Advertisement

Vancomycin-resistant Enterococcus outbreak in a neonatal intensive care unit: Epidemiology, molecular analysis and risk factors

      Background

      Vancomycin-resistant Enterococcus faecium (VRE) may cause outbreaks in neonatal intensive care units (NICU). We describe a biphasic VRE outbreak and identify risk factors for VRE acquisition.

      Methods

      After the occurrence of 2 cases of VRE infections in a 44-bed NICU, a bundle of interventions was implemented that included active surveillance cultures for VRE, enhanced infection control measures, and audits on antimicrobial use, from June to December 2008. Analysis was performed using polymerase chain reaction and pulse-field gel electrophoresis techniques. A case-control study was conducted to identify risk factors.

      Results

      Among 253 neonates screened, 101 (39.9%) were found to be colonized with VRE. During the first 9 weeks of the study period, 59 new cases were detected. Molecular analysis showed 1 predominant clone. During weeks 10-12, no new cases of VRE colonization were detected; however, at week 13, just when the outbreak appeared to be over, a second wave occurred, with 42 new cases and multiple clones detected. Multivariate analysis identified administration of antimicrobial therapy for late-onset neonatal sepsis and hospitalization during the first month of this outbreak as significant risk factors for VRE colonization.

      Conclusion

      Both a high prevalence of VRE colonization and antimicrobial use promoted the transmission of VRE during this biphasic outbreak. Adherence to infection control measures and antimicrobial stewardship policies are of utmost importance.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Butler K.M.
        Enterococcal infection in children.
        Semin Pediatr Infect Dis. 2006; 17: 128-139
        • Sava I.G.
        • Heikens E.
        • Huebner J.
        Pathogenesis and immunity in enterococcal infections.
        Clin Microbiol Infect. 2010; 16: 533-540
        • Bilikova E.
        • Koprnova J.
        • Hafed B.M.
        • Svetlansky I.
        • Chovancova D.
        • Drobna M.
        • et al.
        Nosocomial enterococcal infection in neonates.
        Int J Infect Dis. 2004; 8: 127-129
        • Das I.
        • Gray J.
        Enterococcal bacteremia in children: a review of seventy-five episodes in a pediatric hospital.
        Pediatr Infect Dis J. 1998; 17: 1154-1158
        • Luginbuhl L.M.
        • Rotbart H.A.
        • Facklam R.R.
        • Roe M.H.
        • Elliot J.A.
        Neonatal enterococcal sepsis: case-control study and description of an outbreak.
        Pediatr Infect Dis J. 1987; 6: 1022-1026
        • Woodford N.
        • Stigter J.M.
        Molecular investigation of glycopeptide resistance in gram-positive bacteria.
        in: Woodford N. Johnson A.P. Molecular bacteriology. Humana, Totowa [NJ]1998: 579-615
        • Torres-Viera C.
        • Dembry L.M.
        Approaches to vancomycin-resistant enterococci.
        Curr Opin Infect Dis. 2004; 17: 541-547
        • Lode H.M.
        Clinical impact of antibiotic-resistant Gram-positive pathogens.
        Clin Microbiol Infect. 2009; 15: 212-217
        • Bagga B.
        • Shenep J.L.
        Management of infections caused by vancomycin-resistant gram-positive bacteria.
        Pediatr Infect Dis J. 2010; 29: 662-664
        • Lee H.K.
        • Lee W.G.
        • Cho S.R.
        Clinical and molecular biological analysis of a nosocomial outbreak of vancomycin-resistant enterococci in a neonatal intensive care unit.
        Acta Paediatr. 1999; 88: 651-654
        • Patel R.
        Clinical impact of vancomycin-resistant enterococci.
