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CP are widely used for patients (pts) colonized and infected with VRE. However, in general, CP have been shown to limit VRE transmission only if active surveillance is done to identify all colonized pts.
Objective:
To determine the impact of reducing the use of CP for VRE culture-positive pts to just those with diarrhea or a draining wound.
Methods:
Until 7/01 CP were used at our tertiary care center for pts with VRE recovered from any clinical site. Thereafter, CP were limited as described. Point prevalence surveys of adult pts for VRE perianal colonization were done in 3/01 & 1/09 using vancomycin selective media/broth. In 4/09 stools sent for C. difficile toxin were similarly cultured for VRE.
Results:
The point prevalence of VRE colonization was significantly less in 2009 vs 2001 [66 VRE + (23%) vs 76 VRE + (32%), p= 0.03]. The % colonized with VRE who were not previously known based upon clinical specimen results was similar in 2001 and 2009 [59 (78%) vs 55 (83%), p =0.5]. VRE negative pts had a significantly shorter length of hospital stay [median, range] than VRE positive pts, both in 2001 [6 [1-144] days vs 20 [1-349] days, p<0.001] and in 2009 [6 [1-208] days vs 17 [2-153] days, p<0.001]. In both years, over 60% of VRE colonized pts were housed on just 4 of 16 adult services (oncology, medicine, solid organ transplant and respiratory care). Incidence rates of VRE from clinical specimens/1000 pt days, before and after the policy change were similar (0.75, 0.79) for 1 year before and after; (0.87, 0.88) for 2 years before and after; (1.0, 0.95) for 3 years before and after. Rates for the years after 2004 ranged from 1.12 to 0.68. Among 90 stool specimens sent for C. difficile toxin, VRE was present in 36 (40%) patients, a significantly higher rate than that found for perianal colonization during the same year 2009 [(40%) vs (23%), p= 0.003].
Conclusions:
The use of CP for only VRE + pts with diarrhea/draining wounds did not adversely affect rates of recovery of VRE from clinical specimens or the percentage of colonized pts. The higher rate of recovery of VRE from stool specimens sent from pts with diarrhea compared with all pts suggests that targeted use of CP for pts with diarrhea is a logical strategy. Also VRE+ pts with diarrhea would be especially likely to contaminate the environment. It still remains to be shown, however, if any use of CP for VRE is superior to no use of CP, in the absence of routine surveillance to identify the large submerged population of VRE colonized pts.