Major article Low risk of apparent transmission of vancomycin-resistant Enterococci from bacteraemic patients to hospitalized contacts Nico T. Mutters MD, MSc a, *, Russell J. Brooke MSc b , Uwe Frank MD, PhD c , Klaus Heeg MD, PhD a a Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany b Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands c Department of Infectious Diseases, Division of Infection Control and Hospital Epidemiology, Heidelberg University Hospital, Heidelberg, Germany Key Words: Risk factors Acquisition contact isolation VRE epidemiology Background: Vancomycin-resistant enterococci (VRE) are primarily opportunistic pathogens with incalculable clinical significance. In addition, the effectiveness of isolation in VRE is often not easily assessed. The goals of this study were to estimate the transmissibility of VRE of patients with VRE bacteraemia to other hospitalized patients and to document reliable epidemiologic data on all VRE cases in a large health care center. Methods: A prospective survey on in-patients colonized and/or systemically infected with VRE was conducted at a 2,000-bed tertiary care university hospital in Germany. All roommates of VRE bacteraemia patients were analyzed. Pulsed-field gel electrophoresis was performed to assess clonal relatedness. Results: 16,507 Screening tests were performed on 9,258 patients, of which 560 tested positive for VRE (6.1%). Nineteen patients also suffered from VRE bacteraemia, an incidence of 3.4%. This cohort was multimorbid and had high rates of exposure to external risk factors (eg, previous hospital stay prior to admission, 78.9%). The transmission rate to contacts was low (3.5%). Contact time of negative contacts was significantly lower than that of VRE-positive contacts (19.3 hours vs 72.0 hours, respectively, P < .006). Conclusion: VRE bacteraemia was found exclusively in multimorbid patients, transmission occurred seldom, and average contact time of positive contacts was very high. The risk of transmission of VRE from bacteraemic patients to hospitalized contacts is low. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. Since vancomycin-resistant enterococci (VRE) first appeared in the 1980s in Europe, VRE have become a global issue. 1,2 Resis- tance to glycopeptides is a major clinical issue, although the epidemiologic impact of VRE exhibits remarkable geographic div- ersity and variable temporary trends. 3 Nonetheless, enterococci generally display low levels of virulence and are mainly natural colonizers of the gastrointestinal tract. 4 In addition, it is not always easy to assess the clinical significance of VRE in routine cultures nor to differentiate between colonization and infection. There are, however, certain groups of patients with particular clinical condi- tions such as liver transplant or hematologic malignancy, which are at higher risk for VRE acquisition. 5,6 Nevertheless, the following question remains: how virulent are different VRE strains? We conducted a large prospective survey of in-patients with VRE bacteraemia in one of Germany’s largest university hospitals for a study period of 2 years and assessed relevant epidemiologic data on all VRE cases. The primary goal of this study was to estimate the transmissibility of VRE of patients with VRE bacteraemia to other hospitalized patients. The secondary goal was to document reliable epidemiologic data on all VRE cases in a large health care center, warranting a high validity because of the prospective approach and the large sample size. METHODS Microbiologic methods Our screening test consists of a combination of a vancomycin (4 mg/L) containing broth culture (Enterococcsel broth; Becton, Dickinson and Company, Franklin Lakes, NJ) and subsequent quantitative real-time polymerase chain reaction for vancomycin- resistance vanA and vanB gene detection, as described else- where. 7 Swabs were spiked into the broth and inoculated on * Address correspondence to Nico T. Mutters, MD, MSc, Heidelberg University Hospital, Department of Infectious Diseases, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany. E-mail address: nico.mutters@med.uni-heidelberg.de (N.T. Mutters). Parts of the sections material and methods and results have been presented in a poster on the 22nd ECCMID in London, March 2012. Conflicts of interest: None to report. Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: www.ajicjournal.org American Journal of Infection Control 0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2012.11.019 American Journal of Infection Control 41 (2013) 778-81