        J Antimicrob Chemother. 2003; 51: iii13-iii21
        • Matar M.J.
        • Tarrand J.
        • Raad I.
        • Rolston K.V.
        Colonization and infection with vancomycin-resistant Enterococcus among patients with cancer.
        Am J Infect Control. 2006; 34: 534-536
        • Werner G.
        • Coque T.M.
        • Hammerum A.M.
        • Hope R.
        • Hryniewicz W.
        • Johnson A.
        • et al.
        Emergence and spread of vancomycin resistance among enterococci in Europe.
        Euro Surveill. 2008; 13 (pii-19046)
        • Duchon J.
        • Graham III, P.
        • Della-Latta P.
        • Whittier S.
        • Carp D.
        • Bateman D.
        • et al.
        Epidemiology of enterococci in a neonatal intensive care unit.
        Infect Control Hosp Epidemiol. 2008; 29: 374-376
        • Iosifidis E.
        • Antachopoulos C.
        • Tsivitanidou M.
        • Katragkou A.
        • Farmaki E.
        • Tsiakou M.
        • et al.
        Differential correlation between rates of antimicrobial drug consumption and prevalence of antimicrobial resistance in a tertiary care hospital in Greece.
        Infect Control Hosp Epidemiol. 2008; 29: 615-622
        • Kritsotakis E.I.
        • Assithianakis P.
        • Kanellos P.
        • Tzagarakis N.
        • Ioannides M.C.
        • Gikas A.
        Surveillance of monthly antimicrobial consumption rates stratified by patient-care area: a tool for triggering and targeting antibiotic policy changes in the hospital.
        J Chemother. 2006; 18: 394-401
        • Morrison D.
        • Woodford N.
        • Barrett S.P.
        • Sisson P.
        • Cookson B.D.
        DNA banding pattern polymorphism in vancomycin-resistant Enterococcus faecium and criteria for defining strains.
        J Clin Microbiol. 1999; 37: 1084-1091
        • Kritsotakis E.I.
        • Christidou A.
        • Roumbelaki M.
        • Tselentis Y.
        • Gikas A.
        The dynamic relationship between antibiotic use and the incidence of vancomycin-resistant Enterococcus: time-series modelling of 7-year surveillance data in a tertiary-care hospital.
        Clin Microbiol Infect. 2008; 14: 747-754
        • Iosifidis E.
        • Karakoula K.
        • Protonotariou E.
        • Kaperoni M.
        • Matapa E.
        • Pournaras S.
        • et al.
        Polyclonal outbreak of vancomycin-resistant Enterococcus faecium in a pediatric oncology department.
        J Pediatr Hematol Oncol. 2012; 34: 511-516
        • Muto C.A.
        • Jernigan J.A.
        • Ostrowsky B.E.
        • Richet H.M.
        • Jarvis W.R.
        • Boyce J.M.
        • 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
        • Perencevich E.N.
        • Fisman D.N.
        • Lipsitch M.
        • Harris A.D.
        • Morris Jr., J.G.
        • Smith D.L.
        Projected benefits of active surveillance for vancomycin-resistant enterococci in intensive care units.
        Clin Infect Dis. 2004; 38: 1108-1115
        • Ergaz Z.
        • Arad I.
        • Bar-Oz B.
        • Peleg O.
        • Benenson S.
        • Minster N.
        • et al.
        Elimination of vancomycin-resistant enterococci from a neonatal intensive care unit following an outbreak.
        J Hosp Infect. 2010; 74: 370-376
        • Sherer C.R.
        • Sprague B.M.
        • Campos J.M.
        • Nambiar S.
        • Temple R.
        • Short B.
        • et al.
        Characterizing vancomycin-resistant enterococci in neonatal intensive care.
        Emerg Infect Dis. 2005; 11: 1470-1472
        • Singh N.
        • Leger M.M.
        • Campbell J.
        • Short B.
        • Campos J.M.
        Control of vancomycin-resistant enterococci in the neonatal intensive care unit.
