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• W2143487230 abstract "To the Editors: Vancomycin-resistant enterococci (VRE) are isolated with increasing frequency in hospitals and pose a major threat especially to immunocompromised patients and others in specialist units. From the time they were first reported [1Leclercq R Derlot E Duval J Courvalin P Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium.N Engl J Med. 1988; 319: 157-161Crossref PubMed Scopus (1145) Google Scholar,2Uttley AHC Collins CH Naidoo J George RC Vancomycin-resistant enterococci.Lancet. 1988; i: 57-58Abstract Scopus (856) Google Scholar], the Laboratory of Hospital Infection has received VRE from hospitals throughout the UK in order to further elucidate the epidemiology of these organisms. Although there have been reports of VRE in particular hospitals in the UK [2Uttley AHC Collins CH Naidoo J George RC Vancomycin-resistant enterococci.Lancet. 1988; i: 57-58Abstract Scopus (856) Google Scholar, 3Uttley AHC George RC Naidoo J et al.High-level vancomycin-resistant enterococci causing hospital infection.Epidemiol Infect. 1989; 103: 173-181Crossref PubMed Scopus (266) Google Scholar, 4French GY Abdulla Y Heathcock R Poston S Cameron J Vancomycin resistance in south London.Lancet. 1992; 339: 818-819Abstract PubMed Scopus (36) Google Scholar, 5Hall LM Chen HY Williams RJ Vancomycin-resistant Enterococcus durans.Lancet. 1992; 340: 1105Abstract PubMed Scopus (13) Google Scholar, 6Morrison D, Woodford N, Briant V, et al. Enterococcus faecium resistant to vancomycin and gentamicin causing cross-infection on a liver unit [abstract 1173]. In: Program and abstracts of the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy, Anaheim, CA, 1992.Google Scholar, 7Rao GG Morris KJ George RC Woodford N Vancomycin-resistant enterococci in a district general hospital.Lancet. 1992; 340: 1471-1472PubMed Google Scholar, 8Chadwick P Oppenheim BA Vancomycin-resistant enterococci and bedpan washer machines.Lancet. 1994; 344: 685Abstract PubMed Scopus (25) Google Scholar, 9Jordens JZ Bates J Griffiths DT Faecal carriage and nosocomial spread of vancomycin-resistant Enterococcus faecium].Antimicrob Chemother. 1994; 34: 515-528Crossref Scopus (180) Google Scholar, 10Orr KE Gould FK Perry JD et al.Therapeutic beds: The Trojan horses of the 1990s?.Lancet. 1994; 344: 65-66Abstract PubMed Scopus (24) Google Scholar, 11Woodford N Jones BL Baccus Z Ludlam HA Brown DFJ Linkage of vancomycin and high-level gentamicin resistance genes on the same plasmid in a clinical isolate of Enterococcus faecalis.J Antimicrob Chemother. 1995; 35: 179-184Crossref PubMed Scopus (50) Google Scholar, 12Woodford N Morrison D Johnson AP et al.Plasmid-mediated vanB glycopeptide resistance in enterococci.Microbial Drug Resistance. 1995; (in press)PubMed Google Scholar], no data have been presented on the national distribution of these organisms. Between 1987 and 1994, approximately 500 isolates of VRE (Enterococcus faecium, 86%; Enterococcus faecalis, 11%; and Enterococcus avium, 3%) were referred from 44 hospitals. This series includes only enterococci with acquired vancomycin resistance and excludes the intrinsically vancomycin-resistant species such as Enterococcus gallinarum, Enterococcus casseliflavus and Enterococcus flavescens. The hospitals involved ranged from large teaching hospitals to district general hospitals. At one district general hospital, vancomycin had not been in use for 6 months prior to VRE isolation [7Rao GG Morris KJ George RC Woodford N Vancomycin-resistant enterococci in a district general hospital.Lancet. 1992; 340: 1471-1472PubMed Google Scholar]. Both phenotypes of VRE – VanA (resistant to vancomycin and teicoplanin) and VanB (resistant to vancomycin, but sensitive to teicoplanin in vitro) – were received, although isolates with the VanA phenotype were predominant (80%). Although most institutions referred only one isolate, clusters of VRE were received from 14 hospitals. The foci of these clusters were specialist units such as renal, hematological, intensive care and liver units, but strains had also spread to other departments. In several hospitals, VRE have become endemic with the same strain isolated over a number of years. On investigation of these clusters, using molecular techniques, we found that, although each hospital may have one or two strains which predominate, a number of other strains are often involved, some of which have been found to carry the vancomycin resistance genes on plasmids of similar molecular weight [13Woodford N Morrison D Johnson AP Briant V George RC Cookson B Application of DNA probes for rRNA and vanA genes for investigation of a nosocomial cluster of vancomycin-resistant enterococci.J Clin Microbiol. 1993; 31: 653-658PubMed Google Scholar]. This suggests that the epidemiology of nosocomial VRE involves both the spread of strains between patients and the spread of the vancomycin resistance genes between strains. Typing of vancomycin-resistant E. faecium (VREM) also suggests that, nationwide, a large number of heterogeneous strains are involved. Nevertheless, eight strains have been isolated at more than one hospital as a result of what appear to be instances of interhospital spread. Five of these fulfil our definition of an epidemic strain (isolation from at least two patients in each of two or more hospitals) and have been designated epidemic VREM (EVREM) strains 1 to 5. In the majority of cases, spread occurred among two or three hospitals in the same city. However, one of these strains, EVREM-3, was isolated at seven hospitals in the London area during 1993 and 1994, and was responsible for prolonged outbreaks in the renal units of two of them. In the first 9 months of 1995, this strain was isolated at a further four hospitals in the London area. The majority of isolates of EVREM-3 are multiresistant, with high-level resistance to vancomycin, teicoplanin, gentamicin, streptomycin and penicillin. At present, we are unable to draw any firm conclusions as to the mode of interhospital spread. However, in one instance, the index patient in a bone marrow transplant unit (BMTU) had been transferred from the BMTU of another hospital where the same strain of VREM had been frequently isolated. Similar cases of interhospital spread have recently been reported in the USA [14Chow JW Kuritza A Shlaes DM Green M Sahm DF Zervos MJ Clonal spread of vancomycin-resistant Enterococcus faecium between patients in three hospitals in two states.J Clin Microbiol. 1993; 31: 1609-1611PubMed Google Scholar,15Dembry LM, Saravolatz L, Somero M, Durbin AP, Miller S, Zervos MJ. Clonal spread of a unique vancomycin-resistant phenotype of Enterococcus faecium between patients in four hospitals in southeastern Michigan [abstract L-13]. In: Program and abstracts of the 94th American Society of Microbiologists General Meeting, 1994, Anaheim, CA.Google Scholar]. These and our own observations highlight the urgent need for hospitals to implement infection-control policies to prevent the spread of VRE both within and between hospitals. Recommendations have been established in the USA [16Hospital Infection Control Practices Advisory Committee (HICPAC)Recommendations for preventing the spread of vancomycin resistance.Infect Control Hosp Epidemiol. 1995; 16: 105-113Crossref PubMed Scopus (513) Google Scholar]. We suggest that hospitals in the UK and elsewhere should refer isolates of VRE to reference laboratories to monitor the spread of VREM and to ensure that infection-control teams are kept informed of their epidemic potential, as is done in the case of epidemic strains of methicillin-resistant Staphylococcus aureus." @default.
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• W2143487230 title "Epidemic vancomycin-resistant Enterococcus faecium in the UK" @default.
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