Hospital-Acquired Infections and Antibiotic Resistance



New subsection about Other Hospital Mistakes Affecting Mothers and Babies



What's the simplest thing a hospital can do to lower their rates of hospital-acquired infection?

This is only my personal opinion, but I would say that one of the most obvious, simple changes would be to have hand-washing facilities easily available in the hospital cafeteria.  Here in the United States, at least, I have never seen a hand-washing sink in the eating area.  So, when people go to eat their meals in the cafeteria, they touch many door handles that are rich reservoirs for germs, they handle money, and then they sit down to eat, which is an open invitation to colonize their gut with resistant bacteria, which they can then easily pass on to someone else, such as a patient.

It seems such an obvious improvement to have a hand-washing sink in the eating area so that busy hospital personnel can try to keep themselves from becoming a link in the chain of infection.



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of hospital acquired infections.

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Homes Now 'Reservoirs' for Superbug MRSA - Antibiotic-resistant bacteria common on household surfaces, study finds [4/21/14]


Temporal trends in rates of patient harm resulting from medical care. [full text]
Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ.
N Engl J Med. 2010 Nov 25;363(22):2124-34.
"Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100 admissions; 95% confidence interval [CI], 23.1 to 27.2) [corrected]."

Fact Sheet: Invasive MRSA from the CDC
Approximately 18,650 persons died during a hospital stay related to these serious MRSA infections.

Beth Israel faulted for staph outbreak in mothers, babies - [4/10/09] - Over the past six months, 18 mothers and 19 newborns have become sick with a dangerous bacterial infection soon after being released from Beth Israel Deaconess Medical Center, triggering a state investigation that uncovered serious problems with the hospital's infection control practices.  [Ed: Beth Israel is one of the *best* hospitals around, and if they're having trouble with antibiotic-resistant infections, you can bet that your local community hospital is, too.]

Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002
In 2002, the estimated number of HAIs in U.S. hospitals, was approximately 1.7 million: 33,269 newborns in high-risk nurseries, 19,059 among newborns in nurseries, 417,946 among adults and children in ICUs, and 1,266,851 and children outside of ICUs. The estimated deaths associated U.S. hospitals were 98,987.

Reduction of Health Care Associated Infection Risk in Neonates by Successful Hand Hygiene Promotion
Carmem Lucia Pessoa-Silva et al.
Pediatrics published 30 July 2007, 10.1542/peds.2006-3712
RESULTS. . . . Improved compliance was independently associated with infection risk reduction among very low birth weight neonates. Bacteremia caused by clonally related pathogens markedly decreased after the intervention.

Mortality after Staphylococcus aureus bacteraemia in two hospitals in Oxfordshire, 1997-2003: cohort study.
Wyllie DH, Crook DW, Peto TE.
BMJ. 2006 Jun 23;
CONCLUSION: The spread of MRSA has greatly increased the overall number of cases of S aureus bacteraemia and has contributed to short term mortality after S aureus bacteraemia.

Community-Associated Methicillin-Resistant Staphylococcus aureus Infection Among Healthy Newborns --- Chicago and Los Angeles County, 2004 - This report describes two independent investigations by local health departments, assisted by CDC, into outbreaks of MRSA skin infection among otherwise healthy, full-term newborns delivered at hospitals in Chicago, Illinois, and Los Angeles County, California. In both locations, MRSA transmission likely occurred in the newborn nursery;

Methicillin-Resistant Staphylococcus aureus Colonization and Its Association With Infection Among Infants Hospitalized in Neonatal Intensive Care Units
Yhu-Chering Huang, MD, PhDa,b, Yi-Hong Chou, MDb,c, Lin-Hui Su, MSb,d, Rey-In Lien, MDb,c and Tzou-Yien Lin, MDa,b
 PEDIATRICS Vol. 118 No. 2 August 2006, pp. 469-474 (doi:10.1542/peds.2006-0254)

Deadly bacteria spreading through US hospitals [12/3/05] - A lethal bacteria which surfaces in people being treated with antibiotics is spreading in North America and has grown resistant to drugs, according to two studies published in the New England Journal of Medicine. According to one of the studies, a new, virulent and resistant strain of the bacteria Clostridium difficile broke out in eight US hospital centers between 2000 and 2003. Provoked by antibiotics inside the intestines of hospital patients, the bacteria showed an ability to mutate and increase its resistance to drugs, the report said. Moreover, the bacteria, which infects the colon causing severe diarrhea and colitis, a severe inflammation of the intestine, has begun showing up in patients not taking antibiotics or visiting hospitals.

Doctors Remove Woman's Arms, Legs After Giving Birth - Hospital Says Mom (Claudia Mejia) Developed Infection [1/24/06]
Woman Becomes Quadruple Amputee After Giving Birth

ORLANDO, Fla. -- A Florida woman went to the hospital eight and a half months ago to deliver her son, but she'll never be able to hold him.  Claudia Mejia said an Orlando hospital performed life-altering surgery that left her a quadruple amputee, NewsChannel5 reported. She developed an infection shortly after giving birth and doctors amputated both arms and legs. Mejia and her family want to know why, and they aren't getting the answers they want. She is suing the hospital under Florida's "Patient's Right to Know Act."

An Epidemic, Toxin Gene-Variant Strain of Clostridium difficile. [Full text]
McDonald LC, Killgore GE, Thompson A, Owens RC Jr, Kazakova SV, Sambol SP, Johnson S, Gerding DN.
N Engl J Med. 2005 Dec 1; [Epub ahead of print]
Conclusions A previously uncommon strain of C. difficile with variations in toxin genes has become more resistant to fluoroquinolones and has emerged as a cause of geographically dispersed outbreaks of C. difficile-associated disease.

New Antibiotics Needed as Drug Resistance Continues to Grow  09/03/2004 [Medscape registration is free]
Health providers are running short on ammunition in their battle against antibiotic-resistant infections.

Mycobacterium tuberculosis Transmission in a Newborn Nursery and Maternity Ward --- New York City, 2003

Infectious Diseases Society of America

Vancomycin Susceptibility within Methicillin-resistant Staphylococcus aureus Lineages
Emerg Infect Dis [serial on the Internet]. 2004 Ma

Methicillin-resistant Staphylococcus aureus (MRSA) is a major problem around the world, causing hospital-acquired infections and, more recently, infections in the community (1,2). The glycopeptides, particularly vancomycin, have been the mainstays of therapy for MRSA, and the emergence of resistance to these agents is of great concern.

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In 2002, a Chicago Tribune article stated that the CDC estimate of deaths from hospital-acquired infections was low.  The article said that 103,000 deaths occur annually from hospital-acquired infections, and that 75% of them are preventable.  "[I]nfection rates are soaring nationally, exacerbated by hospital cutbacks and carelessness by doctors and nurses, and serious violations of infection-control standards have been found in the majority of hospitals."  The newspaper noted a 1998 case in which eight children died at a Chicago pediatric medical center; a 1997 Detroit case in which four babies died in 1997; and an infection at a West Palm Beach, Fla., hospital where 13 cardiac patients died in the late 1990s.

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This page contains notes and references from my search for information on the Web about hospital-acquired infections and antibiotic-resistant infections.

National Resources

The best all-around source of information is the CDC - Centers for Disease Control and Prevention in Atlanta.

Emerging Infectious Diseases Journal (EID)

National Center for Infectious Diseases

The National Library of Medicine offers a search engine for medical research - PubMed. Search for (nosocomial OR iatrogenic).


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Notes and references about:

Hospital-Acquired Infections

Antibiotic-Resistant Infections

Vancomycin-Resistant Enterococcus (VRE)


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Hospital-Acquired Infections

Definitions

Nosocomial

Pertaining to a hospital or infirmary

Nosocomial Infection

Infection acquired in a hospital

 

No one knows how many patients are dying from superbug infections in California hospitals [LATimes - 10/02/16] - Many thousands of Californians are dying every year from infections they caught while in hospitals. But you’d never know that from their death certificates.

The epidemiology of antimicrobial resistance in hospital acquired infections: problems and possible solutions
BMJ 1998;317:652-654 ( 5 September )
"Each hospital has its own ecosystem and microsociety, where determinants of antibiotic resistance are quite specific, and therefore effective solutions will need to be tailored to local epidemiological circumstances and resources. "
Hospital germs kill thousands in Canada, too, research finds - [from Canada, 8/6/03, the Globe and Mail] - As many as 12,000 people a year are dying from hospital-acquired infections.

The Impact of Hospital-Acquired Bloodstream Infections
Richard P. Wenzel and Michael B. Edmond
Nosocomial bloodstream infections are a leading cause of death in the United States. If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States.

Nosocomial Group A Streptococcal Infections Associated with Asymptomatic Health-Care Workers -- Maryland and California, 1997 - Group A Streptococcus (GAS), a common cause of pharyngitis and uncomplicated skin and soft tissue infections, can cause serious invasive infections (including necrotizing fasciitis and streptococcal toxic-shock syndrome {STSS}) and death. Since 1965, at least 15 postoperative or postpartum GAS outbreaks attributed to asymptomatic carriage in health-care workers (HCWs) have been reported (1). This report describes two nosocomial outbreaks of GAS infection in Maryland and California during 1996-1997.
One of the hospital patients in this report died from a virulent GAS infection the day she returned home from the hospital after relatively routine surgery.

The Story of Ignaz Semmelweis - History of Hospital-Acquired Infections (from Medscape) -  In Vienna in 1846, the ward where physicians attended births had a mortality rate as high as 31%,  in sharp contrast to the low mortality rate in the midwives' ward next door.  Ignaz Semmelweis was the first physician to identify childbed fever as a hospital-acquired infection caused by invasive techniques and failure to wash hands before attending a birth. Obstetricians ignored him then, and many continue to ignore him now . . . "One study indicates that less than 60 percent of doctors scrub their hands before handling patients."

Infection control - Web site
This Washington Post Web site is devoted to infection control and hand-washing compliance control. While it lacks a how-to, the site gives detailed information on the struggle to improve infection control. Anyone in a health-related field (as well as students of health or medicine) will find the site relevant.

Hospital Bacteria Also Spread by non-Caregiver Hospital Personnel
Subject: UPI Science Briefs [May 7]
Organization: Copyright 1997 by United Press International
Date: Wed, 7 May 1997 1:00:45 PDT

Even hands who don't touch patients can spread bacteria around hospitals. At the annual meeting of the American Society for Microbiology in Miami Beach, an infectious disease expert says health care workers who don't deal directly with patients still accumulate a load of bacteria. That includes bacteria that are resistant to most antibiotics.

 Hospital ICU's a breeding place for bacteria 5/18/97
The Augusta (GA) Chronicle - 11 Sep 97

Bacteria can hide anywhere, and they can collect on clothing, blankets, walls and medical equipment. Hospital workers can pass them on by hand and they can cling to tubes inserted into the body.

 Warning! Infection Risk in Blood Pressure Cuffs
The inflatable cuffs are exposed to a wide variety of bodily fluids (blood, sweat, urine, fecal matter, vomit)  which can harbor any assortment of pathogenic organisms present. The cuff can then readily transfer these pathogens to the next unsuspecting patient through skin contact.


Abstract - Incidence of adverse events and negligence in hospitalized patients
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH
N Engl J Med 1991 Feb 7;324(6):370-376

There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.


Abstract - Staph in a Neonatal Intensive Care Unit
68.Huebner J, Pier GB, Maslow JN, Muller E, Shiro H, Parent M, et al.
Endemic nosocomial transmission of Staphylococcus epidermidis bacteremia isolates in a
neonatal intensive care unit over 10 years.
J Infect Dis 1994;169:526-31.

These findings suggest that distinct clones of S. epidermidis can become endemic in NICUs over periods as long as a decade and that nosocomial transmission plays an important role in neonatal S. epidermidis bacteremia.


Abstract for paper about Nosocomial Infections primarily in ICUs

Attendant-borne Transmission

Emerging hospital-acquired pathogens may pose one of the greatest and most controllable threats to people in countries like the United States, where more than 5% of hospital admissions and about 14% of intensive care patients acquire infections during their stay (55-57). According to some estimates, nosocomial infections rank among the ten leading causes of death in the United States (56), with dangerous bloodstream infections approximately doubling during the 1980s (58).

Water as a Reservoir of Nosocomial Pathogens

Hospital Infections Program
Some good links to CDC reports on recent vancomycin-resistant staph

Overview - CDC Guidelines for the Prevention and Control of Nosocomial Infections

NNIS Report
This report is a summary of the data collected by participating hospitals in the National Nosocomial Infections Surveillance (NNIS) System from October 1986 - May 1996 and updates previously published data.

Karen Burton's pages on Nosocomial Infection
These pages detail a hospital's refusal to allow consumers access to information about their infection rates.


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Antibiotic-Resistant Infections

First US Case of E coli Resistant to Last-Resort Antibiotic [5/26/16] - Researchers have spotted the first known instance of bacteria impervious to the last-resort antibiotic colistin in the United States, exacerbating fears of superbugs that can turn an ordinary infection deadly.

Infections With 'Nightmare Bacteria' Are On The Rise In U.S. Hospitals [3/5/13] - These germs, known as carbapenem-resistant Enterobacteriaceae, or CRE, have become much more common in the last decade, according to the Centers for Disease Control and Prevention. And the risk they pose to health is becoming evident. "What's called CRE are nightmare bacteria," Dr. Thomas Frieden, director of the CDC, tells Shots. "They're basically a triple threat."  First of all, they are resistant to virtually all antibiotics, including the ones doctors use as a last-ditch option.  Second, these bugs can transfer their invincibility to other bacteria. "The mechanism of resistance to antibiotics not only works for one bacteria, but can be spread to others," Frieden says. Third, the bacteria can be deadly. Infection with the bacteria "have a fatality rate as high as 50 percent," Frieden says.


Nosocomial Infection Update - from the 1998 CDC Conference on Emerging Infectious Diseases


 
Nosocomial infection rates in adult and pediatric ICUs are approximately three times higher than elsewhere in hospitals. The sites of infection and the pathogens involved are directly related to treatment in ICUs. In these areas, patients with invasive vascular catheters and monitoring devices have more bloodstream infections due to coagulase-negative staphylococci. In fact, most cases of occult bacteremia in ICU patients are probably due to vascular access-related infections.
Environmental Contamination Due to Methicillin-Resistant Staphylococcus aureus

The Journal of Emerging Infectious Diseases from the CDC

CDC Document - The emergence and Spread of Antibiotic-Resistant Organisms

The emergence of antibiotic-resistant organisms in hospitals in concert with the use of the antibiotics (66) led researchers to conclude that high levels of antibiotic use caused the emergence of resistant organisms and to speculate that antibiotic-resistant organisms might be inherently more virulent than their antibiotic-sensitive counterparts (67). Yet when infections caused by resistant nosocomial organisms are compared with sensitive (generally nosocomial) infections, the former are only sometimes found to be associated with more severe infections

Harmful, often antibiotic-resistant, hospital-acquired pathogens can readily emerge beyond a hospital's boundary, when patients are moved, or attendants move between hospitals; the documentation is particularly strong for dangerous variants of E. coli and S. aureus (62,74-78). The degree to which emerging nosocomial pathogens spill over to generate outbreaks in the outside community is not well understood, but evidence suggests that this spillover represents a substantial threat when the organisms can infect healthy people. When large-scale communitywide epidemics of pathogenic E. coli have occurred, for example, transmission in hospitals often was strongly implicated. During 1953 and 1954, an E. coli epidemic advanced up the East Coast of the United States from the Carolinas through New England; "As it spread, explosive outbreaks were limited to institutions, hospital wards, and newborn nurseries" (59). A focal study of the U.S. Army Hospital at Fort Belvoir, Virginia, indicated that the epidemic strain was brought into the hospital by infected people in the community, with the proportion of inpatient to outpatient cases reversing dramatically during the hospital's 5-month outbreak (59). Similarly, during the winter of 1961, in an outbreak in Chicago and adjacent communities in Indiana, about 5% of the infants were affected, and nearly half of the affected infants had direct or indirect contact with one of the 29 involved hospitals just before their illnesses (75).

Studies of S. aureus have also shown that nosocomial and community outbreaks are sometimes synchronous with transmission occurring in both directions between the hospital and the outside community (79-80). The long-term consequences of emergence of nosocomial strains for the outside community, however, still need to be assessed. The possibility that nosocomial pathogens may tend to be not only more resistant to antibiotics, but also more inherently virulent lends some urgency to this need.

This article also has an excellent bibliography, with many references available online.
 

Antibiotic-resistant ear infection
Sun Herald, Biloxi/Gulfport MS - 04 Aug 97

Kids' ear infections are harder to treat Because of the continued emergence of antibiotic-resistant bacteria, kids' ear infections (otitis media) are even more difficult to cure than previously thought, according to a recent study reported in Pediatric Infectious Disease ...

Experts say antibiotics may become obsolete
Lubbock Online - 27 Aug 97

In the war between humans and germs, most of the recent news has been bad. All over the world, bacteria are responding to people's overuse of antibiotics by evolving ways to resist the drugs' effects. If that trend continues, some of the most powerful weapons against infection may soon ...

Madagascar Case of Bubonic Plague Resists Many Antibiotics, Alarms Scientists
Washington Post - September 4, 1997

The organism isolated from the boy appears to have acquired a set of five antibiotic resistance genes, all at once, from another bacterial species. Similar en bloc gene transfers have been implicated in the spread of drug resistance to other disease-causing bacteria, but never to plague, a disease synonymous with fatal epidemics.

Some bacteria can acquire (or lose) characteristics through the exchange of small loops of DNA called plasmids. Biologists have identified single plasmids that carry numerous genes for drug resistance. A disease-causing bacterium receiving such a windfall can become a medical nightmare overnight.

CDC Pages on Vancomycin Intermediate-resistant Staphylococcus aureus (VISA) including:
First case of resistant staph identified in Japan - June, 1996

First case reported in the U.S. - July, 1997 - Michigan

 LARGE FILE - Second case reported in the U.S. - August, 1997 - New Jersey (259KB)

Good article on general hygiene, with some motivating examples
Detroit Free Press - 06 Sep 97

Maybe the pop-culture panic started with a "Seinfeld" episode in which Poppie the chef failed to wash his hands after using the lavatory. Sickened after witnessing the unhygienic omission, Jerry Seinfeld refused to eat the handmade pizza Poppie set before him. Next came the "ER" show in which a staphylococcus ...

Experts Urge Steps to Stem Antibiotic Resistance
Washington Post - Tuesday, August 26, 1997

In the war between humans and germs, most of the recent news has been bad. All over the world, bacteria are responding to people's overuse of antibiotics by evolving ways to resist the ...

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Vancomycin-Resistant Enterococcus (VRE)


What's new concerning vancomycin-resistant enterococci (VRE)? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Infectious Diseases. [Medscape, 2000. © 2000 Medscape, Inc.]
 

Role of Environmental Contamination in the Transmission of Vancomycin-Resistant Enterococci

"They reported that Enterococcus faecalis survived for 5 days and Enterococcus faecium for 7 days on countertops. Both enterococcal species survived on bedrails for 24 hours without significant die-off, on telephone handpieces for 60 minutes, on the diaphragmatic surface of stethoscopes for 30 minutes, and on gloved and ungloved fingers for at least 60 minutes.

Medicine's Magic Bullet Is Under Siege
Los Angeles Times - Friday, September 5, 1997
Antibiotics: Overuse of broad-spectrum medications has led to bacteria that resist even the most powerful drugs.

Resistant bacteria on rise in Bay hospitals - Once-benign bug has mutated into potential killer
San Francisco Examiner - September 14, 1997
Report that 100% of surveyed hospitals in the San Francisco Bay Area were infected with Vancomycin-Resistant Enterococcus

"It has arrived," said the study's lead investigator Dr. Jon Rosenberg, a medical epidemiologist with the Emerging Infections Program of the California Department of Health Services.

The report reaches the same somber conclusion as dozens of others presented this weekend at the San Francisco meeting of the Infectious Diseases Society of America: Antibiotics, once wonder drugs, don't help like they used to.

Three cases of vancomycin-resistant staph have been reported in the past year - and experts at the conference believe that more cases are right around the corner.

The bug was harmless until it mutated out of reach. In healthy people, it lives in the intestinal tract, causing no illness. But when turned loose in emergency rooms, intensive care units and nurseries, it is dangerous - even deadly.

The hospitals do not experience one single outbreak, but many smaller clusters of infection caused by multiple strains of bacteria, said Rosenberg. He believes that the drug-resistant bugs originate elsewhere but arrive here with sick patients, then quickly spread.

Good Questions and Answers about VRE

Best VRE Overview from a medical perspective

View of VRE from an Oncology perspective - 22-Apr-96
Although this is an excellent article, it is out-of-date, reporting that only 2 cases of VRE had been reported in the Western U.S.

[Warning - this has a disturbing picture of necrotizing cellulitis with VRE sepsis, i.e. a flesh-eating bacteria.

However, the organism can be spread by direct or indirect contact within a particular institution. Enterococci also can be spread among hospitals by health care professionals who work at more than one institution or by patients who were previously infected at another institution.

The section on Acquired Resistance helps explain the way VRE can pass on the resistance genes to other bacteria.

While intrinsic resistance is chromosomally mediated, acquired resistance is mediated by plasmids or transposons. This allows for transfer to other enterococci species or other genuses, such as streptococci and staphylococci.

VRE as a cause of nosocomial infections is a serious problem in the health care system. Its incidence is rapidly increasing, and no treatment has been demonstrated to eradicate these multidrug-resistant organisms. VRE is highly adaptable and acquires resistance easily, making transmission control measures indispensable in preventing the occurrence and spread of this organism.

The organisms can survive on surfaces for long periods of time, thereby allowing transmission through contact. Up to 20% of organisms may remain on the hands after a five-second wash, so health care workers who are in contact with patients with these infections should wash their hands for at least 30 seconds.[16] Gloves are worn and changed prior to contact with other patients. Instruments used in patient care, such as stethoscopes, blood glucose monitors, weighing scales, and rectal thermometers, also may be contaminated with these organisms.

Discussion of how VRE is spread internationally

VRE can be carried for years and be picked up from hard surfaces on which it survives. Since VRE was detected in Canada last year, it’s been cultured from bed rails, bathroom areas, and even patients’ call bells, says Dr. Lee Lior of Health Canada. —Elsie Rosner

In the Netherlands VRE has been detected in 5% of healthy people, he adds.

Though vancomycin is given IV, some seeps into the gut, giving vancomycin-resistant enterococci a chance to develop. Seven microbial genes are involved in enterococci’s resistance to vancomycin, and the genes can be transferred from one type of bacteria to another in a plasmid, says Dr. David Pegues of Mass General.

CDC fact sheet on VANCOMYCIN-RESISTANT ENTEROCOCCI (VRE) FACTS

Recommendations for Preventing the Spread of Vancomycin Resistance
Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC)
Oct 22, 1995 - slightly out-of-date but has an extensive bibliography

Emerging Infectious Diseases * Volume 3 * Number 3 * July - September, 1997
Good discussion of VRE exposure and transmission. Includes discussion of colonization inthe general population - still rare in the U.S. but common in Europe and increasing in the U.S.

Human VRE colonization outside the health-care setting has not been demonstrated in the United States. No VRE was found in two community prevalence surveys designed specifically to detect VRE (26,27). The number of persons studied, however, remains small (304), and the culture methods used may not have been the most sensitive for detecting small numbers of organisms (26,28).

Other lines of epidemiologic evidence in the United States support the possible existence of community VRE transmission. Although several hospital outbreaks of VRE caused by a limited number of genetic clones have been reported

Although high-level aminoglycoside-resistant enterococci have been recovered from chicken prepared in the cafeteria of a hospital where VRE was endemic (35), isolation of VRE with the VanA phenotype from animals or human foods of animal origin have not been reported. Recovery of VRE with the VanA phenotype from dog food sold in the United States (36) and evidence from Europe suggesting that VRE may be prevalent in household pets (cats and dogs) (37, 38) with a genotype common to both human and pet hosts (37) suggests another mode of community transmission. Finally, transmission of VRE from a recently discharged patient to a family member suggests that household contact, including food preparation, may lead to community transmission in the United States (39).

Antimicrobial drugs used in health-care settings may alter bowel flora, rendering patients more susceptible to colonization by VRE transmitted from other colonized or infected patients. Epidemiologic evidence of foodborne VRE transmission in the community suggests that antimicrobial drugs may predispose hospitalized patients to colonization with ingested VRE. Contamination of a patient's food may occur during consumption by a variety of mechanisms, including contamination with VRE from the hands of the patient or health-care worker.

This paper has an interesting reference:

Gaynes RP, Martone WJ, Culver DH, et al.
Comparison of rates of nosocomial infections in
    neonatal intensive care units in the United States.
Am J Med 1991;91(suppl 3B):192S-196S.

CDC Recommendations for Preventing the Spread of Vancomycin Resistance
Hospital Infection Control Practices Advisory Committee (HICPAC)
This Web Page has a good summary of the VRE issues, but is several years out of date.

Since 1989, a rapid increase in the incidence of infection and colonization with vancomycin-resistant enterococci (VRE) has been reported from U.S. hospitals. This increase poses several problems, including a) the lack of available antimicrobials for therapy of infections caused by VRE, because most VRE are also resistant to multiple other drugs (e.g., aminoglycosides and ampicillin) previously used for the treatment of infections due to these organisms, and b) the possibility that the vancomycin resistance genes present in VRE may be transferred to other gram-positive microorganisms such as Staphylococcus aureus.

An increased risk of VRE infection and colonization has been associated with previous vancomycin and/or multi-antimicrobial therapy, severe underlying disease or immunosuppression, and intraabdominal surgery. Because enterococci can be found in the normal gastrointestinal or female genital tract, most enterococcal infections have been attributed to endogenous sources within the individual patient. However, recent reports of outbreaks and endemic infections due to enterococci, including VRE, have shown that patient-to-patient transmission of the microorganisms can occur either via direct contact or indirectly via hands of personnel or contaminated patient-care equipment or environmental surfaces.

The occurrence of VRE in NNIS hospitals was associated with larger hospital size (> or = 200 beds) and university affiliation [1]

Because enterococci are part of the normal flora of the gastrointestinal and female genital tracts, most infections with these microorganisms have been attributed to the patient's endogenous flora [15]. However, recent reports have demonstrated that enterococci, including VRE, can spread by direct patient-to-patient contact or indirectly via transient carriage on hands of personnel [8,16] or contaminated environmental surfaces and patient-care equipment [3,8,17].

This paper also has references to the studies about transference of the VanA gene for vancomycin resistance.

The VanA gene, which is frequently plasmid-borne and confers high-level resistance to vancomycin, can be transferred in vitro from enterococci to a variety of gram-positive microorganisms, [18,19] including S. aureus [20]. Although vancomycin resistance in clinical strains of S. epidermidis or S. aureus has not been reported, vancomycin-resistant strains of S. haemolyticus have been isolated [21,22].

This also has an extensive bibliography - 83 entries - although out of date.

Contamination Information from a Health-Care Products Company
Good information about hospital transmission of germs

Documented studies have shown that the greatest risk of exposure comes from the hospital and its staff. In one instance VRE strains were isolated from 8 patients in a 9 bed intensive care unit. VRE were isolated from the central venous catheter tip and noted as the cause of infection for 7 patients. In other cases, rectal thermometer probes, bedrails and bathroom doors have been contaminated.

It also has some information about how cleaning a bed pan resulted in contamination on "hopper sink, walls, floor and spraywand as well as the care giver's gloves, clothing and shoes - although they appeared clean to the naked eye."

New antibiotic-resistant bacteria worrying hospitals
Detroit News Online - February 21, 1996

Doctors' so-called drug of last resort is threatened by a new bacteria that is worrying hospitals and acute-care nursing homes across the country. The organism is a gastrointestinal bacteria, called enterococcus, ...

About 14 percent of all hospital-acquired enterococcal infections are now resistant to vancomycin, a 20-fold increase from 1989, according to a federal study.

"The general public is at greater risk of antibiotic-resistant organisms than some exotic thing like viral hemorrhagic fever," said Dr. Hildy Meyers, an Orange County (Calif.) Health Department epidemiologist.

If enterococci can become resistant to every antibiotic, so too could other -- more dangerous -- bacteria, said Dr. William Jarvis, an infectious diseases specialist with the Centers for Disease Control and Prevention in Atlanta.