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Outcomes Associated With Vancomycin-Resistant Enterococci: A Meta-Analysis

  • Cassandra D. Salgado (a1) and Barry M. Farr (a2)

Abstract

Background:

Because patients with vancomycin-resistant Enterococcus bacteremia (VREB) usually have a higher severity of illness, it has been unclear whether VREB is worse than vancomycin-susceptible Enterococcus bacteremia (VSEB).

Methods:

Data on morbidity and case fatality rates and costs were pooled from studies comparing VREB and VSEB, identified by Medline (January 1986 to April 2002) and meeting abstracts. Heterogeneity across studies was assessed with contingency table chi-square. Multivariate analyses (MVAs) controlling for other predictors were evaluated.

Results:

Thirteen studies compared case-fatality rates of VREB and VSEB. VREB case fatality was significantly higher (48.9% vs 19%; RR, 2.57; CI95, 2.27 to 2.91; attributable mortality = 30%). Five studies compared VREB with VSEB when bacteremia was the direct cause of death; VREB case fatality was significantly higher (39.1% vs 21.8%; RR, 1.79; CI95, 1.28 to 2.5; attributable mortality = 17%). Four MVAs found significant increases in case-fatality rates (OR 2.10 to 4.0), 3 showed trends toward increase (OR, 1.74 to 3.34 with wide confidence intervals), and 3 with low statistical power found no difference. VREB recurred in 16.9% versus 3.7% with VSEB (P < .0001). Three studies reported significant increases in LOS, costs, or both with VREB.

Conclusion:

Most studies have had inadequate sample size, inadequate adjustment for other predictors of adverse outcomes, or both, but available data suggest that VREB is associated with higher recurrence, mortality, and excess costs than VSEB including multiple studies adjusting for severity of illness.

