso terapéutico , Profilaxis Antibiótica , Costos de los Medicamentos , Farmacorresistencia Microbiana , Utilización de Medicamentos , Fiebre/tratamiento farmacológico , Estudios de Seguimiento , Costos de Hospital , Departamentos de Hospitales , Humanos , Auditoría Médica , Neutropenia/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud , Pediatría , Farmacología Clínica , Servicio de Farmacia en Hospital , Servicio de Cirugía en Hospital , Procedimientos Quirúrgicos Operativos , Resistencia betalactámicaRESUMEN
BACKGROUND: In 1990, the Centers for Disease Control and Prevention recommended substituting dust-mist particulate respirators for simple isolation masks in acid-fast bacillus isolation rooms, reasoning that air leaks around the simple masks could result in a higher rate of purified protein derivative skin-test conversion. In 1993, a Centers for Disease Control and Prevention draft guideline proposed that high-efficiency particulate air filter respirators be used instead of dust-mist particulate respirators. Epidemiologic data were not available to assess the importance of these changes or their cost-effectiveness. METHODS: The University of Virginia was affiliated with a tuberculosis hospital from 1979 until 1987. We surveyed physicians who had served as residents in internal medicine during this period regarding purified protein derivative skin-test history. duration of work at the tuberculosis sanatorium, and any history of unprotected exposures to patients with active pulmonary or laryngeal tuberculosis. Patients with active tuberculosis at the sanatorium were isolated in negative-pressure rooms with UV lights. Physicians wore simple isolation masks in these rooms. RESULTS: Responses were received from 83 former resident physicians. Fifty-two physicians had worked on the tuberculosis wards for a total of 420 weeks, with no subsequent skin-test conversions (95% CI 0 to 1 conversion/8 physician-years). CONCLUSIONS: These data document a low risk of occupational transmission of Mycobacterium tuberculosis to physicians who wear simple isolation masks in negative-pressure ventilation rooms with UV lights. This low rate predicts that the additional protective efficacy and cost-effectiveness of the more expensive high-efficiency particulate air filter respirators and the respiratory protection program will be low.