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An Important Infection Control Variable

Marc J. M. Bonten, MD; Sarah Slaughter, MD; Anton W. Ambergen; Mary K. Hayden, MD; Jean van Voorhis, RN, MS; Catherine Nathan, MS; Robert A. Weinstein, MD

Arch Intern Med. 1998;158:1127-1132.

Objective  The spread of nosocomial multiresistant microorganisms is affected by compliance with infection control measures and antibiotic use. We hypothesized that "colonization pressure" (ie, the proportion of other patients colonized) also is an important variable. We studied the effect of colonization pressure, compliance with infection control measures, antibiotic use, and other previously identified risk factors on acquisition of colonization with vancomycin-resistant enterococci (VRE).

Methods  Rectal colonization was studied daily for 19 weeks in 181 consecutive patients who were admitted to a single medical intensive care unit. A statistical model was created using a Cox proportional hazards regression model including length of stay in the medical intensive care unit until acquisition of VRE, colonization pressure, personnel compliance with infection control measures (hand washing and glove use), APACHE (Acute Physiology and Chronic Health Evaluation) II scores, and the proportion of days that a patient received vancomycin or third-generation cephalosporins, sucralfate, and enteral feeding.

Results  With survival until colonization with VRE as the end point, colonization pressure was the most important variable affecting acquisition of VRE (hazard ratio [HR], 1.032; 95% confidence interval [CI], 1.012-1.052; P=.002). In addition, enteral feeding was associated with acquisition of VRE (HR, 1.009; 95% CI, 1.000-1.017; P=.05), and there was a trend toward association of third-generation cephalosporin use with acquisition (HR, 1.007; 95% CI, 0.999-1.015; P=.11). The effects of enteral feeding and third-generation cephalosporin use were more important when colonization pressure was less than 50%. Once colonization pressure was 50% or higher, these other variables hardly affected acquisition of VRE.

Conclusions  Acquisition of VRE was affected by colonization pressure, the use of antibiotics, and the use of enteral feeding. However, once colonization pressure was high, it became the major variable affecting acquisition of VRE.

From the Departments of Internal Medicine (Dr Bonten) and Methodology and Statistics (Mr Ambergen), University Hospital Maastricht, Maastricht, the Netherlands; and the Division of Infectious Diseases, Cook County Hospital (Drs Bonten, Slaughter, and Weinstein and Mss van Voorhis and Nathan), and Rush Medical College (Drs Slaughter, Hayden, and Weinstein), Chicago, Ill.

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