Copyright

Corresponding author

P.O. Box 800473, University of Virginia Health System, Charlottesville, VA 22908

References

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1.Leclercq, R, Derlot, E, Duval, J, Courvalin, P. Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med 1988;319:157161.
2.Uttley, AH, Collins, CH, Naidoo, J, George, R. Vancomycin-resistant enterococci. Lancet 1988;1:5758.
3.Byers, KE, Anglim, AM, Anneski, CJ, et al.A hospital epidemic of vancomycin-resistant Enterococcus: risk factors and control. Infect Control Hosp Epidemiol 2001;22:140147.
4.Ostrowsky, BE, Trick, WE, Sohn, AH, et al.Control of vancomycin-resistant Enterococcus in healthcare facilities in a region. N Engl J Med 2001;344:14271433.
5.National Nosocomial Infection Surveillance (NNIS) System. NNIS system report, data from January 1990-1999, issued June 1999. Am J Infect Control 1999;27:520532.
6.Gonzales, RD, Schreckenberger, PC, Graham, MB, Kelkar, S, DenBesten, K, Quinn, JP. Infections due to vancomycin-resistant Enterococcus faecium resistant to linezolid. Lancet 2001;357:1179.
7.Stosor, V, Peterson, LR, Postelnick, M, Noskin, GA. Enterococcus faecium bacteremia: does vancomycin resistance make a difference? Arch Intern Med 1998;158:522527.
8.Linden, PK, Pasculle, AW, Manez, R, et al.Differences in outcomes for patients with bacteremia due to vancomycin-resistant Enterococcus faecium or vancomycin-susceptible E. faecium. Clin Infect Dis 1996;22:663670.
9.Bhavnani, SM, Drake, JAForrest, A, et al.A nationwide, multicenter, case-control study comparing risk factors, treatment, and outcome for vancomycin-resistant and -susceptible enterococcal bacteremia. Diagn Microbiol Infect Dis 2000;36:145158.
10.Song, X, Perl, T. Vancomycin-resistant enterococcal (VRE) nosocomial bloodstream infections (BSD: the attributable mortality, length of stay, and excess cost. Presented at the 37th Annual Meeting of the Infectious Diseases Society of America; November 18-21, 1999; Philadelphia, PA.
11.Lautenbach, E, Bilker, WB, Brennan, PJ. Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality. Infect Control Hosp Epidemiol 1999;20:318323.
12.Shay, DK, Maloney, SA, Montecalvo, M, et al.Epidemiology and mortality risk of vancomycin-resistant enterococcal bloodstream infections. J Infect Dis 1995;172:9931000.
13.Stroud, L, Edwards, J, Danzing, L, Culver, D, Gaynes, R. Risk factors for mortality associated with enterococcal bloodstream infections. Infect Control Hosp Epidemiol 1996;17:576580.
14.Ostrowsky, B, Steinberg, JT, Farr, B, Sohn, AH, Sinkowitz-Cochran, RL, Jarvis, WR. Reality check: should we try to detect and isolate vancomycin-resistant enterococci patients? Infect Control Hosp Epidemiol 2001;22:116119.
15.Bhorade, SM, Christenson, J, Pohlman, AS, Arnow, PM, Hall, JB. The incidence of and clinical variables associated with vancomycin-resistant enterococcal colonization in mechanically ventilated patients. Chest 1999;115:10851091.
16.Webb, M, Riley, LW, Roberts, RB. Cost of hospitalization for and risk factors associated with vancomycin-resistant Enterococcus faecium infection and colonization. Clin Infect Dis 2001;33:445452.
17.Edmond, MB, Ober, JF, Dawson, JD, Weinbaum, DL, Wenzel, RP. Vancomycin-resistant enterococcal bacteremia: natural history and attributable mortality. Clin Infect Dis 1996;23:12341239.
18.Papanicolaou, GA, Meyers, BR, Meyers, J, 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.
19.Morris, JG Jr, Shay, DK, Hebden, JN, et al.Enterococci resistant to multiple antimicrobial agents, including vancomycin: establishment of endemicity in a university medical center. Ann Intern Med 1995;123:250259.
20.Garbutt, JM, Ventrapragada, M, Littenberg, B, Mundy, LM. Association between resistance to vancomycin and death in cases of Enterococcus faecium bacteremia. Clin Infect Dis 2000;30:466472.
21.Boyle, JF, Soumakis, SA, Rendo, A, et al.Epidemiologic analysis and genotypie characterization of a nosocomial outbreak of vancomycin-resistant enterococci. J Clin Microbiol 1993;31:12801285.
22.Lucas, GM, Lechtzin, N, Puryear, DW, Yau, LL, Flexner, CW, Moore, RD. Vancomycin-resistant and vancomycin-susceptible enterococcal bacteremia: comparison of clinical features and outcomes. Clin Infect Dis 1998;26:11271133.
23.Peset, V, Talion, P, Sola, C, et al.Epidemiological, microbiological, clinical, and prognostic factors of bacteremia caused by high-level vancomycin-resistant Enterococcus species. Eur J Clin Microbiol Infect Dis 2000;19:742749.
24.Gleason, T, Crabtree, T, Pelletier, S, et al.Prediction of poorer prognosis by infection with antibiotic-resistant gram-positive cocci than by infection with antibiotic sensitive strains. Arch Surg 1999:134:10331040.
25.Montecalvo, MA, Shay, DK, Patel, P, et al.Bloodstream infections with vancomycin-resistant enterococci. Arch Intern Med 1996;56:14581462.
26.Lodise, TP, McKinnon, PS, Tam, VH, Rybak, MJ. Clinical outcomes for patients with bacteremia caused by vancomycin-resistant Enterococcus in a level 1 trauma center. Clin Infect Dis 2002;34:922929.
27.Vergis, E, Hayden, M, Chow, J, et al.Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia. Ann Intern Med 2001;135:484492.
28.Quale, J, Landman, D, Atwood, E, et al.Experience with a hospital-wide outbreak of vancomycin-resistant enterococci. Am J Infect Control 1996;24:372379.
29.Livornese, LL Jr, Dias, S, Samel, C, et al.Hospital-acquired infection with vancomycin-resistant Enterococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112116.
30.Lee, HK, Lee, WG, Cho, SR. Clinical and molecular biological analysis of a nosocomial outbreak of vancomycin-resistant enterococci in a neonatal intensive care unit. Acta Paediatr 1999;88:651654.
31.Newell, KAMillis, JM, Arnow, PM, et al.Incidence and outcome of infection by vancomycin-resistant Enterococcus following orthotopic liver transplantation. Transplantation 1998;65:439442.
32.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.
33.D'Agata, EM, Li, H, Gouldin, C, Tang, YW. Clinical and molecular characterization of vancomycin-resistant Enterococcus faecium strains during establishment of endemicity. Clin Infect Dis 2001;33:511516.
34.Still, J, Law, E, Friedman, B, Fuhrman, S, Newton, T. Vancomycin-resistant organisms on a burn unit. South Med J 2001;94:810812.
35.Wells, C, Juni, B, Cameron, S, et al.Stool carriage, clinical isolation, and mortality during an outbreak of vancomycin-resistant enterococci in hospitalized medical or surgical patients. Clin Infect Dis 1995;21:4550.
36.Gray, J, George, R. Experience of vancomycin-resistant enterococci in a children's hospital. J Hosp Infect 2000;45:1118.
37.Lam, S, Singer, C, Tucci, V, Morthland, VH, Kaller, MA, Isenberg, HD. The challenge of vancomycin-resistant enterococci: a clinical and epidemiologic study. Am J Infect Control 1995;23:170180.
38.Krcmery, V, Bilikova, E, Svetlansky, I, Kovacicova, G. Is vancomycin resistance in enterococci predictive of inferior outcome of enterococcal bacteremia? Clin Infect Dis 2001;32:11101112.
39.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.
40.Edmond, MB, Ober, JF, Weinbaum, DL, et al.Vancomycin-resistant Enterococcus faecium bacteremia: risk factors for infection. Clin Infect Dis 1995;20:11261133.
41.Kapur, D, Dorsky, D, Feingold, JM, et al.Incidence and outcome of vancomycin-resistant enterococcal bacteremia following autologous peripheral blood stem cell transplantation. Bone Marrow Transplant 2000;25:147152.
42.Centers for Disease Control and Prevention. Nosocomial enterococci resistant to vancomycin: United States, 1989-1993. MMWR 1993;42:597598.
43.Mainous, MR, Lipsett, PA, O'Brien, M, Johns Hopkins SICU Study Group. Enterococcal bacteremia in the surgical intensive care unit: does vancomycin resistance affect mortality? Arch Surg 1997;132:7681.
44.Jernigan, J, Hadziyannis, E, Schwarzmann, S, Nolte, F. Vancomycin-resistant Enterococcus faecium (VRE) bacteremia in severely neutropenic patients. Presented at the 36th Annual Meeting of the Infectious Diseases Society of America; September 18-20, 1996; New Orleans, LA.
45.Harrell, FE Jr, Lee, KL, Mark, DB. Multivariable prognostic model: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 1996;15:361387.

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