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Unlabelled: In order to determine the extent of vancomycin resistant enterococcus (VRE) colonisation within a paediatric oncology unit, the risk factors for the acquisition of the organism, the molecular epidemiology of the isolates and the impact of infection control measures, extensive patient and environmental surveillance was undertaken with identification, antibiotic susceptibility testing and pulsed-field gel electrophoresis (PFGE) of all VRE isolates. A matched case control study was carried out. Fourteen patients (19% of screened patients) with VRE colonisation were identified (12 with Enterococcus faecium). All isolates manifested the Van A phenotype. Extensive environmental contamination with VRE was present. PFGE of E. faecium isolates from 10 patients and from five of six environmental cultures revealed patterns suggesting genetic relatedness. Following comparison of the 14 cases with 41 controls matched for age (+/- 4 years) and cohabitation on the oncology unit, risk factors for colonisation with VRE included duration of neutropenia, (OR, 3.72; 95% CI, 1.0-13.1), and antibiotic therapy, (OR, 4.07; 95% CI, 1.08-15.3), the number of antibiotic agents received, (OR, 8.4; 95% CI, 1.34-34.3) and the duration of therapy with amikacin, (OR, 10.7; 95% CI, 1.4-81.5), ceftazidime, (OR, 11.5; 95% CI, 2.2 59.9) or teicoplanin, (OR, 12.3; 95% CI, 2.25-67.4). Implementation of stringent infection control measures reduced environmental contamination from 25% of samples in week 1 to none in week 11. Two additional colonised patients were identified during the subsequent 6 months., Conclusion: Risk factors for VRE colonization in paediatric oncology patients included duration of neutropenia, duration of any antibiotic therapy, exposure to ceftazidime, amikacin or teicoplanin and the number of antibiotics used. The study suggests that environmental contamination played an important role in patient-to-patient transmission of VRE and interventions including implementation of infection control measures were associated with a decreased incidence of gastro-intestinal colonisation.

Objective: To assess the extent and appropriateness of glycopeptide use in a tertiary Australian Paediatric hospital.Methodology: A retrospective analysis of prescriptions during a six-month period between July 1999 and January 2000. Medical records were examined and prescribing practices compared with the recommendations of the Hospital Infectious Control Practices Advisory Committee (HICPAC) and the Infectious Diseases Society of America (IDSA).Results: Fifty-one patients were identified who received a total of 98 glycopeptide prescriptions. The Haematology/ Oncology unit prescribed 71/98 (72.4%). 68/98 (69.4%) patients received vancomycin, 9/98 (9.2%) received teicoplanin and 21/98 (21.4%) a combination of both. 81/98 (82.7%) had central venous catheters and 69/98 (70.4%) were immunocompromised. 48/98 (49%) prescriptions were for empiric treatment with 38/98 (38.8%) for prophylaxis and 11/98 (12.2%) therapeutic. 19/98 (19.4%) prescriptions were deemed appropriate, 6 (6.1%) by HICPAC criteria, and a further 13 (13.3%) by IDSA or other criteria. Of 19 prescriptions started appropriately, only 7/17 (41.1%) were continued appropriately beyond 48 h. Appropriate cultures were taken before prescription in 93.3% of cases. Dose was appropriate in 91/98 (92.9%) and frequency appropriate in all cases. The cost of inappropriate prescribing was approximately $9500.Discussion: A high rate of inappropriate glycopeptide prescribing was evident in this paediatric population. Inappropriate prescribing existed across all subspecialties. Use was primarily for empiric therapy and prophylaxis in young children with an oncology diagnosis. A number of situations existed where glycopeptide prescription was felt appropriate despite not being included in HICPAC/IDSA guidelines. Areas with high rates of inappropriate prescribing were identified and will be targeted for education and intervention. Audit of practice continues. [ABSTRACT FROM AUTHOR]

Unlabelled: This study was undertaken to investigate the frequency of, indications for and appropriateness of glycopeptide prescription in a paediatric tertiary referral hospital and to assess the usefulness of the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines. A prospective audit of all systemic glycopeptide prescriptions over a 2-month period was undertaken. Clinical and microbiological data were recorded. Of 2810 hospital admissions, systemic IV glycopeptides were prescribed on 57 occasions to 50 patients, 30 (52.6%) for vancomycin and 27 (47.4%) for teicoplanin. Prescriptions were for 34 males and 23 females aged from 2 weeks to 11 years (mean 15 months; median 9 months). Median hospital stay was 50 days. Glycopeptides were given to the following patient groups: cardiology 7 (12%), prophylaxis for cardiac surgery 11 (19%), post-cardiac surgery 1 (1.8%), oncology 14 (24.6%), post-gastrointestinal tract surgical 8 (14%), general surgical 9 (15. 8%) and medical 7 (12.3%). Twenty three children (41.8%) had central lines in situ. Reason for use of glycopeptide was therapeutic in 7 (12.3%), empiric in 38 (66.7%), and as prophylaxis in 12 (21.1%). Eight (14%) prescriptions met strict HICPAC criteria, but a further 22 (39%) prescriptions were considered appropriate in this high-risk population. Glycopeptides were chosen appropriately for cardiac surgery prophylaxis in a further 10 (18%) but timing and duration of use in this group was inappropriate. Of all prescriptions, use was empiric in 38 (76%) and appropriate cultures were obtained at the time of commencement in only 13 (34%) of these. Glycopeptides were not used for routine surgical prophylaxis or for first-line empiric treatment of febrile neutropenia.Conclusions: The strict implementation of HICPAC guidelines may not always be appropriate for children at risk of beta-lactam resistant gram-positive infections. Hospital guidelines need to be tailored to the patient population and microbial susceptibility patterns of each institution. Appropriate cultures should be obtained at the time glycopeptide treatment is begun so that duration of exposure can be limited. [ABSTRACT FROM AUTHOR]