What action should be taken to prevent spread of vancomycin resistant enterococci in European hospitals?

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Ben Ridwan, fellow, medical microbiologya,
Ellen Mascini, medical microbiologista,
Netty van der Reijden, financial administratorb,
Jan Verhoef, professor of medical microbiologya,
Marc Bonten, internist (m.j.m.bonten@azu.nl)b

^a Eijkman-Winkler Institute for Microbiology, Infectious Diseases, and Inflammation, Division of Hospital Hygiene and Infection Prevention, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
^b Department of Internal Medicine, Eijkman-Winkler Institute for Microbiology, Infectious Diseases, and Inflammation

Correspondence to: M Bonten

Accepted 8 November 2001

Vancomycin resistant enterococci are important nosocomial pathogens with variable epidemiological characteristics. Infections are becoming increasingly common in American hospitals, although it is rare for healthy people to carry the bacterium. By contrast, infection with vancomycin resistant enterococci is uncommon in European hospitals but many healthy people carry the bacterium. We describe an outbreak of vancomycin resistant enterococci infection in a Dutch hospital that was controlled by costly, labour intensive infection control measures.1 We also discuss what should be done to prevent vancomycin resistant enterococci becoming endemic in European hospitals.

Summary points

Vancomycin resistant enterococci have low virulence but infection is difficult to treat

Infection is endemic in US hospitals but rare in European hospitals

An outbreak in a Dutch hospital was halted by strict infection control measures

These measures were expensive and at times stopped new admissions and surgery

It is unclear whether such strict measures are justified, and European guidelines are needed

Patterns of vancomycin resistant enterococci infection

In the United States, the incidence of infection with vancomycin resistant enterococci has increased greatly in the past 10 years. In the national nosocomial infection surveillance study, the proportion of vancomycin resistant enterococci among enterococcal bloodstream infections rose from 0% in 1989 to 25.9% in 1999.2 Although the initial rise was observed in intensive care patients, infections are also common among patients treated in general hospital wards.2

Enterococci have a low virulence but can cause serious infections in immunocompromised patients, such as transplant recipients or those in intensive care units.3 Infection usually occurs in the abdominal cavity or urinary tract, and the attributable mortality may be as high as 30%,4 although these figures have not been replicated. 5 6 New antibiotics (such as linezolid) that are effective against vancomycin resistant enterococci are available, but development of resistance has already been reported.7 Limiting further …