        Infect Control Hosp Epidemiol. 2005; 26: 646-649
        • Rupp M.E.
        • Marion N.
        • Fey P.D.
        • Bolam D.L.
        • Iwen P.C.
        • Overfelt C.M.
        • et al.
        Outbreak of vancomycin-resistant Enterococcus faecium in a neonatal intensive care unit.
        Infect Control Hosp Epidemiol. 2001; 22: 301-303
        • Golan Y.
        • Doron S.
        • Sullivan B.
        • Snydman D.R.
        Transmission of vancomycin-resistant enterococcus in a neonatal intensive care unit.
        Pediatr Infect Dis J. 2005; 24: 566-567
        • Sakka V.
        • Tsiodras S.
        • Galani L.
        • Antoniadou A.
        • Souli M.
        • Galani I.
        • et al.
        Risk-factors and predictors of mortality in patients colonised with vancomycin-resistant enterococci.
        Clin Microbiol Infect. 2008; 14: 14-21
        • de Bruin M.A.
        • Riley L.W.
        Does vancomycin prescribing intervention affect vancomycin-resistant enterococcus infection and colonization in hospitals? A systematic review.
        BMC Infect Dis. 2007; 7: 24
        • Lee W.G.
        • Ahn S.H.
        • Jung M.K.
        • Jin H.Y.
        • Park I.J.
        Characterization of a vancomycin-resistant Enterococcus faecium outbreak caused by 2 genetically different clones at a neonatal intensive care unit.
        Ann Lab Med. 2012; 32: 82-86
        • Malik R.K.
        • Montecalvo M.A.
        • Reale M.R.
        • Li K.
        • Maw M.
        • Munoz J.L.
        • et al.
        Epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit.
        Pediatr Infect Dis J. 1999; 18: 352-356
        • Byers K.E.
        • Anglim A.M.
        • Anneski C.J.
        • Germanson T.P.
        • Gold H.S.
        • Durbin L.J.
        • et al.
        A hospital epidemic of vancomycin-resistant Enterococcus: risk factors and control.
        Infect Control Hosp Epidemiol. 2001; 22: 140-147
        • Bonten M.J.
        • Slaughter S.
        • Ambergen A.W.
        • Hayden M.K.
        • van Voorhis J.
        • Nathan C.
        • et al.
        The role of “colonization pressure” in the spread of vancomycin-resistant enterococci: an important infection control variable.
        Arch Intern Med. 1998; 158: 1127-1132
        • Metallidis S.
        • Chatzidimitriou M.
        • Tsona A.
        • Bisiklis A.
        • Lazaraki G.
        • Koumentaki E.
        • et al.
        Vancomycin-resistant enterococci, colonizing the intestinal tract of patients in a university hospital in Greece.
        Braz J Infect Dis. 2006; 10: 179-184
        • Yuce A.
        • Karaman M.
        • Gulay Z.
        • Yulug N.
        Vancomycin-resistant enterococci in neonates.
        Scand J Infect Dis. 2001; 33: 803-805
        • Pusch T.
        • Kemp D.
        • Trevino S.
        • Button T.
        • Sanchez P.
        • Gander R.
        • et al.
        Controlling outbreak of vancomycin-resistant Enterococcus faecium among infants caused by an endemic strain in adult inpatients.
        Am J Infect Control. 2013; 41: 51-56
        • Tzavaras I.
        • Siarkou V.I.
        • Zdragas A.
        • Kotzamanidis C.
        • Vafeas G.
        • Bourtzi-Hatzopoulou E.
        • et al.
        Diversity of vanA-type vancomycin-resistant Enterococcus faecium isolated from broilers, poultry slaughterers and hospitalized humans in Greece.
        J Antimicrob Chemother. 2012; 67: 1811-1818
        • Hufnagel M.
        • Liese C.
        • Loescher C.
        • Kunze M.
        • Proempeler H.
        • Berner R.
        • et al.
        Enterococcal colonization of infants in a neonatal intensive care unit: associated predictors, risk factors and seasonal patterns.
        BMC Infect Dis. 2007; 7: 107