VANCOMYCIN-RESISTANT ENTEROCOCCUS IN END-STAGE RENAL-DISEASE

The percentage of nosocomial vancomycin-resistant enterococci (VRE) ha s been increasing rapidly in the United States. This has recently resu lted in recommendations to reserve vancomycin use for cases with prove n resistance to other antimicrobials. We prospectively investigated th e incidence of VRE in our dialysis population and compared it with a c ontrol group of 40 clinic patients with chronic renal insufficiency (C RI) who had a serum creatinine level greater than 1.5 mg/dL, but were not undergoing dialysis, The incidence of VRE on our campus is almost 10%, which is similar to US data, We studied 50 chronic hemodialysis ( HD) patients and 50 peritoneal dialysis (PD) patients. Each patient ha d a rectal swab test performed and cultured for the presence of entero cocci. Antimicrobial exposures over the 6 months before the initial sw ab test were reviewed in each patient. At least one repeated swab test was performed in 30 CRI, 45 HD, and 37 PD patients. From the initial swab culture, vancomycin-sensitive enterococci (VSE) were isolated in 65% of CRI, 54% of HD, and 70% of PD patients. No CRI or HD patients h ad VRE isolated and 2% (1 of 50) of PD patients had VRE isolated, The remaining patients had no enterococci isolated. Review of antimicrobia l exposures in the 6 months before the initial swab test showed 0% of CRI, 32% of HD, and 36% of PD patients received vancomycin, Other anti microbials were administered to 40% of CRI, 46% of HD, and 78% of PD p atients in the same time period. In the month immediately preceding th e initial swab test, 0% of CRI, 12% of HD, and 22% of PD patients rece ived vancomycin and 18% of CRI, 20% of HD, and 36% of PD patients rece ived other antimicrobials, Results from repeated cultures showed that 57% of CRI, 40% of HD, and 38% of PD patients changed their culture st atus related to VSE, VRE, or no enterococci present. Cultures of 342 s wabs from 140 patients yielded three VRE isolates in two patients. We conclude that despite the frequent use of vancomycin and other antimic robials, the incidence of VRE in our renal population is less than the reported incidence. Given this lack of VRE isolates, we recommend the continued judicious use of vancomycin in treating renal patients and continued enterococcal sensitivity surveillance. (C) 1998 by the Natio nal Kidney Foundation, Inc.