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I. Introduction
Vancomycin-resistant enterococci (VRE) have emerged in the past
few years as epidemiologically important pathogens. VRE pose a
unique public health threat because:
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A. Treatment of infection is quite challenging,
since VRE are often resistant to multiple antibiotics,
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B. The potential exists for VRE to transfer
genetic vancomycin resistance to other gram-positive organisms,
including Staphylococcus aureus. This transfer has not yet occurred
clinically.
All health care institutions must become aware of the threat
and involved in the control of these pathogens. Long term care
facilities (LTCFs) may be especially challenged by VRE because
of their at-risk patient population and frequent patient transfers
to and from acute care institutions.
Enterococci are gram-positive bacteria which are found normally
in the gastrointestinal and female genital tracts. They may be
identified on laboratory reports by several different names: Enterococcus
faecium, Enterococcus faecalis, or Enterococcus species. Enterococci
can also be found without causing infection along catheter sites
and in the urine.
Most enterococcal infections occur when enterococci are introduced
into normally-sterile body sites (e.g., blood or urine). Clinical
infections may include: endocarditis, urinary tract infections,
intra-abdominal or pelvic infections, vascular line sepsis, and
wound infections. Many enterococcal infections are mixed infections
in which the role of enterococci is uncertain.
All enterococci have intrinsic low-level resistance to some antibiotics.
In recent years, however, some strains of enterococci have acquired
high-level resistance to multiple antibiotics including aminoglycosides,
ampicillin, and vancomycin.
Virtually all VRE are E. faecium. Vancomycin resistance is of
special concern because it makes treatment difficult, and because
of the potential for this plasmid-mediated vancomycin resistance
trait to be transferred to other microorganisms (although this
has occurred in one experimental laboratory study to date). If
methicillin-resistant S. aureus (MRSA) were to acquire vancomycin
resistance, this pathogen would become virtually untreatable with
current antibiotics.
A dramatic increase in the incidence of VRE has been seen in
the past few years. Although most outbreaks of VRE have occurred
in acute care settings (especially intensive care units), all
health care institutions have the potential to be affected.
Risk factors for acquiring VRE infection or colonization
include:
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severe underlying illness or immunosuppression,
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indwelling urinary or central venous catheters,
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recent abdominal or cardiothoracic surgery,
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prolonged hospital stays,
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stay on an ICU, oncology, or transplant ward,
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treatment with vancomycin, cephalosporins,
metronidazole or clindamycin, or multiple antimicrobial agents
and the number of days treated.
Most enterococcal infections probably arise from bacteria in the
patient's own gastrointestinal tract. People who are colonized with
the bacteria in their gastrointestinal tract may be colonized for
long periods of time. Nosocomial spread has been documented to take
place as well. Direct contact (person-to-person) and indirect contact
(via equipment or hands of personnel) can both transmit the organism.
Because of the serious nature of these infections, it is imperative
to take steps to prevent such transmission.
III. Goals of VRE Control in the LTCF
The goals of VRE control in the LTCF should include:
A. Preventing the transmission of VRE:
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to residents within the facility,
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to staff and visitors of the facility, and
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to those outside the facility when residents
are transferred;
B. Allowing for admission or readmission of patients with VRE;
and
C. Preventing the potential transfer of vancomycin resistance
to other gram- positive microorganisms (including S. aureus
and S. epidermidis) within the facility and the community.
IV. Prevention and Control Measures
A. Staff Education All staff working in
a LTCF should receive education and training regarding the importance
of VRE control. Education should be provided regularly, at least
annually, and may be incorporated into a larger infection control
training program. In addition, refresher training in infection
control practices should be provided in response to any increase
in VRE frequency within the facility.
B. Prescriber Education
The overuse of vancomycin has been implicated in promoting an
increase in VRE. Education of antibiotic prescribers is also important
in VRE control. LTCFs can distribute information on vancomycin
use to their prescribers. The Centers for Disease Control and
Prevention (CDC) has provided recommendations for the prudent
use of vancomycin; these are included in a sample provider handout
(Appendix A). Especially note that vancomycin use should be discouraged
for:
- treatment in response to a single blood culture positive
for coagulase-negative staphylococcus, if other blood cultures
drawn in the same time frame are negative (#3),
- continued empiric use for presumed infections in patients
whose cultures are negative for beta-lactam-resistant gram-positive
organisms (#4), and
- primary treatment of antibiotic-associated colitis (C.
difficile and others) (#8).
C. Identification of Patients with VRE
1. Case Definition - A VRE case is defined
as a resident who has been identified by culture to be currently
infected or colonized with VRE. A notation should be made in the
resident's record (e.g., problem list and care plan) when he/she
is identified as a VRE case.
2. Culturing - Culturing for VRE should be performed according
to clinical criteria established at the LTCF. Routine screening
of all residents, staff personnel, and environmental surfaces
is not recommended. When culturing is performed, the LTCF should
ensure that the laboratory:
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a. tests all enterococci-positive cultures
for vancomycin resistance,
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b. is capable of detecting both high and moderate
levels of vancomycin resistance, and
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c. reports VRE findings to the LTCF expeditiously
D. Infection Control Practices
Consistent application of sound infection control
practices will reduce the spread of many nosocomial pathogens, including
VRE. Such practices do not depend on the identification of VRE cases,
and should be applied in all patient care situations. Specific practices
which should be especially followed when caring for VRE cases include:
Hand Washing, Gloves, and Gowns
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Antiseptic soap is recommended for hand washing.
