The Toronto Hospital Policy & Procedure Manual
INFECTION CONTROL
SECTION: DISEASE SPECIFIC INFORMATION
SUBJECT TITLE:VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE)
POLICY #: 60.14
ISSUED BY: INFECTION CONTROL
DATE:02.97 (O)
APPROVED BY:
INFECTION CONTROL COMMITTEE
REVIEW DATE: 07.97(R)
GUIDELINES
Enterococcus is a gram-positive bacterium and is part of the normal flora of the intestinal and genital tract. Enterococci are often resistant to aminoglycosides and ampicillin, however vancomycin resistance (VRE) was first identified in 1988 in the U.K. Since then, there has been a rapid increase of VRE isolates noted in North America as well. The microorganism can withstand variable degrees of heat and drying and is able to survive on surfaces for prolonged periods of time thus representing an organism for which the potential for environmental transmission is a concern. Before describing the details of risk factors and modes of transmission it is important to outline the differences between colonization and infection. Many more patients will be colonized than infected with VRE.
Colonization: the presence of a microorganism in or on a host with multiplication and growth but without tissue invasion, damage or symptoms e.g. in the gastrointestinal or genital tract
Infection: the presence of a microorganism which causes an immune response generally with clinical symptoms e.g. surgical wound, urinary tract, blood stream or soft tissue infections.
Risk Factors:
use of multiple antibiotics, steroids or chemotherapy
prolonged duration of antibiotic use
diarrhea/C. difficile colitis
high frequency of intrahospital transfers
intensive care unit admission
elderly or malnourished
a prolonged stay or repeated admissions to a hospital
immunosuppression
poor environmental cleaning
Mode of Transmission
- VRE is transmitted by contaminated or inadequately disinfected patient care equipment or furniture (fomites) such as bed rails, call bells, electric thermometers and toilets
- Hands of health care workers which have become transiently colonized may become a mode of transmission from health care worker to patients. Therefore frequent handwashing is a very important control measure.
- VRE is not airborne
.
Equipment
Isolation cart to store supplies are obtained from transportation.
A dedicated glass thermometer, blood pressure cuff and stethoscope must remain in the room.
Long sleeve yellow gowns and gloves are available at the doorway to the room or in the anteroom (if available).
Dishes are to be removed from meal trays and taken into the room. Disposable dishes are not necessary.
Linen is disposed of in a clear plastic bag that remains in the room.
Garbage is disposed of in black garbage bags which remains in the room.
Yellow bags are needed only for blood soaked items and chest drainage sets.
Sharps are disposed of into sharps containers at point of use and should be wiped using an approved disinfectant prior to removal from the room.
Lab specimens are handled in the usual manner securing them in plastic bags.
Re-usable equipment is sent to CPD for terminal disinfection
Control Measures for Vancomycin-Resistant Enterococcus
An assessment will be made by Infection Control or other staff familiar with risk assessment in collaboration with the attending staff regarding the level of hygiene, continence, severity of illness of the VRE positive patient and the setting in which the patient is placed to determine the likelihood of transmission (LOT) and necessity of continued isolation. Isolation is not considered necessary in all circumstances (please see next section)
Patients with confirmed or suspect VRE who are considered at higher risk of transmission are placed in a single room on STOP isolation or may be cohorted with another VRE positive patient.
Gloves must be worn when entering an isolation room and discarded when leaving the room.
Gloves are to be removed before touching a phone, keyboard or chart
Hands must be washed before and after using gloves using a chlorhexidene or alcohol based handwash solution
Gloves must be changed between procedures done on the same patient, such as catheter and tracheotomy care, dressing changes or suctioning.
Long sleeve gowns must be used when entering a room and used only once.
Dedicated equipment is to remain in the room. (thermometer, commode, stethoscope)
If equipment is removed, it must be cleaned with an approved disinfectant (eg a phenolic )
Re-usable equipment which can be sent to CPD is placed directly in the transport box.
Charts are not to be taken into the room.
Thorough environmental cleaning using a hospital approved disinfectant( eg a phenolic or hydrox or 0.5% sodium hypochlorite) should be done
Surveillance cultures are taken from contacts in an effort to identify any further cases. An assessment of the patient populations, risk factors within that population, costs and resources must be taken into consideration with respect to the extent of screening which is undertaken. As a minimum stools or perirectal swabs are obtained from roommates and other close contacts of patients found to be newly colonized with VRE. Depending on the individual circumstances screening of all patients on a unit or a ward may be considered prudent. It is not necessary to do massive hospital-wide screening or screening of all discharged patients .Current evidence also suggests that there is minimal to no transmission to healthy care-givers or health care personnel and screening of these populations is not necessary. Surveillance cultures of the following sites may be done :
peri-rectal swab or stool culture
draining wounds or exit sites
?VRE must be entered in the comment section when entered in the computer
environmental and staff cultures or additional screening cultures are done only when ordered by the Infection Control Nurse and the Hospital Epidemiologist
VRE positive patients and their visitors will be given information about VRE and instructions concerning isolation practices.
