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VancomycinResistantEnterococci(VRE) Althoughnotespeciallyvirulent,Enterococcihavebecomethesecondmostcommonnosocomial pathogenandarethethirdleadingcauseofnosocomialbloodstreaminfections.Enterococciare intrinsicallyresistanttomanycommonantibiotics.Giventheintrinsicresistancetomostantibiotics,the additionofvancomycinresistancehasmeantthatmanyinfectionshavebecomeuntreatable. Bacteriology VREstandsforvancomycinresistantenterococci.Thesearebacteriathathavedevelopedaresistanceto mostantibioticscommonlyusedforenterococcalinfections.Theantibioticsincludevancomycin, aminoglycosides,andampicillin.Enteroccocciarebacteriathatarenormallypresentinthehuman intestines,thefemalegenital,intheenvironmentandlesscommonlytheoralcavity..Thisspeciesof bacteriaarefacultativelyanaerobic,catalase-negativeGrampositivecoccithataregenerallyarranged individually,inpairs,orshortchains.TheoptimaltemperatureforgrowthofE.faecalisandE.faeciumis 35°C. ClinicalManifestations BecauseEnterococciarepartofthenormalfloraoftheGItractandvaginaltracts,mostinfectionswith thesemicroorganismshavebeenattributedtothepatients’endogenousflora.Mostcommonly attributedinfectionstoVREincludeurinarytractinfections,bloodstreaminfections,orinfectionsof woundsassociatedwithcathetersorsurgicalprocedures. RiskfactorsassociatedwithVREinfectioninclude;previoustreatmentwithvancomycinorother antibioticsforlongperiodsoftime,extendedperiodsofhospitalization,weakenedimmunesystems suchaspatientsinintensivecareunits,orincancerortransplantwards,surgicalproceduressuchas abdominalorchestsurgeryandindwellingmedicaldevicessuchasurinarycathetersorcentral intravenous(IV)catheters. EpidemiologyofTransmission Becauseenterococciarepartofthenormalfloraofthegastrointestinalandfemalegenitaltracts,most infectionswiththesemicroorganismshavebeenattributedtothepatient'sownflora.Antibiotic exposureplaysanimportantroleinthetransmissiondynamicofVRE.Peoplewhohavebeenpreviously treatedwithvancomycinareatthehighestriskfordevelopingVRE.VREcanalsobespreadfrompersonto-personbydirectpatient-to-patientcontact,orindirectlyonhealthcareworkers'hands,oron contaminatedenvironmentalsurfacesandpatient-careequipment.Theunrecognizedcolonizedpatient alsopresentsaparticularriskfortransmissiontootherpatients. BasicPrevention TheimportanceofhandhygieneintheeliminationofVREtransmissioncannotbeoverstated.Hands shouldalwaysbewashedthoroughlyafterusingthebathroomandbeforepreparingfoodaswellas aftercontactwithpersonswhohaveVRE.Alcoholbasedhandsanitizers(≥62%ethanol)maybehelpful asanadjunctmethodofhandhygiene,butshouldnotreplacewashingwithsoapandwater.Additional preventionmeasuresinclude;frequentcleaningareasofthehome,suchasbathrooms,thatmay becomecontaminatedwithVREandwearingglovesifhandsmaycomeincontactwithbodyfluidsthat maycontainVRE,suchasstoolorbandagesfrominfectedwounds. PreventionMeasures InadditiontoRoutine/StandardPrecautions,ContactPrecautionsshouldbeimplementedwithpatients whoaresuspectedorconfirmedtohaveVRE. • PatientswithsuspectedorconfirmedVREmaybeplacedinprivateroomsorcohortwithother patientswiththesameinfection. • Followhand-hygieneguidelinesbyeithercarefullywashinghandswithsoapandwaterorusing Alcohol-BasedHandSanitizers(ABHS)aftercontactwithpatientswithVREinfection • Usegownsandgloveswhenincontactwith,orcaringforpatientswhoaresymptomaticwith VREforallinteractionsthatmayinvolvecontactwiththepatientorpotentiallycontaminated areasinthepatientsenvironment • Dedicatedequipmentforpatientcareshouldbeutilizedwheneverpossible(disposable stethoscopes,thermometers,BPcuffs,etc) • Limitthetypeandamountofsuppliesenteringtheroomanddisposeofallunuseditemsat patientdischarge EnvironmentalControlMeasures VREcangrowandsurviveinharshenvironments,andcanpersistalmostanywhereincludingsoil,plants, water,andfood.Ithasbeenshowntosurvive5daysto4monthsondryinanimatesurfaces.OnceVRE hasbecomeendemiconawardorhasspreadtomultiplewardsortothecommunity,eradication becomesextremelydifficultandcostly. Hospital-gradecleaninganddisinfectingagentsaresufficientforenvironmentalcleaninginthecontext ofVRE.Allhorizontalandfrequentlytouchedsurfacesshouldbecleanedtwicedailyandwhensoiled. Thehealthcareorganization’sterminalcleaningprotocolforcleaningofthepatient’sroomfollowing discharge,transferordiscontinuationofContactPrecautionsshouldbefollowed.Allpatientcare equipment(e.g.,thermometers,bloodpressurecuff,pulseoximeter,etc.)shouldbededicatedtothe useofonepatient.AllpatientcareequipmentshouldbecleanedanddisinfectedasperRoutine/ StandardPracticesbeforereusewithanotherpatientorasingleusedeviceshouldbeusedand discardedinawastereceptacleafteruse.Toys,electronicgamesorpersonaleffectsshouldnotbe sharedbypatients. References: 1.PublicHealthAgencyofCanada(PHAC),MaterialSafetyDataSheet–InfectiousSubstances: Enterococcusfaecalis. http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/enterococcus-eng.php 2.GuidelinesforEnvironmentalInfectionControlinHealthcareFacilities,CDC.MMWRJune2003, Vol52,NoRR-10 3.BestPracticesforCleaning,DisinfectionandSterilizationinAllHealthCareSettings,Provincial InfectiousDiseasesAdvisoryCommittee(PIDAC),February2010 4.GuidelineforIsolationPrecautions:PreventingTransmissionofInfectiousAgentsinHealthcare Settings,HICPAC,2007 5.ManagementofMultidrug-ResistantOrganismsInHealthcareSettings,HICPAC,2006
