Download VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE

VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE)
INFORMATION SHEET
Introduction/Importance:
• VRE has become an important nosocomial pathogen in the last 10 years. In the
last 3-5 years VRE has appeared at our institution with increasing frequency.
• The most important pathogenic isolates are Enterococcus faecalis and
Enterococcus faecium. VRE is resistant to all beta-lactam and aminoglycoside
antibiotics, limiting therapeutic options, particularly in cases of endocarditis and
meningitis where bactericidial combinations of drugs are desirable.
• Patients with prolonged hospital stays and those receiving prolonged courses of
multiple antibiotics are at highest risk for acquisition of VRE. VRE infections are
associated with a higher mortality than infections caused by antibiotic susceptible
Enterococcus.
• Enterococcus can have three phenotypes of vancomycin resistance: Van A – high
level resistance to vancomycin (usually in E faecium), Van B – moderate level
resistance to vancomycin (usually in E. faecalis) and Van C – low level
resistance to vancomycin (usually E. gallinarum, E. casseliflavus or E.
flavescens).
• Vancomycin resistance mediated through Van A and Van B phenotypes has been
shown to transfer from VRE to other gram positive bacteria, including methicillin
– resistant Staphylococcus aureus (MRSA). As such presence of VRE in the
hospital poses not just the risk of VRE infection, but also of continuing evolution
of resistance, possibly involving more virulent pathogens. Van C containing
bacteria are usually minimally pathogenic and usually incapable of spreading
resistance to other bacterial species.
• The primary site of enterococcal colonization is the gastrointestinal tract. In
women, the genital tract may also be colonized. Once colonized or infected, the
patient may harbor VRE for months to years (median duration after
discontinuation of antibiotics = 2 months). Attempts to eradicate VRE carriage
have been unsuccessful in clinical trials.
• VRE is usually transmitted by direct or indirect contact (i.e. by the unwashed
hands of personnel or contact with contaminated objects such as stethoscopes, lab
coats or equipment shared by patients). Items in patient’s rooms, such as
telephones, over-bed tables, and ECG monitors, may remain culture positive for
weeks if not properly disinfected.
Isolation:
• Contact Precautions are used for patients infected or colonized with VRE. If a
patient with a history of prior isolation of VRE from a clinical specimen from any
source is admitted place the patient on Contact Precautions and notify Infection
Control Department at 42188. Infection Control will follow the patient for the
duration of their hospitalization. In an outbreak situation, patients and staff may
need to be cohorted. Patients harboring vancomycin resistant strains of E.
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gallinarum, E. casseliflavus or E. flavescens may be managed using only standard
precautions.
Contact Precautions require a private room and wearing gown and gloves if hands
or clothes will touch the patient or anything in the patient’s room that may be
contaminated; since Enterococcus is an extremely hardy organism and can exist
for long periods of time on inanimate objects, and because it spreads widely on
surfaces of patients rooms (especially patients incontinent of stool), consider all
surfaces in the patient’s room contaminated.
Isolated patients should have their own personal equipment (e.g. thermometers,
stethoscopes and BP cuffs) which must not leave the room.
Patients on isolation precautions are asked to stay in their rooms as much as
possible. Patients may go off the ward for procedures and/or therapy if isolation
precautions are maintained. When patients are sent off the unit, the unit secretary
should call that patient’s destination to inform them that they are about to receive
a patient in isolation. Ideally, procedures and therapies should be done at the end
of the day and away from other patients. When the patient leaves the room he/she
should wear a cover gown and wash hands thoroughly with soap and water. Staff
transporting isolation patients should be mindful not to contaminate common
areas of the hospital during transport. The transporter should wear gown and
gloves. The transporter’s gown and gloves are considered contaminated and
should not have contact with anything except the patient and/or transportation
equipment.
If the patient must ambulate outside of his/her room, he/she must wear an
isolation gown and wash hands thoroughly with soap and water prior to leaving
the room. Ambulatory patients must avoid direct contact with other patients and
should be encouraged not to leave the unit. They should particularly avoid
common areas such as play rooms, nursing stations, cafeteria, gift shop etc.
Ambulatory patients who insist may be allowed outside to smoke if they will
comply with the above precautions and agree to go directly from their rooms to
the smoking area and back.
If a patient in a semi-private room is newly diagnosed with VRE the roommate
should be immediately moved to another private room. The roommate will remain
in contact isolation until results of surveillance cultures show no VRE carriage.
Family and Visitors:
Family members and visitors should maintain isolation precautions. Infants born to
mothers infected or colonized with VRE should be allowed usual visits and be allowed to
breast feed. These infants should remain under Contact Precautions while in the nursery.
The mother, if hospitalized, should also be managed under contact isolation.
Disinfection:
• All equipment should be thoroughly disinfected with an approved hospital
disinfectant as it is brought out of the isolation room.
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After a patient carrying VRE is discharged from the hospital the room must
undergo terminal cleaning. The room may be re-occupied immediately upon
completion of terminal cleaning.
Supplies:
• Only 24 hours of supplies necessary for patient care should be kept in the room.
Supplies in the patient’s room should be sent with the patient if he/she is
transferred to another unit.
• Upon discharge, all disposable supplies must be discarded with the exception of
unopened packages of supplies; although the outside of the box is considered
contaminated, the contents are clean and may be used if they can be removed
from the packaging in a manner that avoids their contamination.
Patient Discharge:
When a patient is ready for discharge, call Ambassador Services and inform them of
patient’s isolation status. Ambulatory patients should wash his or her hands thoroughly;
the patient does not need to wear isolation garb between his/her room as long as he/she is
going directly outside.
Transfers to Other Facilities:
• Healthcare facilities accepting patients in transfer should be notified in advance
regarding the patient’s VRE status and need for isolation.
• Healthcare facilities in Mississippi, including nursing homes, cannot refuse to
accept a patient solely on the basis of he/she being colonized with VRE.
Frequently employees of nursing homes are misinformed and will refuse to accept
these patients. If they require clarification of state regulations, please contact
Infection Control at 42188 and we will ask a representative of the State Board of
Nursing Home Licensure to intercede.
Outpatient Care:
• Patients discharged home may resume normal activities, but isolation precautions
must be observed on subsequent clinic visits.
• On arrival to clinic, patients should be placed immediately in an examination
room to avoid contamination of the waiting area. Healthcare workers will observe
Contact precautions with gown and gloves
• Care should be taken to avoid contamination of equipment used on multiple
patients. If such equipment must be used, it must be decontaminated prior to use
on other patients.
• When the patient leaves the clinic, all surfaces contacted by the patient
(examination table, chair, door knob etc.) should be thoroughly sprayed with
disinfectant then wiped dry.
Discontinuation of Isolation:
• Patients harboring VRE remained colonized for weeks to months. To date,
attempts to eradicate stool carriage of VRE have been unsuccessful in published
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clinical trials. For these reasons patients placed in Contact Precautions will remain
in same until discharged.
Eight weeks after a patient’s last positive culture a follow-up surveillance culture
of stool or peri-rectal region may be obtained to screen for clearance. The patient
does not need to be off antibiotics prior to being cultured, but such therapy makes
clearance less likely.
If the initial stool/peri-rectal culture is negative for VRE, two additional stool or
peri-rectal cultures should be obtained at least one week apart. Three negative
cultures are required to discontinue contact isolation.
Infection Control must be called (42188) prior to discontinuation of isolation.