Determinants of Vancomycin Resistance and Mortality Rates in Enterococcal Bacteremia: A Prospective Multicenter Study

  1. Emanuel N. Vergis, MD;
  2. Mary K. Hayden, MD;
  3. Joseph W. Chow, MD;
  4. David R. Snydman, MD;
  5. Marcus J. Zervos, MD;
  6. Peter K. Linden, MD;
  7. Marilyn M. Wagener, MPH;
  8. Barbara Schmitt, RN, BSN; and
  9. Robert R. Muder, MD
  1. From Veterans Affairs Medical Center–University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois; Wayne State University School of Medicine and John D. Dingell Veterans Affairs Medical Center, Detroit, and William Beaumont Hospital, Royal Oak, Michigan; and New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts.

    Abstract

    Background: Enterococcus species are major nosocomial pathogens and are exhibiting vancomycin resistance with increasing frequency. Previous studies have not resolved whether vancomycin resistance is an independent risk factor for death in patients with invasive disease due to Enterococcus species or whether antibiotic therapy alters the outcome of enterococcal bacteremia.

    Objective: To determine whether vancomycin resistance is an independent predictor of death in patients with enterococcal bacteremia and whether appropriate antimicrobial therapy influences outcome.

    Design: Prospective observational study.

    Setting: Four academic medical centers and a community hospital.

    Patients: All patients with enterococcal bacteremia.

    Measurements: Demographic characteristics; underlying disease; Acute Physiology and Chronic Health Evaluation (APACHE) II scores; antibiotic therapy, immunosuppression, and procedures before onset; and antibiotic therapy during the ensuing 6 weeks. The major end point was 14-day survival.

    Results: Of 398 episodes, 60% were caused by E. faecalis and 37% were caused by E. faecium. Thirty-seven percent of isolates exhibited resistance or intermediate susceptibility to vancomycin. Twenty-two percent of E. faecium isolates showed reduced susceptibility to quinupristin–dalfopristin. Previous vancomycin use (odds ratio [OR], 5.82 [95% CI, 3.20 to 10.58]; P < 0.001), previous corticosteroid use (OR, 2.43 [CI, 1.22 to 4.86]; P = 0.01), and total APACHE II score (OR, 1.06 per unit change [CI, 1.02 to 1.10 per unit change]; P = 0.003) were associated with vancomycin-resistant enterococcal bacteremia. The mortality rate was 19% at 14 days. Hematologic malignancy (OR, 3.83 [CI, 1.56 to 9.39]; P = 0.003), vancomycin resistance (OR, 2.10 [CI, 1.14 to 3.88]; P = 0.02), and APACHE II score (OR, 1.10 per unit change [CI, 1.05 to 1.14 per unit change]; P < 0.001) were associated with 14-day mortality. Among patients with monomicrobial enterococcal bacteremia, receipt of effective antimicrobial therapy within 48 hours independently predicted survival (OR for death, 0.21 [CI, 0.06 to 0.80]; P = 0.02).

    Conclusions: Vancomycin resistance is an independent predictor of death from enterococcal bacteremia. Early, effective antimicrobial therapy is associated with a significant improvement in survival.

    Article and Author Information

    • Acknowledgment: The authors thank Victor L. Yu, MD, for review of the manuscript.

    • Requests for Single Reprints: Robert R. Muder, MD, Infectious Disease Section, Veterans Affairs Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240.

    • Current Author Addresses: Dr. Vergis: Division of Infectious Diseases, University of Pittsburgh, Suite 3A, Falk Medical Building, 3601 Fifth Avenue, Pittsburgh, PA 15213.

    • Dr. Hayden and Ms. Schmitt: Section of Infectious Diseases, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, 1653 West Congress Parkway, Chicago, IL 60612.

    • Dr. Chow: Division of Infectious Diseases, Wayne State University School of Medicine, 3990 John R, Detroit, MI 48201.

    • Dr. Snydman: Division of Infectious Diseases, New England Medical Center, 720 Washington Street, Box 238, Boston, MA 02111.

    • Dr. Zervos: William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073.

    • Dr. Linden: Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, 614 Scaife Hall, Pittsburgh, PA 15261.

    • Ms. Wagener and Dr. Muder: Infectious Disease Section, Veterans Affairs Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240.

    • Author Contributions: Conception and design: M.K. Hayden, J.W. Chow, D.R. Snydman, M.J. Zervos, P.K. Linden, R.R. Muder.

    • Analysis and interpretation of the data: E.N. Vergis, M.K. Hayden, J.W. Chow, D.R. Snydman, M.J. Zervos, M.M. Wagener, R.R. Muder.

    • Drafting of the article: E.N. Vergis, D.R. Snydman.

    • Critical revision of the article for important intellectual content: E.N. Vergis, M.K. Hayden, J.W. Chow, D.R. Snydman, M.J. Zervos, R.R. Muder.

    • Final approval of the article: E.N. Vergis, M.K. Hayden, J.W. Chow, D.R. Snydman, M.J. Zervos, P.K. Linden, M.M. Wagener, R.R. Muder.

    • Provision of study materials or patients: E.N. Vergis, M.K. Hayden, J.W. Chow, D.R. Snydman, M.J. Zervos, P.K. Linden, B.A. Schmitt.

    • Statistical expertise: M.M. Wagener.

    • Administrative, technical, or logistic support: M.J. Zervos, P.K. Linden, B.A. Schmitt, R.R. Muder.

    • Collection and assembly of data: E.N. Vergis, J.W. Chow, D.R. Snydman, M.J. Zervos, M.M. Wagener, B.A. Schmitt.

    Summary for Patients

    • Summaries for Patients:Determinants of Vancomycin Resistance and Death in Enterococcal Bacteremia Ann Intern Med October 2, 2001 135:S43
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    1. Ann Intern Med October 2, 2001 vol. 135 no. 7 484-492
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