Skip to main content Accessibility help

Outbreak of Vancomycin-Resistant Enterococci in a Burn Unit

  • Pamela S. Falk (a1), Janice Winnike (a1), Carta Woodmansee (a1), M. Desai (a1) and C. Glen Mayhall (a1)...



To investigate and control an outbreak of colonization and infection caused by vancomycin-resistant enterococci (VRE) in a burn intensive care unit (BICU).


Epidemiological investigation, including multiple point-prevalence culture surveys of patients and environment, cultures from hands of healthcare workers (HCWs), pulsed-field gel electrophoresis (PFGE) typing of patient and environmental isolates, case-control study, and institution and monitoring of control measures.


BICU in an 800-bed university medical center in Galveston, Texas.


Between June 6, 1996, and July 14, 1997, 21 patients were colonized by VRE, and 4 of these patients developed bacteremia. Of 2,844 environmental cultures, 338 (11.9%) were positive, but all hand cultures from HCWs were negative. PFGE typing indicated that the outbreak was clonal, with VRE isolates from patients differing by ≤4 bands from the index case. Thirteen of 14 environmental isolates varied by ≤4 bands from the pattern of the index case. A case-control study analyzed by exact logistic regression identified diarrhea (odds ratio [OR], 43.9; 95% confidence interval [CI95], 5.5-infinity; P=.0001) and administration of an antacid (OR, 24.2; CI95,2.9-infinity; P=.002) as independent risk factors for acquisition of VRE. During a 5-week period in October and November 1996, all patient and 317 environmental cultures were negative for VRE. The outbreak recurred from a contaminated electrocardiogram lead that had not been identified during the prior 5 weeks. VRE were finally eradicated from the BICU in July 1997, using barrier isolation and a very aggressive environmental decontamination program.


A VRE outbreak in a BICU over 13 months was caused by a single clone. After apparent eradication of VRE from a BICU, recrudescence of the outbreak occurred, evidently from a small inapparent source of environmental contamination. Changes in gastrointestinal (GI) tract function (motility) and administration of medications, other than antibiotics, that have an effect on the GI tract may increase the risk of GI tract colonization by VRE in burn patients. Application of barrier isolation and an aggressive environmental decontamination program can eradicate VRE from a burn population.


Corresponding author

Division of Infectious Diseases, 301 University Blvd, Rte 0835, University of Texas Medical Branch, Galveston, TX 77555-0835