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Staff and visitors should wash hands after
any contact with a VRE case prior to leaving the resident's
room.
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A resident identified as a VRE case should
wash his/her hands after any personal hygiene activities (e.g.,
toileting) and prior to leaving his/her room for group activities.
A resident who cannot wash his/her own hands should be assisted
with hand washing in these instances.
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Staff should wear gloves when providing care
which involves any personal contact (e.g., changing clothes,
bathing). In the course of resident care, gloves should be
changed before further contact with clean surfaces, the resident,
or staff if they have become soiled with potentially infectious
material (e.g., stool, urine). After such care, staff should
remove gloves and wash hands. Care should be taken to avoid
touching environmental surfaces or other residents or staff
after caring for a VRE case and prior to washing hands.
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Gowns should be worn if the provider's clothing
is likely to have substantial contact with a VRE case in the
course of care. Gowns should be removed
Environmental Surface Precautions
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Rooms of VRE cases should be cleaned daily;
frequently touched surfaces (e.g., bed rails, bedside tables,
doorknobs) should be cleaned with an EPA-approved hospital
grade disinfectant-detergent, in accordance with the manufacturer's
instructions. It should be noted that, although VRE is difficult
to treat in the individual, it is not more difficult to eradicate
from environmental surfaces than other enterococci or similar
bacteria.
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Patient-care equipment with which a VRE case
has contact should be cleaned and disinfected prior to use
on another resident.
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Upon discharge or transfer, the room of a
VRE case should undergo "terminal cleaning" with an EPA-approved
hospital grade disinfectant-detergent.
Room Placement
A VRE case should receive special consideration
for room placement within the LTCF. The order of preference for
room placement is:
- A private room;
- A room with other resident(s) known to be VRE cases (i.e.,
cohorting); or
- A room with other resident(s) who are not at increased
risk for infection (e.g., residents without vascular lines,
catheters, stomas, decubiti, or other wounds), and who do
not have MRSA infection or colonization.
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A resident identified as a VRE case who is
incontinent of either urine or feces (regardless of the site
of documented infection or colonization) or who is unreliable
in personal hygiene should be placed in a private room or cohorted
in a room with another VRE case.
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A VRE case should never be placed in the same
room as a resident with current MRSA infection or colonization
Termination of Special Infection Control Practices
A VRE case should be considered to carry the pathogen indefinitely,
unless:
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three consecutive cultures, taken after antibiotic
treatment has ceased and at least one week apart, from the
original culture-positive site(s) are negative for VRE, and
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three consecutive cultures, taken after antibiotic
treatment has ceased and at least one week apart, from stool
or rectal swabs are negative for VRE. Once these negative
cultures are documented, the individual can be considered
VRE-free and special infection control practices may be terminated.
V. Avoidance of
Unnecessary Restrictions
A. Activities within the LTCF
A VRE case should not be excluded from therapeutic or group activities
as long as reasonable personal hygiene is maintained. Care should
be taken to prevent stool, urine, and other body fluids from contacting
environmental surfaces outside of the resident's room.
B. Admission and Transfer of VRE Cases
A VRE case may be admitted to or retained in a LTCF. Also, the
presence of VRE infection or colonization should not in itself
preclude transfer of patients between health care facilities.
Transferring facilities should notify receiving facilities as
far in advance as possible and again upon transfer whenever a
VRE case is transferred .
VI. Tracking
All cases of VRE should be documented in a line-listing
which is reviewed by professionals responsible for infection control
at the LTCF. An example of a line-list format is included in Appendix
B
VII. Notification
of Providers
A resident's primary care providers should be
notified when the resident is newly identified as a VRE case.
All primary care providers who admit residents to the LTCF should
be notified whenever there is concern for increased transmission
of VRE within the facility.
VIII. Control of VRE
Outbreak Situations
When three or more VRE cases (not including newly
admitted residents who have VRE or residents being readmitted
after a hospitalization who have VRE) are identified in a six
month period, the LTCF should report this finding to the Local
Health Department. Consultation should occur whenever there is
evidence of an increase in VRE rates or transmission between residents.
IX. Identification of Vancomycin-Resistant
Staphylococci
If the LTCF becomes clinically suspicious or receives laboratory
notification of a case of vancomycin-resistant Staphylococcus
aureus (VRSA) or vancomycin-resistant Staphylococcus epidermidis
(VRSE), the LTCF should immediately contact the Local Health Department
for infection control guidance.
The Maryland Department of Health and Mental Hygiene (DHMH),
Division of Outbreak Investigation, (410) 767-6677, should also
be notified if vancomycin resistance is suspected in these pathogens.
The LTCF should have the laboratory contact the DHMH Division
of Outbreak Investigation for guidance on where to submit the
isolate for confirmatory testing
Acknowledgment:
These recommendations were reviewed by the individuals
listed below. We appreciate their comments.
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John G. Bartlett, M.D., Johns Hopkins Hospital
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J. Mehsen Joseph, Ph.D., Maryland Department
of Health and Mental Hygiene
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J. Glenn Morris, Jr., M.D., M.P.H.&T.M., University
of Maryland Medical Center
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Trish Perl, M.D., M.Sc., Johns Hopkins Hospital
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Louis B. Polish, M.D., D.T.M.&H., University
of Maryland Medical Center
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Harold C. Standiford, M.D., Baltimore Veterans
Administration Medical Center
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Dorothea Stern, M.D., Maryland Department
of Health and Mental Hygiene
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