Robert A. Weinstein, MD; Mary Hayden, MD; Sarah Slaughter, MD
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Weinstein R., Hayden M., Slaughter S.; Control of Vancomycin-Resistant Enterococcus. Ann Intern Med. 1997;126:1001. doi: 10.7326/0003-4819-126-12-199706150-00018
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Published: Ann Intern Med. 1997;126(12):1001.
We agree with Dr. Lai's restatement of our findings. In addition, Dr. Lai asks specifically about the cost-effectiveness of rectal surveillance cultures in an intensive care unit in which vancomycin-resistant enterococci are already endemic.
Most patients who are colonized by vancomycin-resistant enterococci never develop infections, and those who do also have multiple comorbid conditions that complicate the assessment of treatment costs. Moreover, the incremental benefit of surveillance cultures, beyond that of other control measures, is difficult to measure. Therefore, the cost-effectiveness of rectal surveillance cultures might be difficult to ascertain, even in the context of a prospective, controlled clinical trial. We have found that surveillance cultures are most helpful in tracking responses to an intervention and that they allow epidemiologic typing of isolates. If isolates are found to represent a single strain, evaluation for a possible common source of contamination should be done. In most instances, however, dissemination of a single strain of vancomycin-resistant enterococci results from lapses of hygiene that result in indirect patient-to-patient spread of organisms via the unwashed hands of health care workers and environmental contamination. The presence of a single strain suggests that maximal control efforts  may be effective. Outbreaks of multiple strains of vancomycin-resistant enterococci seem to be more difficult to control; this may reflect the repeated introduction of resistant strains from other units, other hospitals, or nursing homes  or the presence of a promiscuous resistance plasmid. If typing of surveillance isolates indicates that multiple strains are circulating, additional control strategies may include developing a source-patient profile; evaluating newly admitted patients as possible sources; introducing more stringent antibiotic controls; developing a vancomycin-resistant enterococci cohort system; and using more aggressive standard precautions, as described below.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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