The Effect of Vancomycin and Third-Generation Cephalosporins on Prevalence of Vancomycin-Resistant Enterococci in 126 U.S. Adult Intensive Care Units

The Effect of Vancomycin and Third-Generation Cephalosporins on Prevalence of Vancomycin-Resistant Enterococci in 126 U.S. Adult Intensive Care Units

Scott K. Fridkin, MD;
Jonathan R. Edwards, MS;
Jeanne M. Courval, PhD;
Holly Hill, MD, PhD;
Fred C. Tenover, PhD;
Rachel Lawton, MPH;
Robert P. Gaynes, MD;
John E. McGowan, Jr., MD; and
for the Intensive Care Antimicrobial Resistance Epidemiology (ICARE) Project and the National Nosocomial Infections Surveillance (NNIS) System Hospitals

From National Center for Infectious Diseases, U.S. Centers for Disease Control and Prevention, and Rollins School of Public Health, Emory University, Atlanta, Georgia.

Abstract

Background: Patient-specific risk factors for acquisition of vancomycin-resistant enterococci (VRE) among hospitalized patients are becoming well defined. However, few studies have reported data on the institutional risk factors, including rates of antimicrobial use, that predict rates of VRE. Identifying modifiable institutional factors can advance quality-improvement efforts to minimize hospital-acquired infections with VRE.

Objective: To determine the independent importance of any association between antimicrobial use and risk factors for nosocomial infection on rates of VRE in intensive care units (ICUs).

Design: Prospective ecologic study.

Setting: 126 adult ICUs from 60 U.S. hospitals from January 1996 through July 1999.

Patients: All patients admitted to participating ICUs.

Measurements: Monthly use of antimicrobial agents (defined daily doses per 1000 patient-days), nosocomial infection rates, and susceptibilities of all tested enterococci isolated from clinical cultures.

Results: Prevalence of VRE (median, 10%; range, 0% to 59%) varied by type of ICU and by teaching status and size of the hospital. Prevalence of VRE was strongly associated with VRE prevalence among inpatient non-ICU areas and outpatient areas in the hospital, ventilator-days per 1000 patient-days, and rate of parenteral vancomycin use. In a weighted linear regression model controlling for type of ICU and rates of VRE among non-ICU inpatient areas, rates of vancomycin use (P < 0.001) and third-generation cephalosporin use (P = 0.02) were independently associated with VRE prevalence.

Conclusions: Higher rates of vancomycin or third-generation cephalosporin use were associated with increased prevalence of VRE, independent of other ICU characteristics and the endemic VRE prevalence elsewhere in the hospital. Decreasing the use rates of these antimicrobial agents could reduce rates of VRE in ICUs.

Article and Author Information

Acknowledgments: The authors thank the infection control, pharmacy, and microbiology personnel from the participating ICARE hospitals of NNIS for reporting the data for this study. In addition, they wish to recognize the contributions of Lennox Archibald, MD, Erica R. Pryor, RN, PhD, Carol McClay, RN, and Christine D. Steward, MPH, for coordinating submission and processing of data from the participating hospitals. They also thank Harland Austin, PhD, for expert statistical support.
Grant Support: In part by grants to the Rollins School of Public Health of Emory University for Phases 2 and 3 of Project ICARE by AstraZeneca Pharmaceuticals, Wilmington, Delaware, Pfizer, Inc. (New York, New York), and Roche Laboratories (Nutley, New Jersey) as full sponsors; and Aventis Pharma (formerly Rhône–Poulenc Rorer) (Collegeville, Pennsylvania), the National Foundation for Infectious Diseases (Bethesda, Maryland), The American Society for Health Systems Pharmacists Research and Education Foundation (Bethesda, Maryland), Kimberly-Clark Corp. (Roswell, Georgia), and Bayer Corp., Pharmaceuticals Division (West Haven, Connecticut), as partial sponsors.
Requests for Single Reprints: Scott K. Fridkin, MD, Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, MS A-35, 1600 Clifton Road, Atlanta, GA 30333; e-mail, skf0{at}cdc.gov.
Current Author Addresses: Dr. Fridkin: Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, MS A-35, 1600 Clifton Road, Atlanta, GA 30333.
Dr. Courvel: Division of Parasitic Diseases/Immunology, Centers for Disease Control and Prevention, MS F-12, 4770 Buford Highway, Chamblee, GA 30341.
Mr. Edwards, Dr. Gaynes, and Ms. Lawton: Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, MS E-55, 1600 Clifton Road, Atlanta, GA 30333.
Drs. McGowan and Hill: Epidemiology Department, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322.
Dr. Tenover: Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, MS G-08, 1600 Clifton Road, Atlanta, GA 30333.
Author Contributions: Conception and design: S.K. Fridkin, J.R. Edwards, J.E. McGowan.
Analysis and interpretation of the data: S.K. Fridkin, J.R. Edwards, J.M. Courval, H. Hill, F.C. Tenover, J.E. McGowan.
Drafting of the article: S.K. Fridkin, J.M. Courval, J.E. McGowan.
Critical revision of the article for important intellectual content: S.K. Fridkin, J.R. Edwards, H. Hill, F.C. Tenover, J.E. McGowan.
Final approval of the article: S.K. Fridkin, J.R. Edwards.
Statistical expertise: S.K. Fridkin, J.R. Edwards, J.M. Courval, H. Hill.
Administrative, technical, or logistic support: S.K. Fridkin, J.R. Edwards, F.C. Tenover, R.M. Lawton.
Collection and assembly of data: S.K. Fridkin, J.R. Edwards, R.M. Lawton.