Small hospitals matter: insights from the emergence and spread of vancomycin-resistant enterococci in 2 public hospitals in inner Brazil

Although vancomycin-resistant enterococci (VRE) are reported in Brazil since 1996, data on their impact over settings of different complexity are scarce. We performed a study aimed at identifying determinants ofVRE emergence and spread in a public hospital consortium (comprising 2 hospitals, with 318 and 57 beds) in inner Brazil. Molecular typing and case-control studies (addressing predictors of acquisition or clonality) were performed. Among 122 authocthonous isolates, 106 were Enterococcus faecium (22 clones), and 16, Enterococcus faecalis (5 clones). Incidence was greater in the small-sized hospital, and a previous admission to this hospital was associated with greater risk of VRE colonization or infection during admission to the larger one. Overall risk factors included comorbidities, procedures, and antimicrobials (piperacillin-tazobactam, cefepime, and imipenem). Risk factors varied among different hospitals, species, and clones. Our findings demonstrate that VRE can spread within low-complexity facilities and from these to larger hospitals. (C) 2015 Elsevier Inc. All rights reserved.

Vancomycin-resistant enterococcus outbreak in a pediatric intensive care unit: report of successful interventions for control and prevention

The objective of this study is to retrospectively report the results of interventions for controlling a vancomycin-resistant enterococcus (VRE) outbreak in a tertiary-care pediatric intensive care unit (PICU) of a University Hospital. After identification of the outbreak, interventions were made at the following levels: patient care, microbiological surveillance, and medical and nursing staff training. Data were collected from computer-based databases and from the electronic prescription system. Vancomycin use progressively increased after March 2008, peaking in August 2009. Five cases of VRE infection were identified, with 3 deaths. After the interventions, we noted a significant reduction in vancomycin prescription and use (75% reduction), and the last case of VRE infection was identified 4 months later. The survivors remained colonized until hospital discharge. After interventions there was a transient increase in PICU length-of-stay and mortality. Since then, the use of vancomycin has remained relatively constant and strict, no other cases of VRE infection or colonization have been identified and length-of-stay and mortality returned to baseline. In conclusion, we showed that a bundle intervention aiming at a strict control of vancomycin use and full compliance with the Hospital Infection Control Practices Advisory Committee guidelines, along with contact precautions and hand-hygiene promotion, can be effective in reducing vancomycin use and the emergence and spread of vancomycin-resistant bacteria in a tertiary-care PICU.

Adverse events related to vancomycin use in a University Hospital in Brazil

Introduction and Objectives: Vancomycin is indicated to patients who have not responded to treatment with other antibiotics in serious infections caused by organisms susceptible to it and resistant to other antimicrobials. However, over the last five years, many adverse reactions have been reported with this medicine in the University Hospital of the University of Silo Paulo (HU/USP), such as nephrotoxicity and toxicity related to infusion. Some critical patients, for example surgical patients with sepsis and severe trauma are generally susceptible to renal failure due to the severity of the underlying disease. The-aim of this study is to quantify and delineate the epidemiological profile of confirmed adverse reactions caused by vancomycin. Material and Methods: We conducted a retrospective observational quantitative study of medical records of patients who had confirmed.adverse reactions occurred with vancomycin in the period from January 2007 to May 2012, at the HU/USP - Brazil. All notifications related to vancomycin were evaluated in the following items: age and sex of patients, type and ward where the adverse event occurred involving this drug. Results and Conclusions: During the analysed period, were confinued 37 adverse events with vancomycn. The adults represented 75,7% of the cases, and the children 24,3%. The present study shows that adult patients admitted to the medical clinic had greater susceptibility to adverse reactions to vancomycin and for pediatric patients its higher frequency was at ICU. Despite the adverse skin reactions performed with greater frequency, it is known that the most severe reactions were related to the kidney resulting in more complex clinical interventions.

Vancomycin-resistente Enterokokken (VRE) bei Patienten und in der aquatischen Umwelt

