A population-based investigation of invasive vancomycin-resistant Enterococcus infection in metropolitan Atlanta, Georgia, and predictors of mortality

BACKGROUND. Vancomycin-resistant Enterococcus organisms (VRE) have emerged as common nosocomial pathogens, but few population-based data are available on the impact of invasive VRE infections. METHODS. We assessed the incidence of invasive VRE infections and predictors of mortality among patients identified during prospective, population-based surveillance performed in the metropolitan statistical area (MSA) of Atlanta, Georgia. RESULTS. From July 1997 through June 2000, a total of 192 patients who resided in the Atlanta MSA developed an invasive VRE infection, for a rate of 1.57 cases per 100,000 person-years. The incidence of invasive VRE disease significantly increased from 0.91 cases per 100,000 person-years during the first year of the study to 1.73 cases per 100,000 person-years during the third year of the study (P < .001). Rates of invasive VRE infection were significantly higher among African American patients than white patients (2.59 vs 0.70 cases per 100,000 person-years;). Blood was the most common sterile site from which VRE was recovered (161 [83%] of 193 isolates), followed by P < .001 deep surgical sites (17 [9%]), peritoneal fluid (10 [5%]), pleural fluid (3 [2%]), and cerebrospinal fluid (1 [0.5%]). In multivariate analysis, a Charlson comorbidity index of 5 or greater, previous receipt of antibiotic therapy, having 2 or more sets of blood cultures positive for VRE, and receipt of central parenteral nutrition were independent predictors of mortality, whereas receipt of an antibiotic with in vitro activity against the VRE isolate was associated with a decreased risk of mortality. Molecular typing revealed 38 different pulsed-field gel electrophoresis patterns, but the 2 most common pulsed-field gel electrophoresis types were found at 3 Emory University-affiliated hospitals. CONCLUSIONS. The incidence of invasive VRE infection significantly increased in the Atlanta MSA during the 3-year study period, with significant racial disparities detected. Receipt of an antimicrobial agent with in vitro activity against VRE was associated with a lower mortality rate. Molecular typing results demonstrated polyclonal emergence of VRE in Atlanta.