Bommarito, Kerry M

Burnham, Carey-Ann D

Dubberke, Eric R

Hink, Tiffany

Kwon, Jennie H

Reske, Kimberly A

Seiler, Sondra M

Wallace, Meghan A

Infection Control and Hospital Epidemiology

English

Digital Commons@Becker

Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2017An evaluation of the prevalence of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) inhospital foodJennie H. KwonWashington University School of Medicine in St. LouisKimberly A. ReskeWashington University School of Medicine in St. LouisTiffany HinkWashington University School of Medicine in St. LouisSondra M. SeilerWashington University School of Medicine in St. LouisMeghan A. WallaceWashington University School of Medicine in St. LouisSee next page for additional authorsFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationKwon, Jennie H.; Reske, Kimberly A.; Hink, Tiffany; Seiler, Sondra M.; Wallace, Meghan A.; Bommarito, Kerry M.; Burnham, Carey-Ann D.; and Dubberke, Eric R., ,"An evaluation of the prevalence of vancomycin-resistant enterococci (VRE) and methicillin-resistantStaphylococcus aureus (MRSA) in hospital food." Infection Control & Hospital Epidemiology.38,11. 1373-1375. (2017).https://digitalcommons.wustl.edu/open_access_pubs/6344AuthorsJennie H. Kwon, Kimberly A. Reske, Tiffany Hink, Sondra M. Seiler, Meghan A. Wallace, Kerry M.Bommarito, Carey-Ann D. Burnham, and Eric R. DubberkeThis open access publication is available at Digital Commons@Becker: https://digitalcommons.wustl.edu/open_access_pubs/6344Infect Control Hosp Epidemiol. 2017;38:1371–1373© 2017 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2017/3811-0018. DOI: 10.1017/ice.2017.205references1. Boyce JM. Environmental contamination makes an importantcontribution to hospital infection. J Hosp Infect 2007;65(Suppl 2):50–54.2. Carling PC, Parry MM, RuppME, et al. Improving cleaning of theenvironment surrounding patients in 36 acute care hospitals.Infect Control Hosp Epidemiol 2008;29:1035–1041.3. Guh A, Carling P. Environmental Evaluation Workgroup.Options for evaluating environmental cleaning. Centers for Dis-ease Control and Prevention website. https://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html. Published 2010.Accessed January 26, 2017.4. Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal roomdisinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difﬁcile (the Beneﬁts ofEnhanced Terminal Room Disinfection study): a cluster-rando-mised, multicentre, crossover study. Lancet 2017;398:805–814.5. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A quanti-tative approach to deﬁning “high-touch” surfaces in hospitals.Infect Control Hosp Epidemiol 2010;31:850–853.6. Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS.Impact of an environmental cleaning intervention on the presence ofmethicillin-resistant Staphylococcus aureus and vancomycin-resistantenterococci on surfaces in intensive care unit rooms. Infect ControlHosp Epidemiol 2008;29:593–599.7. Munoz-Price LS, Fajardo-Aquino Y, Arheart KL. Ultravioletpowder versus ultraviolet gel for assessing environmental clean-ing. Infect Control Hosp Epidemiol 2012;33:192–195.8. Boyce JM, Havill NL, Havill HL, Mangione E, Dumigan DG,Moore BA. Comparison of ﬂuorescent marker systems with 2quantitative methods of assessing terminal cleaning practices.Infect Control Hosp Epidemiol 2011;32:1187–1193.9. Dhar S, Tansek R, Toftey EA, et al. Observer bias in hand hygienecompliance reporting. Infect Control Hosp Epidemiol 2010;31:869–870.An Evaluation of the Prevalence ofVancomycin-Resistant Enterococci (VRE) andMethicillin-Resistant Staphylococcus aureus(MRSA) in Hospital FoodMethicillin-resistant Staphylococcus aureus (MRSA) andvancomycin-resistant Enterococci (VRE) are associated with sig-niﬁcant patient morbidity and mortality.1 MRSA and VRE havebeen found in retail foods, primarily animal products,2–6 but therole of hospital food in MRSA and VRE transmission in health-care facilities is unknown. The purpose of this study was todetermine the prevalence of MRSA and VRE in hospital food,with an emphasis on foods consumed by hospital patients.methodsThis prospective cohort study was conducted at Barnes-JewishHospital, a 1,250 bed tertiary care center in St Louis, Missouri,from May 2011 through July 2012 in conjunction with a studyof Clostridium difﬁcile in hospital food.7 Our methods weredescribed previously.7,8 Brieﬂy, patients onmedical and surgicalwards collected food samples from their meals in sterile speci-men cups (1 cup per meal; ≥1 food item per cup) to