We welcome the correction to the Seminar by Erik von Seth and colleagues,1 which clarifies that no vancomycin-resistant enterococci were found in published studies of patients with primary sclerosing cholangitis treated with oral vancomycin. The incidence reported initially in the Seminar (8·7%) has been corrected to 0%.1

Fam K. et al. identified peptidoglycan hydrolase SagA that modulates antibiotic susceptibility of vancomycin-resistant Enterococcus faecium. Pharmacological inhibition of SagA restored vancomycin efficacy across multidrug-resistant clinical strains.

Fam K. et al. identified peptidoglycan hydrolase SagA that modulates antibiotic susceptibility of vancomycin-resistant Enterococcus faecium. Pharmacological inhibition of SagA restored vancomycin effi...

Current Infectious Diseases Society of America guidelines recommend the use of vancomycin (VAN) or daptomycin (DAP) monotherapy for the management of methicillin-resistant Staphylococcus aureus bloods...

Vancomycin is frequently administered empirically for suspected serious bacterial infections (SBI) in the pediatric intensive care unit (PICU) despite low prevalence of methicillin-resistant Staphylococcus aureus (MRSA).MethodsWe performed a multicenter interrupted time series (ITS) study including five PICUs in three U.S. children’s hospitals evaluating the impact of a multifaceted stewardship intervention including consensus guidelines, education, and group level audit and feedback on reducing empiric vancomycin use. The primary outcomes were (1) vancomycin administration within 12 hours of suspected SBI onset and (2) empiric vancomycin days of therapy (DOT) during the first 3 days after suspected SBI onset. Secondary outcomes included overall vancomycin DOT/1000 patient days; organ dysfunction at days 3 and 7; 14-day mortality; and invasive MRSA infection not covered empirically. Empiric vancomycin use was modeled using mixed-effects logistic regression and vancomycin DOT was modeled using mixed effects Poisson regression.ResultsAmong 4,549 episodes targeted by the intervention, there was an immediate reduction in empiric vancomycin use after the intervention (OR 0.71, 95% CI 0.54–0.95, P=0.02), with no significant change in post-intervention slope. Empiric vancomycin days after suspected SBI onset decreased by 24% immediately after the intervention (IRR 0.76, 95% CI 0.65–0.89, P<0.01), with no significant change in postintervention slope. There were no increases in mortality, organ dysfunction, or missed MRSA infections postintervention.ConclusionA multifaceted stewardship intervention reduced empiric vancomycin without evidence of harm, supporting the safety and feasibility of targeting empiric antibiotic prescribing in the PICU setting.

Fear of methicillin-resistant Staphylococcus aureus (MRSA) as a cause of community-acquired pneumonia (CAP) frequently leads to empiric vancomycin coverage. Data evaluating the use of MRSA polymerase chain reaction (PCR) nasal swab testing to guide vancomycin de-escalation is limited for patients in the intensive care unit (ICU).MethodsSwab Testing to Optimize Pneumonia Treatment With Empiric Vancomycin (STOP-Vanc) is a pragmatic, prospective, single-center, non-blinded randomized trial in which adult ICU patients with suspicion of CAP were randomized 1:1 to receive usual care either with (intervention) or without (control) the addition of MRSA nares PCR testing following ICU admission. The primary outcome was vancomycin-free hours alive, defined as the expected number of hours alive and free of vancomycin use within the first 7 days of trial enrollment as estimated using a longitudinal proportional odds state transition model adjusted for baseline covariates.ResultsA total of 277 adult ICU patients were randomized. Methicillin-resistant Staphylococcus aureus PCR nasal swab testing had a negative predictive value (NPV) of 98.9% in the intervention arm. The primary endpoint, vancomycin-free hours alive, was 105.7 in the control arm and 109.7 in the intervention arm (adjusted difference, 4 hours; 95% CI, −9.5–18.2; P = .458).ConclusionsDespite MRSA PCR nasal swab testing demonstrating a high NPV in this critically ill population, MRSA PCR nasal swab testing did not decrease the duration of vancomycin use or 30-day mortality among ICU patients with suspected CAP. Additional clinician education and antimicrobial stewardship interventions might be needed to reduce vancomycin use in this patient population.Clinical Trials RegistrationClinicalTrials.gov NCT06272994 (STOP-Vanc).

The increasing prevalence of multidrug-resistant <i>Staphylococcus aureus</i> continues to compromise the effectiveness of conventional antimicrobial therapy and highlights the need for novel adjunctive...

Four inpatients were found positive

Enterococcus faecium is a major global health threat, particularly in high-risk patient groups, and the emergence of vancomycin-resistant strains (VREfm) has severely limited treatment options. Here,...

Performic acid (PFA) achieved rapid, linear, and consistent inactivation of enterococci and vancomycin-resistant enterococci, peracetic acid (PAA) exhibited slower, variable kinetics with distinctive...

The heterogeneous vancomycin-intermediate <i>Staphylococcus aureus</i> (hVISA) phenotype in methicillin-resistant <i>S. aureus</i> (MRSA) is a major driver of vancomycin treatment failure. Within the...

Uncertainty remains about how gut-based organisms such as vancomycin-resistant Enterococcus (VRE) are spread within the local hospital environment. We hypothesized that, in the medical intensive care unit (ICU), VRE is spread predominantly patient-to-environment rather than environment-to-patient.MethodsMedical ICU patients with sepsis and receiving broad-spectrum antibiotics were sampled via deep rectal swabs at ICU admission and on ICU days 3, 7, 14, and 30. Corresponding ICU room environmental samples were taken at the same time points. All samples were analyzed with 16S sequencing and selective culture, and VRE isolates were genetically characterized via whole-genome sequencing (WGS).ResultsThere were 680 samples gathered from 90 unique patients and their ICU rooms; 47 of 90 (52%) patients and 36 of 90 (40%) rooms showed VRE colonization at 1 or more time point. On 16S sequencing, Enterococcus relative abundance was enriched in room samples when the room housed a VRE-positive patient (0.63% VRE positive vs < 0.01% VRE negative, P < .01). In a network analysis, patient and room Enterococcus were connected for VRE-positive but not VRE-negative patients. WGS identified 23 genetically distinct clusters of VRE. There were 3 events when distinct clusters appeared first in the patient gut and then in the room and 3 events when clusters appeared simultaneously in the gut and room; in no cases was a cluster first detected in the room.ConclusionsWe detected 3 events with spread of genetically distinct VRE clusters from hospitalized patients into their local ICU environment but no reverse events. Effectiveness of infection prevention might be increased by gut-targeting interventions.Clinical Trials Registration. NCT03865706.

Colonization of the gastrointestinal (GI) tract by vancomycin-resistant Enterococcus faecium (VREfm) often precedes bloodstream infection and serves as a reservoir for onward patient transmission in h...