Vancomycin-resistente Enterokokken (VRE) treten als Erreger von nosokomialen Infektionen immer häufiger auf und schränken die Therapiemöglichkeiten deutlich ein. In den eigenen Untersuchungen wurde das Vorkommen von Vancomycin-resistenten Enterococcus faecium (VREf) bei Patienten und in der aquatischen Umwelt (Abwasser und Oberflächenwasser) über einen Zeitraum von sechs Jahren (2004 bis 2009) untersucht. Eine Genotypisierung mittels Pulsfeld-Gelelektrophorese (PFGE) von 294 VREf sollte Aufschluss über genetische Verwandtschaften geben. rnEs konnte gezeigt werden, dass VREf in der aquatischen Umwelt weit verbreitet sind. In Bezug auf ihre genetische Diversität zeigten sie ein breites Spektrum an Variabilität. Ebenso konnte im zeitlichen Auftreten von VREf-Typen eine Dynamik beobachtet werden, wodurch sich Veränderungen der Population mit zeitlichem Wechsel ergaben. Enge Verwandtschaften zwischen VREf von Patienten und VREf aus der aquatischen Umwelt konnten nachgewiesen werden. Für zwei VREf gelang der Nachweis des Eintrags in die aquatische Umwelt, von Patienten aus dem Krankenhaus als Eintragsquelle ausgehend, während Zeiten eines Ausbruchs mit nosokomialen Erregern auf den Stationen. rnZusätzlich zur VREf-Population wurden außerdem die Wirkungsweise und Effizienz einer Elektroimpulsanlage untersucht, um ein zukunftsorientiertes Verfahren zur Desinfektion von bakteriell belasteten Abwässern zu entwickeln. Weiterführend wurde getestet, inwiefern sich verschiedene klinisch relevante VREf durch ein gepulstes elektrisches Feld abtöten lassen. rnEs konnte gezeigt werden, dass das synergistische Zusammenwirken des elektrischen Feldes und der Prozesstemperatur die Höhe der Keimzahlreduktion der Enterokokken beeinflussen. Dabei wurde eine isolatabhängige Elektroresistenz der VREf gegenüber gepulsten elektrischen Feldern bewiesen. Die untersuchten VREf ließen sich, im Gegensatz zu einem Vancomycin-sensiblen Stamm, nicht effizient durch die Elektroimpulsanlage abtöten, was den praktischen Einsatz einer solchen Elektroimpulsanlage als wirkungsvolles Desinfektionsverfahren in Frage stellte.

Daptomycin is more efficacious than vancomycin against a methicillin-susceptible Staphylococcus aureus in experimental meningitis

OBJECTIVES: To test the efficacy of daptomycin, a cyclic lipopeptide antibiotic, against a methicillin-susceptible Staphylococcus aureus strain in experimental rabbit meningitis and to determine its penetration into non-inflamed and inflamed meninges RESULTS: Over a treatment period of 8 h, daptomycin (15 mg/kg) was significantly superior to the comparator regimen vancomycin (-4.54 +/- 1.12 log(10)/mL for daptomycin versus -3.43 +/- 1.17 log(10)/mL for vancomycin). Daptomycin managed to sterilize 6 out of 10 CSFs compared with 4 out of 10 for vancomycin. The penetration of daptomycin into inflamed meninges was approximately 5% and approximately 2% into non-inflamed meninges. CONCLUSIONS: The superior bactericidal activity of daptomycin was confirmed in vivo and in time-killing assays in vitro.

Vancomycin acts synergistically with gentamicin against penicillin-resistant pneumococci by increasing the intracellular penetration of gentamicin

Vancomycin and gentamicin act synergistically against penicillin-resistant pneumococci in vitro and in experimental rabbit meningitis. The aim of the present study was to investigate the underlying mechanism of this synergism. The intracellular concentration of gentamicin was measured by using the following experimental setting. Bacterial cultures were incubated with either gentamicin alone or gentamicin plus vancomycin for a short period (15 min). The gentamicin concentration was determined before and after grinding of the cultures by using the COBAS INTEGRA fluorescence polarization system (Roche). The grinding efficacies ranged between 44 and 54%, as determined by viable cell counts. In the combination regimen the intracellular concentration of gentamicin increased to 186% compared to that achieved with gentamicin monotherapy. These data suggest that the synergy observed in vivo and in vitro is based on an increased intracellular penetration of the aminoglycoside, probably due to the effect of vancomycin on the permeability of the cell wall.

Gentamicin increases the efficacy of vancomycin against penicillin-resistant pneumococci in the rabbit meningitis model

In experimental meningitis a single dose of gentamicin (10 mg/kg of body weight) led to gentamicin levels in around cerebrospinal fluid (CSF) of 4 mg/liter for 4 h, decreasing slowly to 2 mg/liter 4 h later. The CSF penetration of gentamicin ranged around 27%, calculated by comparison of areas under the curve (AUC in serum/AUC in CSF). Gentamicin monotherapy (-1.24 log(10) CFU/ml) was inferior to vancomycin monotherapy (-2.54 log(10) CFU/ml) over 8 h against penicillin-resistant pneumococci. However, the combination of vancomycin with gentamicin was significantly superior (-4.48 log(10) CFU/ml) compared to either monotherapy alone. The synergistic activity of vancomycin combined with gentamicin was also demonstrated in vitro in time-kill assays.

Sub-inhibitory concentrations of vancomycin prevent quinolone-resistance in a penicillin-resistant isolate of Streptococcus pneumoniae

BACKGROUND: The continuous spread of penicillin-resistant pneumococci represents a permanent threat in the treatment of pneumococcal infections, especially when strains show additional resistance to quinolones. The main objective of this study was to determine a treatment modality impeding the emergence of quinolone resistance. RESULTS: Exposure of a penicillin-resistant pneumococcus to increasing concentrations of trovafloxacin or ciprofloxacin selected for mutants resistant to these drugs. In the presence of sub-inhibitory concentrations of vancomycin, development of trovafloxacin-resistance and high-level ciprofloxacin-resistance were prevented. CONCLUSIONS: Considering the risk of quinolone-resistance in pneumococci, the observation might be of clinical importance.