ensure thatthe foods sampled were those consumed by patients. Foodspecimens were frozen at −30°C. Prior to culture, specimenswere thawed, combined with 10 mL sterile water, and homo-genized for 1 minute. A 1 mL volume of food homogenate wasadded to TSB broth with 6.5% NaCl; then the mixture wasincubated overnight at 35°C. The broth was subcultured onsheep blood agar (Hardy Diagnostics, SantaMaria, CA), SpectraMRSA (Remel Diagnostics, Lenexa, KS), and chromID VRE(bioMèrieux,Marcy-l'Étoile, France). The Vitek matrix-assistedlaser desorption/ionization time-of-ﬂight mass spectroscopy(MALDI-TOFMS, bioMèrieux, Marcy-l'Étoile, France)methodwas utilized to identify S. aureus or Enterococcus spp. Suscepti-bility testing was performed using Kirby Bauer disk diffusion inaccordance with CLSI standards,9 and SCCmec typing wasperformed.10Data were collected from patient interviews, chart review, andmedical informatics queries, including MRSA and VRE clinicallaboratory results from 1 year before enrollment to 1 year afterenrollment. Descriptive data analyses were performed usingSPSS version 21 software (IBM, Armonk, NY). TheWashingtonUniversity Institutional Review Board approved the study.resultsIn total, 149 patients were enrolled in the study and 910food specimens were collected (median, 5 specimens perpatient; range, 1–24 specimens). The median patient agewas 55 years (range, 23–90 years); 80 patients (54%) werefemale. 8 patients (5%) had clinical cultures (infection and/orsurveillance) positive for MRSA, and 7 patients (5%) hadclinical cultures positive for VRE, in the year before enrollment.Overall, 1 or more food specimens from 17 patients (11%)were positive for MRSA, and 1 or more food specimens from17 patients (11%) were positive for VRE. MRSA was culturedfrom 29 specimens (3.2%), and VRE was cultured from 22specimens (2.4%); more than 1 positive specimen was col-lected from some patients. Of the 29 MRSA-positive isolates,9 (31%) were SCCmec II, 2 (7%) were SCCmec III, and 18(62%) were SCCmec IV. Notably, 7 SCCmec IV isolates camefrom a single patient (ie, 39% of SCCmec IV isolates). MRSAand VRE were cultured from every food category except nuts(Table 1). VRE was recovered from 5% of dairy or egg speci-mens and MRSA was recovered from 5% of bread or grainspecimens and “other” specimens; for all other foods, theculture positivity rate was <5%.Only 4 patients (3%) had a clinical culture positive forMRSA or VRE after having positive food without a previousvre and mrsa in hospital food 1373clinical history of MRSA or VRE. MRSA was isolated from theurine of patient A 28 days after the positive food specimen(SCCmec IV) was collected. Patient B had 2 positive MRSAsurveillance screens, 48 and 50 days after the positive foodspecimens were collected. MRSA was cultured from foodspecimens collected by this patient on 5 separate days, and 7 ofthe SCCmec IV isolates were obtained from specimens col-lected by this patient. Enterococcus faecalis was cultured fromfood collected by patient C 23 days before this patient had apositive VRE surveillance screen. Between the food and screendates, patient C had 2 urine specimens positive for Enter-ococcus (1 vancomycin susceptible, the other unknown) and1 blood culture positive for E. faecalis (vancomycin susceptible).Finally, 2 food specimens, positive for MRSA and E. faecalis,were collected by patient D on 2 separate days, and this patienthad a positive VRE surveillance screen more than 3 months afterthe positive food specimens were collected.discussionTo the best of our knowledge, ours is the ﬁrst study to evaluatethe presence of MRSA and VRE in the food of hospitalizedpatients. We previously found that food is unlikely to be asigniﬁcant source of C. difﬁcile acquisition for hospitalizedpatients.7 The prevalence of MRSA and VRE found in food inthe current study (3.2% and 2.4%, respectively) was higherthan the prevalence of C. difﬁcile (0.2%), but the overall con-tamination rate was still low.While this study was not designed to determine conclusivelywhether patients acquired MRSA or VRE from their hospitalfood, our results suggest that acquisition via food may be rare.Additionally, patients enrolled in this study collected their ownfood specimens; thus, the patients themselves may have been thesource of the contamination. Of the 4 patients with positiveMRSA or VRE clinical cultures after a positive food culture andno prior clinical history of MRSA or VRE, 2 patients had MRSAor VRE cultured from food specimens on more than 1 day.Because the overall