Housekeeping is to be contacted and bathrooms are to be thoroughly cleaned and then disinfected using a 0.5% sodium hypochlorite or 3% Hydrox solution.
A 70% alcohol based handwashing solution should be used, especially on mobile carts or chart racks, as a supplement to handwashing at a sink.
When a VRE positive patient is moved from a room, discharged or removed from isolation, a thorough surface cleaning is done (e.g. call bells) and curtains and drapes are changed.
Termination of isolation practices must be done in consultation with the Infection Control Nurse or the Hospital Epidemiologist. Prolonged carriage of VRE is very common in many patient populations.
Treatment of VRE
2% Chlohexidene soap should be used for bathing the patient and for staff handwashing.
Other antibiotics e.g.Teicoplanin or Synercid may be used if there is an infection.
There is no effective decolonization therapy at this time.
Transfer of a Patient with Suspected/Diagnosed VRE within the Hospital:
Avoid unnecessary transfers of patients without compromising care.
Inform any receiving unit or test area (e.g. radiology) prior to transporting the patient.
Notify the Infection Control Nurse if the patient is transferred.
If the patient requires surgery, notify both OR and PACU
Transfer of a Patient with Suspected/Diagnosed VRE from Another Facility:
The Infection Control Nurse must be notified when a patient is to be or has been admitted.
Patients who are transferred from an institution with an identified outbreak of VRE should have cultures done on admission.
The patient should be placed on isolation precautions until results are available.
All patients who have been recently discharged or transferred directly from a hospital outside of Canada must have cultures sent on admission to rule out VRE and MRSA.
Discharge of a Patient with Suspected/Diagnosed VRE:
If appropriate, the hospital home care coordinator should be informed prior to discharge.
The family physician should be informed.
A notation should be made in the discharge summary.
If returning to a clinic, a note should be made in the clinic chart.
If they are admitted to a hospital, the patient or family should inform the admitting physician so that an appropriate assessment may be made
Guidelines for the Integration of VRE Colonized Patients
The risk of transmission of VRE is increased in bed-ridden patients who have diarrhoea especially in settings with inadequate environmental cleaning. Certain chronic patients populations such as those on dialysis may be intermittently colonized for an extended period of time. There may not be sufficient resources such as single rooms to isolate these patients. Isolation of all patients colonized with VRE , not taking into consideration their current state of health and severity of illness may delay transfer of patients to rehabilitation, chronic care and nursing facilities leading to gridlock within the acute care setting and promoting unnecessary and harmful stigmatization of the patient. Long term isolation practices can have a negative effect on the psycho-social well-being of a VRE positive patient.
Many patients may be successfully re-integrated.into the general hospital population and present little risk of transmission of VRE if simple assessments of risk and general hygienic principles are followed.
Principle:
The use of body substance precautions, with special attention to handwashing and environmental cleaning can interrupt the transmission of VRE.
Each case of a patient with long term VRE colonization should be assessed regarding the level of personal hygiene, the presence of diarrhoea, severity of illness and his/her understanding of the transmission of VRE.
Recommendations:
- Patients and their family will receive information concerning the transmission and control measures of VRE.
- A single room is necessary only if the patient has diarrhoea, is incontinent or has poor hygiene.
- A 70% alcohol solution should be readily available to facilitate handwashing after patient contact during rounds.
- Body Substance Precautions are sufficient for direct patient care.
- Ambulatory patients will be asked to wash their hands or use a 70% isopropyl alcohol based solution upon their arrival to a clinic or a dialysis unit.
- All staff should wear gloves as appropriate to the task and wash their hands frequently.
- VRE colonized patients may have follow-up cultures as ordered by the attending physician or Infection Control.
- Antibiotic administration or diarrhoea are considered risk factors for reappearance of VRE in previously colonized patients. A stool specimen or rectal swab should be sent for VRE, C&S and C difficile in this setting
- Gowns and gloves and isolation must be used when caring for any patient with diarrhoea.
- Equipment (stethoscope, B/P cuff) must be cleaned with an approved hospital disinfectant.
- VRE positive patients should be instructed to use an antimicrobial soap on a daily basis.
- The environment must be disinfected between all patients e.g. dialysis chair, table etc.
References
- Recommendations for preventing the spread of vancomycin resistant Enterococcus: The Hospital Infection Control Practices Advisory Committee (HICPAC). American Journal of Infection Control,1995;23:87-94.
- Boyce, J. et al. Controlling vancomycin-resistant Enterococcus. Infection Control and Hospital Epidemiology,1995;16:634-637.
- Wade, J. et al. Hygienic hand disinfection for the removal of epidemic vancomycin-resistant
- Enterobacter cloacae. Journal of Hospital Infections,1991;18:211-218.
- Health Canada.Guidelines for Preventing the Spread of Vancomycin-Resistant Enterococci in Canada (in press) 1997
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