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Defining the Role of the Environment in the Emergence and Persistence of vanA Vancomycin-Resistant Enterococcus (VRE) in an Intensive Care Unit: A Molecular Epidemiological Study

Published online by Cambridge University Press:  03 April 2018

Andie S. Lee ,
Elizabeth White ,
Leigh G. Monahan ,
Slade O. Jensen ,
Raymond Chan  and
Sebastiaan J. van Hal
Andie S. Lee*
Affiliation:
Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
Elizabeth White
Affiliation:
Infection Control Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
Leigh G. Monahan
Affiliation:
The ithree institute, University of Technology Sydney, Sydney, New South Wales, Australia
Slade O. Jensen
Affiliation:
Antibiotic Resistance and Mobile Elements Group, Ingham Institute, Sydney, New South Wales, Australia Medical Sciences Research Group, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
Raymond Chan
Affiliation:
Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
Sebastiaan J. van Hal
Affiliation:
Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Antibiotic Resistance and Mobile Elements Group, Ingham Institute, Sydney, New South Wales, Australia Medical Sciences Research Group, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
*
Address correspondence to Andie S. Lee, Department of Microbiology, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Sydney, NSW, Australia ([email protected]).
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Abstract

OBJECTIVE

To describe the transmission dynamics of the emergence and persistence of vanA vancomycin-resistant enterococcus (VRE) in an intensive care unit (ICU) using whole-genome sequencing of patient and environmental isolates.

DESIGN

Retrospective cohort study.

SETTING

ICU in a tertiary referral center.

PARTICIPANTS

Patients admitted to the ICU over an 11-month period.

METHODS

VanA VRE isolated from patients (n=31) were sequenced using the Illumina MiSeq platform. Environmental samples from bed spaces, equipment, and waste rooms were collected. All vanA VRE-positive environmental samples (n=14) were also sequenced. Data were collected regarding patient ward and bed movements.

RESULTS

The 31 patient vanA VRE isolates were from screening (n=19), urine (n=4), bloodstream (n=3), skin/wound (n=3), and intra-abdominal (n=2) sources. The phylogeny from sequencing data confirmed several VRE clusters, with 1 group accounting for 38 of 45 isolates (84%). Within this cluster, cross-transmission was extensive and complex across the ICU. Directionality indicated that colonized patients contaminated environmental sites. Similarly, environmental sources not only led to patient colonization but also to infection. Notably, shared equipment acted as a conduit for transmission between different ICU areas. Infected patients, however, were not linked to further VRE transmission.

CONCLUSIONS

Genomic sequencing confirmed a predominantly clonal outbreak of VRE with complex transmission dynamics. The environmental reservoir, particularly from shared equipment, played a key role in ongoing VRE spread. This study provides evidence to support the use of multifaceted strategies, with an emphasis on measures to reduce bacterial burden in the environment, for successful VRE control.

Infect Control Hosp Epidemiol 2018;39:668–675

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 6 , June 2018 , pp. 668 - 675
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

PREVIOUS PRESENTATION. Data in this manuscript were presented in abstract form at the Australian Society of Antimicrobials (ASA) Conference on February 24, 2017, in Melbourne, Australia.

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