Meropenem alone and in combination with vancomycin in experimental meningitis caused by a penicillin-resistant pneumococcal strain

In a rabbit model of meningitis caused by a pneumococcus highly resistant to penicillin (MIC, 4 microg/ml), meropenem, a broad-spectrum carbapenem, was bactericidal (-0.48+/-0.14 deltalog10 cfu/ml h) and slightly superior to ceftriaxone (-0.34+/-0.23 deltalog10 cfu/ml x h) and vancomycin (-0.39+/-0.19 deltalog10 cfu/ml x h). Although the combination of vancomycin with ceftriaxone was significantly more active than ceftriaxone alone (-0.55+/-0.19 deltalog10 cfu/ml x h), only an insignificant gain was observed by the addition of vancomycin to meropenem (-0.55+/-0.28 deltalog10 cfu/ml x h).

Evaluation of cefepime alone and in combination with vancomycin against penicillin-resistant pneumococci in the rabbit meningitis model and in vitro

Cefepime, a broad-spectrum, fourth-generation cephalosporin, showed excellent CSF penetration with levels ranging between 10 and 16 mg/L after two intravenous injections (100 mg/kg). The bactericidal activity of cefepime (-0.60 +/- 0.28 Deltalog(10) cfu/mL/h) was superior to that of ceftriaxone (-0.34 +/- 0.23 Deltalog(10) cfu/mL/h, P < 0.05) and vancomycin (-0.39 +/- 0.19 Deltalog(10) cfu/mL/h, P < 0.05) in the treatment of rabbits with meningitis caused by an isolate highly resistant to penicillin (MIC of penicillin G: 4 mg/L). The addition of vancomycin to both cephalosporins did not significantly increase the killing rate compared with monotherapies (P > 0.05). Similar results were obtained in time-killing experiments in vitro.

Trovafloxacin in combination with vancomycin against penicillin-resistant pneumococci in the rabbit meningitis model

Trovafloxacin, a new fluoroquinolone, produced bactericidal activity (-0.33 +/- 0.13 delta log10 CFU/ml.h; intravenously [i.v.] administered dose, 15 mg/kg) comparable to that of vancomycin (-0.39 +/- 0.18 delta log10 CFU/ml.h; i.v. admininistered dose, 20 mg/kg) in the treatment of experimental meningitis in rabbits due to a pneumococcal strain highly resistant to penicillin (MIC of penicillin G, 4 micrograms/ml). The combination of both drugs significantly increased (P < 0.05) the killing rate (-0.60 +/- 0.23 delta log10 CFU/ml.h) compared to that produced by either monotherapy. These results were also confirmed in vitro.

Fulminant liver failure after vancomycin in a sulfasalazine-induced DRESS syndrome: fatal recurrence after liver transplantation

DRESS syndrome (drug rash with eosinophilia and systemic symptoms) is a rare drug hypersensitivity reaction with a significant mortality. We describe a 60-year-old man with polyarthritis treated with sulfasalazine who developed DRESS and fulminant liver failure after additional vancomycin treatment. Liver histology revealed infiltration of granzymeB+ CD3+ lymphocytes in close proximity to apoptotic hepatocytes. After a superurgent liver transplantation and initial recovery, the patient developed recurrent generalized exanthema and eosinophilia, but only moderate hepatitis. Histology showed infiltration of FasL+ lymphocytes and eosinophils in the transplanted liver. Treatment with high-dose methylprednisolone was unsuccessful. Postmortem examination revealed extensive necrosis of the liver transplant. This case report illustrates that patients with DRESS may develop fulminant liver failure and that DRESS recurrence can recur in the transplanted liver. Histological and immunological investigations suggest an important role of granzymeB and FasL mediated cell death in DRESS associated hepatitis.

Combination of daptomycin plus ceftriaxone is more active than vancomycin plus ceftriaxone in experimental meningitis after addition of dexamethasone

We examined the cerebrospinal fluid penetration of daptomycin after the addition of dexamethasone and its bactericidal efficacy with and without ceftriaxone in an experimental rabbit model of pneumococcal meningitis. The combination of daptomycin with ceftriaxone was the most efficacious regimen for pneumococcal meningitis. The previous addition of dexamethasone affected the antibacterial activity of daptomycin only marginally, either as monotherapy or combined with ceftriaxone, although the penetration of daptomycin into inflamed meninges was significantly reduced from 6 to 2%. Daptomycin with ceftriaxone might be a potential candidate for the empirical therapy of bacterial meningitis, although the activity of this regimen against Listeria monocytogenes remains to be demonstrated.