Lai K K, Kelley A L, Melvin Z S, Belliveau P P, Fontecchio S A
Department of Medicine, University of Massachusetts Medical Center, Worcester 01655, USA.
Infect Control Hosp Epidemiol. 1998 Sep;19(9):647-52. doi: 10.1086/647892.
To describe the effect of infection control interventions on the incidence of vancomycin-resistant enterococci (VRE), the utility of pharyngeal cultures for surveillance for VRE colonization, and the cost of barrier precautions.
Evaluation of the occurrence of VRE infection or colonization, rates of vancomycin use, results of surveillance cultures before and after interventions, and the cost of increased barrier precautions.
University of Massachusetts Medical Center, a 347-bed tertiary-care teaching hospital with eight intensive-care units, one burn unit, and one bone marrow transplant unit.
Patients in the intensive-care units and staff who were involved with patients colonized or infected with VRE.
Infection control interventions included placement of patients with VRE in private rooms, strict contact isolation, cohorting of patient and nursing staff, prohibiting of equipment sharing, and monitoring of compliance with the vancomycin restriction policy, with hand washing, and of the adequacy of environmental cleaning. Both rectal and pharyngeal cultures were obtained from patients at the beginning of the outbreak, and the utility of pharyngeal cultures was evaluated. The cost of barrier precautions was estimated by comparing the cost of glove and gown use before and after the outbreak began.
The interventions decreased the number of new cases of VRE, but total eradication of VRE was not achieved. Compliance with the room-cleaning protocol was 91% (141/155 observations). Hand washing following interaction with patients who were not in isolation was 51%, vs 100% for patients in isolation. Overall, handwashing compliance was 71% (319/449): 56% (130/231) for physicians and 86% (187/218) for nurses (P<.0001). The mean number of doses of vancomycin dispensed per 1,000 patient days decreased from 145 to 114 per 1,000 patient days (P<.001). Compliance with vancomycin-use guidelines was 85%. Forty-six (77%) of 60 surveillance rectal swabs yielded enterococci, as compared to only 4 (11%) of 36 pharyngeal cultures (P<.0001). Expenses on glove and gowns alone increased by over $11,000 per year since the epidemic began.
Implementation of the various infection control measures did not eradicate VRE cases from the hospital. Rectal cultures were more useful than pharyngeal cultures for surveillance of VRE. Controlling VRE epidemics can be costly.
描述感染控制干预措施对耐万古霉素肠球菌（VRE）发病率的影响、咽拭子培养用于监测VRE定植的效用以及屏障预防措施的成本。
对VRE感染或定植的发生情况、万古霉素使用频率、干预前后监测培养结果以及增加屏障预防措施的成本进行评估。
马萨诸塞大学医学中心，一家拥有347张床位的三级护理教学医院，设有8个重症监护病房、1个烧伤病房和1个骨髓移植病房。
重症监护病房的患者以及接触过VRE定植或感染患者的工作人员。
感染控制干预措施包括将VRE患者安置在单人病房、严格的接触隔离、患者及护理人员分组、禁止设备共享，以及监测万古霉素限制政策的遵守情况、洗手情况和环境清洁是否充分。在疫情爆发初期从患者身上采集直肠和咽拭子培养样本，并评估咽拭子培养的效用。通过比较疫情爆发前后手套和隔离衣的使用成本来估算屏障预防措施的成本。
干预措施减少了VRE的新发病例数，但未实现VRE的完全根除。房间清洁方案的遵守率为91%（141/155次观察）。与未隔离患者接触后的洗手率为51%，而隔离患者的洗手率为100%。总体而言，洗手依从率为71%（319/449）：医生为56%（130/231），护士为86%（187/218）（P<0.0001）。每1000个患者日的万古霉素平均发放剂量从145剂降至114剂（P<0.001）。万古霉素使用指南的遵守率为85%。60份监测直肠拭子中有46份（77%）培养出肠球菌，而36份咽拭子中只有4份（11%）培养出肠球菌（P<0.0001）。自疫情爆发以来，仅手套和隔离衣的费用每年就增加了超过11,000美元。
实施各种感染控制措施未能使医院根除VRE病例。直肠培养对于监测VRE比咽拭子培养更有用。控制VRE疫情可能成本高昂。