Hide All
1. Uttley, AHC, Collins, CH, Naidoo, J, George, RC. Vancomycin-resistant enterococci. Lancet 1988;1:5758.
2. Centers for Disease Control and Prevention. Nosocomial enterococci resistant to vancomycin—United States, 1989-1993. MMWR 1993;42:597599.
3. Karanfil, LV, Murphy, M, Josephson, A, Gaynes, R, Mandel, L, Hill, BC, et al. A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol 1992;13:195200.
4. Livornese, LL Jr Dias, S, Samel, C, Romanowski, B, Taylor, S, May, P, et al. Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112116.
5. Rubin, LG, Tucci, V, Cercenado, E, Eliopoulos, G, Isenberg, HD. Vancomycin-resistant Enterococcus faecium in hospitalized children. Infect Control Hosp Epidemiol 1992;13:700705.
6. Handwerger, S, Raucher, B, Altarac, D, Monka, J, Marchione, S, Singh, KV, et al. Nosocomial outbreak due to Enterococcus faecium highly resistant to vancomycin, penicillin, and gentamicin. Clin Infect Dis 1993;16:750755.
7. Boyce, JM, Opal, SM, Chow, JW, Zervos, MJ, Potter-Bynoe, G, Sherman, CB, et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol 1994;32:11481153.
8. Morris, JG Jr Shay, DK, Hebden, JN, McCarter, RJ Jr Perdue, BE, Jarvis, W, et al. Enterococci resistant to multiple antimicrobial agents, including vancomycin. Establishment of endemicity in a university medical center. Ann Intern Med 1995;123:250259.
9. Wells, CL, Juni, BA, Cameron, SB, Mason, KR, Dunn, DL, Ferried, P, et al. Stool carriage, clinical isolation, and mortality during an outbreak of vancomycin-resistant enterococci in hospitalized medical and/or surgical patients. Clin Infect Dis 1995;21:4550.
10. Henning, KJ, Delencastre, H, Eagan, J, Boone, N, Brown, A, Chung, M, et al. Vancomycin-resistant Enterococcus faecium on a pediatric oncology ward: duration of stool shedding and incidence of clinical infection. Pediatr Infect Dis J 1996;15:848854.
11. Uttley, AHC, George, RC, Naidoo, J, Woodford, N, Johnson, AP, Collins, CH, et al. High-level vancomycin-resistant enterococci causing hospital infections. Epidemiol Infect 1989;103:173181.
12. Chadwick, PR, Oppenheim, BA, Fox, A, Woodford, N, Morgenstern, GR, Scarffe, JH. Epidemiology of an outbreak due to glycopeptide-resistant Enterococcus faecium on a leukaemia unit. J Hosp Infect 1996;34:171182.
13. Papanicolaou, GA, Meyers, BR, Meyers, J, Mendelson, MH, Lou, W, Emre, S, et al. Nosocomial infections with vancomycin-resistant Enterococcus faecium in liver transplant recipients: risk factors for acquisition and mortality. Clin Infect Dis 1996;23:760766.
14. Jordens, JZ, Bates, J, Griffiths, DT. Faecal carriage and nosocomial spread of vancomycin-resistant Enterococcus faecium . J Antimicrob Chemother 1994;34:515528.
15. Gordts, B, Van Landuyt, H, Ieven, M, Vandamme, P, Goossens, H. Vancomycin-resistant enterococci colonizing the intestinal tracts of hospitalized patients. J Clin Microbiol 1995;33:28422846.
16. Noskin, GA, Stosor, V, Cooper, I, Peterson, LR. Recovery of vancomycin-resistant enterococci on fingertips and environmental surfaces. Infect Control Hosp Epidemiol 1995;16:577581.
17. Slaughter, S, Hayden, MK, Nathan, C, Hu, T-C, Rice, T, van Voorhis, J, et al. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 1996;125:448456.
18. Law, EJ, Blecher, K, Still, JM. Enterococcal infections as a cause of mortality and morbidity in patients with burns. J Burn Care Rehabil 1994;15:236239.
19. Ang, SW, Seah, CS, Lee, ST. Vancomycin-resistant Enterococcus in the Singapore National Burns Centre: a case report. Ann Acad Med Singapore 1996;25:270272.
20. Goering, RV. The molecular epidemiology of nosocomial infection. An overview of principles, application, and interpretation. In: Specter, S, Bendinelli, M, Friedman, H, eds. Rapid Detection of Infectious Agents. New York, NY: Plenum Publishing Co; 1998:140142.
21. Tornieporth, NG, Roberts, RB, John, J, Hafner, A, Riley, LW. Risk factors associated with vancomycin-resistant Enterococcus faecium infection or colonization in 145 matched case patients and control patients. Clin Infect Dis 1996;23:767772.
22. Bonten, MJM, Hayden, MK, Nathan, C, van Voorhis, J, Matushek, M, Slaughter, S, et al. Epidemiology of colonisation of patients and environment with vancomycin-resistant enterococci. Lancet 1996;348:16151619.
23. Lai, KK, Kelley, AL, Melvin, ZS, Belliveau, PP, Fontecchio, SA. Failure to eradicate vancomycin-resistant enterococci in a university hospital and the cost of barrier precautions. Infect Control Hosp Epidemiol 1998;19:647652.
24. Bonilla, HF, Zervos, MJ, Kauffman, CA. Long-term survival of vancomycin-resistant Enterococcus faecium on a contaminated surface. Infect Control Hosp Epidemiol 1996;17:770771.
25. Bonten, MJM, Slaughter, S, Ambergen, AW, Hayden, MK, van Voorhis, J, Nathan, C, et al. The role of “colonization pressure” in the spread of vancomycin-resistant enterococci. Arch Intern Med 1998;158:11271132.
26. Fleming, RYD, Zeigler, ST, Walton, MA, Herndon, DN, Heggers, JP. Influence of burn size on the incidence of contamination of burn wounds by fecal organisms. J Burn Care Rehabil 1991;12:510515.
27. Weinstein, JW, Roe, M, Towns, M, Sanders, L, Thorpe, JJ, Corey, GR, et al. Resistant enterococci: a prospective study of prevalence, incidence, and factors associated with colonization in a university hospital. Infect Control Hosp Epidemiol 1996;17:3641.
28. McManus, AT, Goodwin, CW, Pruitt, BA Jr. Observations on the risk of resistance with the extended use of vancomycin. Arch Surg 1998;133:12071211.
29. Ford, M, Perry, JD, Gould, FK, Orr, KE. Neomycin blood agar as a selective medium for vancomycin resistant Enterococcus faecium . J Clin Pathol 1996;49:437.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed