OUTBREAK OF VANCOMYCIN-RESISTANT, AMPICILLIN-RESISTANT, AND AMINOGLYCOSIDE-RESISTANT ENTEROCOCCUS-FAECIUM BACTEREMIA IN AN ADULT ONCOLOGY UNIT

An outbreak of bacteremia caused by Enterococcus faecium with high-level resistance to vancomycin (MIC of greater than or equal to 256 mu g/ml), ampicillin (MIC of greater than or equal to 64 mu g/ml), and gentamicin or streptomycin (MIC of greater than or equal to 2,000 mu g/ml) occurred in an adult oncology unit from June 1991 to May 1992. Active surveillance for the presence of this organism in stool or perianal cultures was begun in September 1991. Between June 1991 and May 1992, seven patients with bacteremia and 22 noninfected carriers of the organism in stool were identified. The vanA gene, tested for by PCR and gene probe, was present in all isolates evaluated. All bacteremic patients also had resistant E. faecium present in a stool or perianal culture; the stool isolates tested were closely related to the respective blood isolates as determined by pulsed-field gel electrophoresis. Antibiotic regimens using high-dose ampicillin and an aminoglycoside were ineffective with four patients. Five patients (71%) had multiple positive blood cultures; four of these patients died. Following a multiple logistic regression analysis, it was found that bacteremic patients received a significantly greater number of total antibiotic days compared with noninfected stool carriers (P = 0.019). The emergence of E. faecium with high-level resistance to vancomycin, ampicillin, and aminoglycosides underscores the importance of performing susceptibility testing on all clinically significant isolates. In the neutropenic adult oncology patient, bacteremia with this organism is of probable gastrointestinal origin, is often persistent, and is refractory to treatment with ampicillin in combination with an aminoglycoside. Prolonged use of antibiotics may predispose patients with gastrointestinal colonization to develop bacteremia.