Thirteen-year evolution of azole resistance in yeast isolates and prevalence of resistant strains carried by cancer patients at a large medical center.

Drug resistance is emerging in many important microbial pathogens, including Candida albicans. We performed fungal susceptibility tests with archived isolates obtained from 1984 through 1993 and fresh clinical isolates obtained from 1994 through 1997 by testing their susceptibilities to fluconazole, ketoconazole, and miconazole and compared the results to the rate of fluconazole use. All isolates recovered prior to 1993 were susceptible to fluconazole. Within 3 years of widespread azole use, we detected resistance to all agents in this class. In order to assess the current prevalence of resistant isolates in our hematologic malignancy and transplant patients, we obtained rectal swabs from hospitalized, non-AIDS, immunocompromised patients between June 1995 and January 1996. The swabs were inoculated onto sheep's blood agar plates containing 10 microg of vancomycin and 20 microg of gentamicin/ml of agar. One hundred one yeasts were recovered from 97 patients and were tested for their susceptibilities to amphotericin B, fluconazole, flucytosine, ketoconazole, and miconazole. The susceptibility pattern was then compared to those for all clinical isolates obtained throughout the medical center. The antifungal drug histories for each patient were also assessed. The yeasts from this surveillance study were at least as susceptible as the overall hospital strains. There did not appear to be a direct linkage between prior receipt of antifungal agent therapy and carriage of a new, drug-resistant isolate. Increased resistance to newer antifungal agents has occurred at our medical center, but it is not focal to any high-risk patient population that we studied. Monitoring of susceptibility to antifungal agents appears to be necessary for optimizing clinical therapeutic decision making.

Use of in-house studies of molecular epidemiology and full species identification for controlling spread of vancomycin-resistant Enterococcus faecalis isolates.

Infection with multidrug-resistant (MDR) organisms is a major clinical challenge, and few, if any, therapeutic options remain available. Increasingly, infection control measures have taken on greater importance in preventing the nosocomial transmission of MDR organisms. During December 1994 and January 1995, we identified a cluster of vancomycin-resistant Enterococcus faecalis isolates involving 16 patients situated in different areas of our university-affiliated teaching hospital. Initial review of laboratory requisition forms for the patients' locations revealed no common association, suggesting that the occurrence was not due to horizontal spread. However, using genomic DNA extraction, restriction enzyme analysis, and gel electrophoresis, we found that 12 patients were infected with isolates originating from a single clone, 2 other patients were infected with isolates from a different clone, and the remaining 2 patients were infected with unique strains. Because the typing data suggested nosocomial spread, chart review was undertaken to determine a possible common exposure source. With three exceptions, clonal isolates were linked to patient movement between surgical floors, intensive care units, and a rehabilitation unit. A detailed review of patient records revealing the association would not have been performed without realization of clonality. Thus, the data demonstrate the utility of genomic typing for epidemiological purposes. In turn, targeted infection control measures that halted the spread of the potentially lethal MDR pathogen were instituted.