Vancomycin-resistant enterococcus in end-stage renal disease

• Published in: American journal of kidney diseases Vol. 32; no. 3; pp. 415 - 418
• Main Authors: Brady, JP, Snyder, JW, Hasbargen, JA
• Format: Journal Article
• Language: English
• Published: Orlando, FL Elsevier Inc 01-09-1998; Elsevier
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anti-Bacterial Agents - adverse effects; Anti-Bacterial Agents - pharmacokinetics; Anti-Bacterial Agents - therapeutic use; Biological and medical sciences; Cross Infection - blood; Cross Infection - drug therapy; Cross Infection - microbiology; Drug Resistance, Multiple; Emergency and intensive care: renal failure. Dialysis management; Enterococcus - drug effects; Gram-Positive Bacterial Infections - blood; Gram-Positive Bacterial Infections - drug therapy; Gram-Positive Bacterial Infections - microbiology; Humans; Intensive care medicine; Kidney Failure, Chronic - blood; Kidney Failure, Chronic - drug therapy; Kidney Failure, Chronic - microbiology; Medical sciences; Metabolic Clearance Rate - physiology; Microbial Sensitivity Tests; Peritoneal Dialysis; Prospective Studies; Renal Dialysis; Risk Factors; Treatment Outcome; Vancomycin - adverse effects; Vancomycin - pharmacokinetics; Vancomycin - therapeutic use; Kidney disease; Enterococcus; Human; Urinary system disease; Hemodialysis; Pharmacovigilance; Vancomycin; Epidemiology; Incidence; Extrarenal dialysis; Streptococcaceae; Chronic; Treatment; Renal failure; Bacteria; Micrococcales; Superinfection; Negative therapeutic reaction
• ISSN: 0272-6386; 1523-6838
• DOI: 10.1053/ajkd.1998.v32.pm9740157

The percentage of nosocomial vancomycin-resistant enterococci (VRE) has been increasing rapidly in the United States. This has recently resulted in recommendations to reserve vancomycin use for cases with proven resistance to other antimicrobials. We prospectively investigated the incidence of VRE in our dialysis population and compared it with a control group of 40 clinic patients with chronic renal insufficiency (CRI) who had a serum creatinine level greater than 1.5 mg/dL, but were not undergoing dialysis. The incidence of VRE on our campus is almost 10%, which is similar to US data. We studied 50 chronic hemodialysis (HD) patients and 50 peritoneal dialysis (PD) patients. Each patient had a rectal swab test performed and cultured for the presence of enterococci. Antimicrobial exposures over the 6 months before the initial swab test were reviewed in each patient. At least one repeated swab test was performed in 30 CRI, 45 HD, and 37 PD patients. From the initial swab culture, vancomycin-sensitive enterococci (VSE) were isolated in 65% of CRI, 54% of HD, and 70% of PD patients. No CRI or HD patients had VRE isolated and 2% (1 of 50) of PD patients had VRE isolated. The remaining patients had no enterococci isolated. Review of antimicrobial exposures in the 6 months before the initial swab test showed 0% of CRI, 32% of HD, and 36% of PD patients received vancomycin. Other antimicrobials were administered to 40% of CRI, 46% of HD, and 78% of PD patients in the same time period. In the month immediately preceding the initial swab test, 0% of CRI, 12% of HD, and 22% of PD patients received vancomycin and 18% of CRI, 20% of HD, and 36% of PD patients received other antimicrobials. Results from repeated cultures showed that 57% of CRI, 40% of HD, and 38% of PD patients changed their culture status related to VSE, VRE, or no enterococci present. Cultures of 342 swabs from 140 patients yielded three VRE isolates in two patients. We conclude that despite the frequent use of vancomycin and other antimicrobials, the incidence of VRE in our renal population is less than the reported incidence. Given this lack of VRE isolates, we recommend the continued judicious use of vancomycin in treating renal patients and continued enterococcal sensitivity surveillance. (Am J Kidney Dis 1998 Sep;32(3):415-8)