The control of hyperendemic glycopeptide-resistant Enterococcus spp. on a haematology unit by changing antibiotic usage

Abstract

The rectal carriage of glycopeptide-resistant Enterococcus spp. (GRE) had been established at approximately 50% in a series of prevalence studies on a busy haematological malignancy unit. The aim of this study was to reduce the chance of patients acquiring GRE. A prospective three-phase sequential study was performed. In Phase 1, the acquisition rate of GRE detectable by rectal swab was measured without any intervention for a period of 4 months. For the following 8 months (Phase 2), the first-line treatment for febrile neutropenic episodes was changed from monotherapy with ceftazidime to piperacillin/tazobactam. In addition, an intense education programme was introduced to improve hygiene to reduce the risk of case-to-case spread. In the final 4 months (Phase 3), ceftazidime was again used as the first-line antimicrobial, while continuing the same level of training in relation to hygiene. The carriage of GRE was measured from rectal swabs done weekly. During the initial 4 months, at any time, 40-50% of patients in the unit were colonized with GRE, and 43 of 75 (57%) new patients initially negative for GRE acquired it within 6 weeks of their admission. In Phase 2, 25 patients out of 129 (19%) acquired GRE, with the acquisition rate falling progressively so that in the last 3 months, only one new patient acquired GRE (logrank comparison of probabilities for cohort 1 vs cohort 2b: P < 0.0001). A return to ceftazidime in Phase 3 was associated with a return of the risk of acquiring detectable GRE colonization, despite continued hygiene teaching and surveillance, with 21 out of 58 patients (36%) acquiring GRE (cohort 1 vs cohort 3: P = 0.08). Glycopeptide usage was not reduced during the period of the study. Clinical cases were seen only in Phases 1 and 3. Although the reduction in the risk of acquiring GRE may have been due in part to hygiene practices as well as to the change in antimicrobial usage, or may have occurred spontaneously for other reasons, the return of the problem with the reintroduction of ceftazidime strongly suggests that this antibiotic was responsible for encouraging the acquisition of detectable GRE.

Antibiotic cycling to decrease bacterial antibiotic resistance: a 5-year experience on a bone marrow transplant unit

“…21 Whether there is a cause-effect between cycling and VRE emergence is less clear. 22 On one hand, the use of anaerobic coverage (pip-tazo) has been associated with increased incidence of VRE colonization after its use, during the period of recovery of the original gut microflora. [23][24][25] On the other hand, a previous study by Bradley et al 22 found a decreased incidence of VRE while cycling ceftazidime and pip-tazo.…”

“…22 On one hand, the use of anaerobic coverage (pip-tazo) has been associated with increased incidence of VRE colonization after its use, during the period of recovery of the original gut microflora. [23][24][25] On the other hand, a previous study by Bradley et al 22 found a decreased incidence of VRE while cycling ceftazidime and pip-tazo. A sample of VRE isolates collected from our hematologyoncology unit during our study period was found to be primarily clonal by pulsed-field gel electrophoresis analysis (data not shown).…”

Eradication of a Large Outbreak of a Single Strain of vanB Vancomycin-Resistant Enterococcus faecium at a Major Australian Teaching Hospital

“…33 Although introduced as part of the overall strategy, the reduction in use did not occur until the outbreak was almost completely controlled. It is possible that continuing restrictions may help maintain control, but its role in the eradication process is uncertain.…”

Successful prevention of the transmission of vancomycin-resistant enterococci in a Brazilian public teaching hospital

“…There are a large number of studies showing the impact of antibiotic use on the prevalence of VRE [19][20][21][22] . The majority of these reports show the previous use of antibiotics, e.g., vancomycin, carbapenem, metronidazole, clindamycin, and cephalosporin, as independent risk factor for the acquisition of VRE.…”