Observations on the risk of resistance with the extended use of vancomycin.

OBJECTIVE To document the risk of the development of vancomycin-resistant bacteria in a population of seriously burned patients during a 10-year period of common vancomycin hydrochloride use. DESIGN Retrospective study. SETTING The US Army Institute of Surgical Research, Burn Center, Fort Sam Houston, Tex. POPULATION AND METHODS Microbiology, infection, and antibiotic use records collected during the hospitalization of 2266 consecutively admitted seriously burned patients were reviewed. Vancomycin was the primary therapeutic agent used for gram-positive infections and was also used as a perioperative prophylactic antibiotic during burn wound excision. This policy was established prior to this review because of a high incidence of methicillin-resistant Staphylococcus aureus colonization and an anecdotal association of increased beta-lactam resistance in endemic gram-negative pathogens associated with the use of penicillinase-resistant penicillins and cephalosporins. MAIN OUTCOME MEASURES Isolation of vancomycin-resistant enterococci (VRE) or other gram-positive organisms resistant to vancomycin. RESULTS Examinations of 15 125 gram-positive isolates, including 957 enterococci, for in vitro sensitivity to vancomycin yielded 3 VRE isolates in 3 patients. Vancomycin was used prior to VRE isolation in one of these patients. Resistance was found in 3 other organisms (2 Corynebacterium species, 1 Lactobacillus species). Vancomycin was used prior to these isolations in 2 of 3 patients. None of the vancomycin-resistant organisms was associated with infection and all 6 patients survived. Vancomycin-resistant enterococci or other vancomycin-resistant gram-positive organisms were not found in 663 patients treated with vancomycin for documented gram-positive infections or in 1027 patients where perioperative vancomycin was used. CONCLUSION Use of vancomycin as the primary therapeutic agent in seriously burned patients was not associated with increased risk of VRE isolation or VRE infection.