Cross-transmission of vancomycin-resistant Enterococcus in patients undergoing dialysis and kidney transplant

The objective of this study was to investigate the occurrence of vancomycin-resistant Enterococcus (VRE) cross-transmission between two patient groups (long-term dialysis and kidney transplant patients). Molecular typing, by automated ribotyping with the RiboPrinter Microbial Characterization System (Qualicon, USA), was used to analyze VRE isolates from 31 fecal samples of 320 dialysis patients and 38 fecal samples of 280 kidney transplant patients. Clonal spread of E. faecalis and E. casseliflavus was observed intragroup, but not between the two groups of patients. In turn, transmission of E. gallinarum and E. faecium between the groups was suggested by the finding of vancomycin-resistant isolates belonging to the same ribogroup in both dialysis and transplant patients. The fact that these patients were colonized by VRE from the same ribogroup in the same health care facility provides evidence for cross-transmission and supports the adoption of stringent infection control measures to prevent dissemination of these bacteria.

Late diagnosis of chronic renal failure

A comparison was made between patients with a late diagnosis chronic renal failure (1 month or less before starting dialysis, N = 9 and those with an early diagnosis (6 months or more, N = 45) in terms to of the following aspects: referral characteristics during the pre-dialysis phase, demographic details and patient biochemistry prior to maintenance dialysis. Information was obtained by surveying consecutive patients with primary renal disease admitted to a university dialysis unit in Sao Paulo. Fifty-three percent of all patients surveyed had a late diagnosis. These patients had a lower median duration of symptoms (2 vs 6 months, P<0.01) and were less likely to be referred for dialysis by a nephrologist (9 per cent vs 51 per cent, P<0.001) than early diagnosis patients. In the early diagnosis group, 7 patients (16 per cent) had follow-up care for less than 6 months and 11 (24 per cent) did not receive any follow-up; 21 patients (47 per cent) did not follow a low-protein diet. At the start of dialysis, patients with a late diagnosis had higher blood pressure and a higher rate of pulmonary infections (19 per cent vs 4 per cent, P= 0.03). Mean concentrations of BUN, serum creatinine and potassium were significantly higher and mean blood bematocrit was lower for the late diagnosis group. After 3 months of dialysis, the mortality rate was higher in the late than in the early diagnosis group (22.9 per cent vs 6.7 per cent, = 0.02). Late diagnosis of chronic renal failure and lack of adequate follow-up care, prior to the start of dialysis, are common. Interventions to promote early diagnosis of chronic renal failure and to improve compliance with regular nephrological follow-up can be important to reduce the morbidity and the mortality of patients with chronic renal insufficiency.