Clostridium difficile and vancomycin-resistant enterococcus: The new nosocomial alliance

OBJECTIVES: The aims of this study were to determine the frequency of the a ssociation between Clostridium difficile (C. difficile) and vancomycin-resi stant Enterococcus (VRE) and delineate the role of C. difficile coinfection as a predictor of VRE infection versus colonization and adverse outcome. METHODS: Patients with both C, difficile colitis and VRE (CD/VRE) were comp ared to patients with VRE alone with regard to demographics, comorbidity, p rior antibiotic therapy, and coinfection with methicillin-resistant Staphyl ococcus: cns aureus and funguria. C. difficile as a predictor of VRE infect ion (VRE-I) versus colonization (VRE-C) and adverse outcome was also studie d. RESULTS: Eighty-nine patients with VRE. infection or colonization were stud ied. This included 31 cases of VRE-I and 58 VRE-C. C. difficile was isolate d in 17 (19.1%) of patients; of these C. difficile was isolated before VRE in 9 patients and after VRE in 8. The two groups did not differ in age, res idence, or comorbidity. C. difficile coinfection was not predictive of VRE- I versus VRE-C, nor was it associated with increased length of stay or mort ality. However, the mortality rates in both groups was high, around 30%. A significant association was noted between the use of vancomycin and metroni dazole (before the isolation of VRE) and C. difficile coinfection (I, = 0.0 3 and p, = 0.001, respectively). A high incidence of nosocomial coinfection with methicillin-resistant Staphylococcus aureus, funguria, and gram-negat ive sepsis was noted in both groups; the association with funguria was stat istically significant (I, = 0.029). CONCLUSIONS:ln conclusion, C. difficile coinfection is common in patients w ith VRE infection or colonization and is significantly associated with othe r nosocomial dilemmas like funguria. This may result in the emergence of hi ghly virulent pathogens including vancomycin-resistant C. difficile, posing new challenges in the management of nosocomial diarrheas. (C) 2000 by Am. Cell. of Gastroenterology.