The clinical significance of vancomycin-resistant Enterococcus (VRE) infections has been debated for many years. An article in this issue of the journal by Dubberke and coworkers (Vancomycin-resistant enterococcal bloodstream infections on a hematopoietic stem cell transplant unit: are the sick getting sicker?) addresses this question. This is a retrospective cohort study of patients with hematologic malignancies and recipients of hematopoietic stem cell transplant (HSCT) who developed nosocomial VRE bloodstream infections (BSIs) over the course of almost 7 years at Barnes-Jewish Hospital. Data regarding VRE infections in this highly immunosuppressed population has been sparse, 1, 2 and this paper, reporting the characteristics and outcomes of 60 patients who suffered 68 VRE BSIs, represents the largest published series of VRE BSIs in this population to date. 3

Infections with gram-positive bacteria are a major cause of morbidity in stem cell transplant recipients. Chemotherapy-induced neutropenia and mucositis, heavy exposure to prophylactic antimicrobials with limited gram-positive bacterial coverage and near universal use of central venous catheters predispose HSCT recipients to gram-positive bacteremia. Additionally, these patients frequently have had numerous hospitalizations with many courses of antibiotics that can promote the emergence and overgrowth of resistant colonizing flora. Lastly, because these patients are often seriously ill, they require extensive contact with health-care providers who through contamination of their hands, clothing and equipment represent the vector of transmission for resistant gram-positive organisms in health-care facilities. Taken together, these features place HSCT recipients at high risk for colonization and subsequent infection with resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and VRE. 4