Guidelines for Preventing the Spread of Vancomycin-Resistant Enterococci (VRE)
An increase in the incidence of infection and colonization with Vancomycin-resistant Enterococci (VRE) has been reported by US hospitals but has been rarely encountered in hospitals in Canada. A rising incidence of VRE creates problems including: a) the lack of available antimicrobials for treatment of infections due to VRE, since VRE are also resistant to multiple other drugs used for the treatment of infections caused by Enterococci b) the possibility that the vancomycin-resistance genes present in VRE may be transferred to other gram-positive microorganisms such as Staphylococcus aureus.
The majority of enterococcal infections have been attributed to endogenous sources within the patient. However, recent reports of outbreaks and endemic infections due to VRE have shown that patient-to-patient transmission can occur either directly via hands of personnel or indirectly through contaminated patient care equipment and environmental surfaces.
Patient populations found to be at increased risk of VRE infection or colonization include: critically ill patients; those with severe underlying disease or immunosuppression; patients in ICU, oncology and transplant units; patients with indwelling urinary or central venous catheters; those who have had intra-abdominal or cardiothoracic surgery; and those who have received multi-antimicrobial treatment and vancomycin therapy.
Prevention and control of the spread of VRE require concerted effort from various departments of the hospital and may be achieved with the following:
1) Education of staff regarding the problem of vancomycin resistance;
2) Early detection and prompt reporting of vancomycin resistance in Enterococci by the Microbiology Laboratory;.
3) Prudent use of vancomycin by clinicians; and
4) Immediate implementation of isolation precautions to prevent person-to-person transmission.
Isolation Precautions
1) Place VRE infected or colonized patients in single rooms or in the same room as other patients with VRE. Place an isolation sign outside the room with appropriate boxes checked.
2) Wear a cuffed, long-sleeved gown upon entering the room. Remove gown before leaving the patients room.
3) Wear gloves (unsterile gloves) upon entering the room. Remove gloves before leaving the room. A change of gloves may be necessary after contact with body substances that may contain high concentrations of VRE (e.g. feces). A mask is indicated only if blood/body fluid splashing is anticipated.
4) Wash hands with 2% chlorhexidine. Dry hands with paper towel and use the same paper towel to hold the door open. Make sure that after gloves and gown are removed and hands are washed that clothing and hands do not come in contact with environmental surfaces potentially contaminated with VRE, before leaving the room.
5) Dedicate the use of patient care items such as stethoscope, sphygmomanometer, and thermometers to the patient or cohorts of patients. These items should be disinfected with sodium hypochlorite 1:10 dilution before reuse on another patient.
6) Before termination of isolation precautions for a colonized/infected patient, there should be at least three consecutive VRE negative laboratory reports obtained one or more weeks apart from multiple body sites (sputum, stool or rectal swab, draining wound, foley catheter, and IV site if present).
7) Roommates of patients newly identified to be colonized or infected with VRE should be checked by obtaining cultures of stools or rectal swab, urine, sputum, wounds and IV sites as appropriate.
8) Thorough terminal cleaning of the isolation room should be done by housekeeping using a phenolic germicidal detergent (DOC) or sodium hypochlorite 1:10 dilution. Curtains should be changed. All horizontal surfaces including door knobs should be washed.
References
1) Ayliffe GAJ, Collins BJ, Devrill CEA. Tests of disinfection by heat in a bedpan washing machine. J Clin Pathol 1974;27:760-63.
2) Kearsn AM, Freeman R, Lightfoot NF. Nosocomial enterococci: resistance to heat and sodium hypochlorite. J Hosp Infect 1995;30:193-199.
3) Hospital Infection Control Practices Advisory Committee. Recommendations for preventing the spread of vancomycin resistance. Infect Contr Hosp Epidemiol 1995;16:105-113.
4) The Hospital Infection Control Practices Advisory Committee. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). Am J Infect Contr 1995;23:87-94
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