For nosocomial vancomycin-resistant enterococcal infections: the ounce of prevention or the pound of cure?

This issue of the journal contains an important article by Perencevich et al. [1] describing the results of a mathematical model evaluating various measures for controlling the spread of vancomycin-resistant enterococci (VRE) among intensive care unit (ICU) patients. It concludes that active surveillance cultures and contact precautions for all colonized patients provide significantly better control than do standard precautions and/or isolation of the small minority of colonized patients who are recognized to be colonized through the results of routine clinical cultures. It further concludes that presump-tive isolation at the time of ICU admission (i.e., pending surveillance culture results) adds significantly to this control. The article is important for multiple reasons. First, a patient cannot have VRE infection if VRE is not first spread to the patient [2], and spread of VRE is out of control in the United States health care system, in which probably at least one-half of all VRE infections have affected ICU patients. This is a significant problem, because VRE infections appear to be more deadly and more costly than do infections caused by vancomycin-susceptible strains [3–5]. Second, many epidemiologic studies have shown better control of VRE using active surveillance cultures and contact precautions, adding support to the model's conclusions [6–8]. Third, the results are further corroborated by those of a prior mathematical model, which found that increasing compliance with hand hygiene to 80% (i.e., an as-yet unattainable level for most hospitals) would reduce spread of VRE in the ICU by only approximately one-quarter, and that optimal control would instead require surveillance cultures and cohort isolation [9]. The article by Perencevich et al. [1] is also important because it may reflect a growing consensus that active surveillance cultures and contact precautions for all colonized patients work much better than do standard precautions for controlling nosocomial spread of such pathogens. Multiple recent studies that were presented at the 2003 meeting of the Society for Healthcare Epidemiology of America (SHEA) found this to be true [10–17]. The SHEA board's endorsement of a new guideline for controlling nosocomial spread of VRE and methicillin-resistant Staphylococcus aureus (MRSA) using surveillance cultures and contact precautions also likely reflects an emerging consensus [8]. John McGowan spoke at the SHEA meeting in Toronto several years ago about moving the field towards a " tipping point " at which an important consensus could be reached, and progress could then proceed much more rapidly and effectively toward …