food contamination rate was low, thispattern suggests patient contamination. Thus, prior clinicalhistory or possible self-contamination may eliminate thepossibility of food acquisition in all but 2 patients (1%).While MRSA and VRE have been documented in retail foodpreviously, the comparability of results prior to our studycannot be determined.2,3,5,6 The effect of food preparation onthe bacterial burden in hospital food is unknown. Despitethese limitations, our study indicates that MRSA and VREcan be present in the food of hospitalized patients, and theimplications of this ﬁnding warrant additional study.acknowledgmentsFinancial support: This study was supported by the National Institute ofDiabetes and Digestive and Kidney Diseases (grant no. P30DK52574); and theWashington University Institute of Clinical and Translational Sciences (grant no.UL1TR000448, sub-award no KL2TR000450, from the National Center forAdvancing Translational Sciences of the National Institutes of Health, to J.H.K.).Potential conﬂicts of interest: C.A.B. reports grants from bioMerieux, Cep-heid, Accelerate, Theravance, and Aperture Bio, and she has received personalfees from Accelerate, BD, Monsanto, and ThermoFisher, all unrelated to thisstudy. All other authors report no conﬂicts of interest.Jennie H. Kwon, DO, MSCI;1Kimberly A. Reske, MPH;1Tiffany Hink, BS;1Sondra M. Seiler, BA;1Meghan A. Wallace, BS;2Kerry M. Bommarito, PhD;1Carey-Ann D. Burnham, PhD;2,3,4Erik R. Dubberke, MD, MSPH1Afﬁliations: 1. Division of Infectious Diseases, Washington University Schoolof Medicine, St Louis, Missouri; 2. Department of Pathology and Immunology,Washington University School of Medicine, St Louis, Missouri; 3. Department ofMolecular Microbiology, Washington University School of Medicine, St Louis,Missouri; 4. Department of Pediatrics, Washington University School ofMedicine, St Louis, Missouri.table 1. Food Specimens Positive for Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-ResistantEnterococci (VRE), by Food TypeaFood ItemNo. of Samples(N= 910)bMRSA Positive(N [%])cVRE Positive(N [%])cMeat 308 7 (2) 9 (3)Poultry 142 2 (1) 2 (1)Fruit 179 2 (1) 2 (1)Vegetable 455 14 (3) 5 (1)Nuts 1 0 0Dairy/eggs 210 7 (3) 11 (5)Bread/grains 376 19 (5) 12 (3)Other 200 9 (5) 3 (2)Other (list) Veggie burger, sauce, pudding,jelly, gravy (2), ﬁsh, cake (2)Gravy (2), ﬁshaN= 149 patients; 910 food specimens.bMore than 1 food item could be included in a sample.cPercentages are number of positive specimens per total food items of that type.1374 infection control & hospital epidemiology november 2017, vol. 38, no. 11Address correspondence to Jennie H. Kwon DO, MSCI, Division of Infec-tious Diseases, Washington University School of Medicine, 4523 Clayton Ave,Campus Box 8051, St Louis, MO 63110 (j.kwon@wustl.edu).Received June 28, 2017; accepted September 3, 2017; electronicallypublished September 27, 2017Infect Control Hosp Epidemiol 2017;38:1373–1375© 2017 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2017/3811-0019. DOI: 10.1017/ice.2017.207references1. Antibiotic Resistance Threats in the United States, 2013. Centersfor Disease Control and Prevention website. http://www.cdc.gov/drugresistance/threat-report-2013/. Published 2014. AccessedJanuary 9, 2016.2. Gambarotto K, Ploy MC, Dupron F, Giangiobbe M, Denis F.Occurrence of vancomycin-resistant Enterococci in pork andpoultry products from a cattle-rearing area of France. J ClinMicrobiol 2001;39:2354–2355.3. Lopez M, Saenz Y, Rojo-Bezares B, et al. Detection of vanA andvanB2-containing enterococci from food samples in Spain,including Enterococcus faecium strains of CC17 and the newsingleton ST425. Int J Food Microbiol 2009;133:172–178.4. Basanisi MG, La Bella G, Nobili G, Franconieri I, La Salandra G.Genotyping of methicillin-resistant Staphylococcus aureus(MRSA) isolated from milk and dairy products in South Italy.Food Microbiol 2017;62:141–146.5. de Boer E, Zwartkruis-Nahuis JT, Wit B, et al. Prevalence ofmethicillin-resistant Staphylococcus aureus in meat. Int J FoodMicrobiol 2009;134:52–56.6. Vojkovska H, Myskova P, Gelbicova T, Skockova A, Kolackova I,Karpiskova R. Occurrence and characterization of food-bornepathogens isolated from fruit, vegetables and sprouts retailed inthe Czech Republic. Food Microbiol 2017;63:147–152.7. Kwon JH, Lanzas C, Reske KA, et al. An evaluation of food as apotential source for Clostridium difﬁcile acquisition in hospitalizedpatients. Infect Control Hosp Epidemiol 2016;37:1401–1407.8. Dubberke ER, Reske KA, Seiler S, Hink T, Kwon JH, Burnham CA.Risk factors for acquisition and loss ofClostridium difﬁcile colonizationin hospitalized patients. Antimicrob Agents Chemother 2015;59:4533–4543.9. Clinical and Laboratory Standards Institute. Performance Stan-dards for Antimicorbial Susceptibility Testing; Twenty-FifthInformational Supplement. Vol. M100-S25. Wayne, Pennsylvania:Clinical and Laboratory Standards Institute; 2015.10. Boye K, Bartels MD, Andersen IS, Moller JA, Westh H. A new mul-tiplex PCR for easy screening of methicillin-resistant Staphylococcusaureus SCCmec types I–V. Clin Microbiol Infect 2007;13:725–727.Placing Venous Catheters in the Home:Pilot Data from the Mobile VAD ProgramPatients requiring vascular access devices (VADs) for homeinfusion therapy typically receive them as inpatients prior todischarge home. However, for years many otherwise-stableoutpatients requiring VADs have avoided hospitalizationsaltogether by having the VADs placed in ambulatory health-care settings.1 In the novel Johns Hopkins Home Care GroupMobile VAD Program, VAD placement is even removed fromambulatory healthcare facilities such as clinics: trained nursesplace VADs in patient homes. The program allows the entirehome infusion therapy process (VAD placement, patient andcaregiver training, delivery of supplies, infusion therapy, andassessment by home care nurses) to take place in the home,outside healthcare settings. We present preliminary outcomesfrom a prospective cohort of patients in the program.methodsStarting in December 2015, outpatients1 requiring VADs butnot needing hospitalization were referred to the Mobile VADprogram. Telephone screenings ensured patients had a loca-tion in the home appropriate for VAD placement (ie, with aclean bed and a clean accessible sink, and where trafﬁc fromother household residents and pets can be avoided). A trainednurse placed the VAD (peripherally inserted central catheter[PICC] or midline catheter), using electrocardiogram (EKG)-based technology to conﬁrm placement (Bard Site Rite 8Ultrasound System, Bard Access Systems, Salt Lake City, UT).Patients could then be followed by any home infusion agencyfor medications, infusions, and supplies, and by any homenursing agency for training and support in VAD care.We expanded a previously described prospective cohort ofhome infusion therapy patients2 to includeMobile VAD patients.Eligible patients (>18 years of age, with a PICC or midlinecatheter placed in the home through the Mobile VAD programDecember 2015 through April 2017 for home infusion therapy)consented to a telephone survey and chart abstraction 2 weeksafter VAD placement. Patients were ineligible if they were inhospice care, did not speak English, or could not verbally consent.Consenting patients completed a 10-minute telephone surveyfocusing on VAD complications.2 The electronic health record(EHR) was abstracted for demographic and clinical informationthrough 1 month after VAD removal. VAD days were calculatedas the number of days betweenVADplacement and removal. TheCharlson Comorbidity Index was calculated.3The primary outcome was any VAD complication per 1,000home VAD days and included any of the following:central-line–associated bloodstream infection (CLABSI),catheter-associated venous thromboembolism (CA-VTE),bloodstream infection (BSI), or VAD occlusion, dislodgement,accidental removal, kinking, coiling, breaking, phlebitis, orlinking. CA-VTE was deﬁned as a venous thromboembolism(VTE) on imaging in any location, as PICCsmay be risk factorsfor upper and lower VTEs.4 CLABSI were deﬁned based onAssociation for Professionals in Infection Control (APIC) cri-teria for CLABSI in home infusion5 (adapted from NationalHealthcare Surveillance Network [NHSN] CLABSI deﬁnitions).6Bloodstream infections were deﬁned as at least 2 positive samplesvascular access placement in the home 1375

An evaluation of the prevalence of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) in hospital food

Jennie H. Kwon

Kimberly A. Reske

Tiffany Hink

Sondra M. Seiler

Meghan A. Wallace

Kerry M. Bommarito

Carey-Ann D. Burnham

Erik R. Dubberke

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An Evaluation of the Prevalence of Vancomycin-Resistant <i>Enterococci</i> (VRE) and Methicillin-Resistant <i>Staphylococcus aureus</i> (MRSA) in Hospital Food

https://digitalcommons.wustl.edu/cgi/viewcontent.cgi?article=7350&amp;context=open_access_pubs

An evaluation of the prevalence of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) in hospital food

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