Guidelines
for
Vancomycin-
Resistant
Enterococcus
(VRE)
VRE Guidelines
September 1996
TABLE OF
CONTENTS
��������������������������������������������������������������������������������������������������������� Page
Background
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .�������������� �� 1
Treatment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .���������������� �� 3
Prudent
Use of Vancomycin . . . . . . . . . . . . . . . . . . . . . ��������������� ���3
Admission
and Discharge . . . . . . . . . . . . . . . . . . . . . . . .�������������� �� 4
Environmental
Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . .� � ������� 10
Epidemic
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .� � 11
Education
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � ��14
Appendices:
��������� A � HICPAC Report . . . . . . . . . .
. . . . . . . . . . . . . . . .��������� � 15
��������� B � Staff Education . . . . . . . . .
. . . . . . . . . . . . . . . . . .�������� � 17
��������� C � Patient and Care Giver Education .
. . . . . . . . . . .�������� � 19
��������� D � Patient and Care Giver Education:
Handwashing�������� �������� �21
Glossary
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � 23
Reference
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � ��25
VRE Guidelines
September 1996
Many sources were used to develop this document, including currently available medical literature.� A list of suggested readings is provided if additional material or support is desired.
This document was written by the VRE Task Force of the Greater Omaha Area Chapter of the Association for Professionals in Infection Control and Epidemiology, Inc. With review and input from infectious disease specialist in Omaha and Lincoln areas.
These members represented Infection Control Practitioners from home health agencies, long term care facilities, and hospitals.� Members of the Task Force were:
Nedra D. Marion, RN, BSN, Chairperson
Peggy A. Christ, EN, ET, CIC, NE
Ann Lorenzen, RN, MSN, CIC
Sandra K. Vyhlidal, RN, BSB, CIC
Carol Clemons, RN
Nancy Noda, RN, BSN, CIC
D. Dawn Mayer, RN
Linda A. Horning, RN, CIC
Judy Tonniges, RN
Sally Frohn, RN, BSN, CIC
We gratefully acknowledge the support and input from the following physicians:
Daniel J. Boken, MD
Howard Gendelman, MD
Edward Horowitz, MD
Robert G. Penn, MD
Jane Roccaforte, MD
Mark E. Rupp, MD
Louis Safranek, MD
Tom Safranek, MD
Phillip Smith, MD
Susan Swindells, MD
�
VRE Guidelines
September 1996
INTRODUCTION
The Association for Professionals in Infection Control & Epidemiology Inc, - Greater Omaha Area, identified an opportunity to improve communication among agencies, health care facilities, and health care providers and to control the spread of vancomycin-resistant enterococci (VRE).� With the advent of VRE in the Nebraska area, concern is growing regarding treatment, control, and transfer of patients between institutions.
Health care professionals are caring for increasing numbers of patients with VRE colonization and infections.� Because of the possibility that the vancomycin-resistant genes present in VRE can be transferred to other gram-positive microorganisms, and the lack of available antimicrobial therapy for VRE infections, prevention of nosocomial transmission of VRE has become an important infection control issue.
The purpose of this document is to provide an educational resource for facilities in developing or revising their own policies.� This document provides minimum, basic measures for patient care to control the spread of VRE.� Institutions may implement more stringent precautions based on sound infection control practices.� Issues addressed will help prevent and control the spread of vancomycin resistance.� Communication and coordinated efforts within and among all institutions is essential for effective prevention and control.
As with the document, �Guidelines for the Control of Methicillin-Resistant Staphylococcus aureus�, total agreement on policy is unlikely to occur until there is more consensus in the scientific literature regarding management of VRE.� However, the VRE problem is being recognized earlier than was MRSA.� This has given us an opportunity to develop an organized approach to the issues concerning VRE.
In 1996, the Hospital Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention (CDC) published Recommendations for Isolations Precautions in Hospitals.� This documents reflects the recommendations.
BACKGROUND
Enterococci are gram-positive bacteria first described in 1899.� Initially classified as Streptococci, they were reclassification as enterococci in 1984.� There are numerous species of enterococci with E. faecalis and E. faecium being the most clinically significant.
Enterococci are normal flora of the gastrointestinal tract and female genital tract.� The most common enterococcal pathogens cause urinary tract infections, intraabdominal infections, and bacteremias.� Community-acquired infections such as endocarditis, intraabdominal, and skin/soft tissue can be caused by these organisms.� Nosocomial infections can be associated with the urinary tract, surgical wounds, pressure sores and the use of IV catheters.
Enterococcal infection sources include endogenous, as from the terminal ileum and colon, and exogenous such as nosocomial transmission via contaminated equipment and hands of personnel
Widespread use and misuse of antimicrobial drugs has been identified as a factor for increased prevalence of enterococcal strains which are vancomycin-resistant.� Vancomycin-resistant enterococci (VRE) have been noted throughout the United States and are posing a serious problem because of the lack of effective antimicrobial therapy.� The possibility exists that the vancomycin-resistant genes present in VRE can be transferred to other gram-positive microorganisms such as Staphylococcus aureus and Staphylococcus epidermis.
According to the CDC�s National Nosocomial Infections Surveillance (NNIS) system, from 1989 � 1993, the percentage of reported nosocomial enterococcal infections caused by vancomycin-resistant enterococci increased from 0.3% to 7.9% and from 0.4% to 13.6% in intensive care units.� The occurrence of VRE was associated with larger hospitals and those with university affiliations.� Other hospitals have also reported increased endemic rates and clusters of VRE infection and colonization.� Mortality associated with systemic enterococcal infections have been high, from 34% to 46%.
RISK FACTORS
ASSOCIATED WITH ENTEROCOCCAL INFECTIONS INCLUDE:
� Prolonged survival of ages and debilitated persons
� Severity of underlying disease and/or immunosuppressions such as granulocytopenia, diabetes, renal failure, CHF
� Increased length of hospital stay
� Hospitalization in ICUs, oncology and transplant services
� Prolonged exposure to antimicrobials; cephalosporins, aminoglycosides, vancomycin
� Intraabdominal or cardiovascular surgery
� Invasive devices (indwelling urinary and intravenous catheterization and feeding tubes)
Studies have indicated that VRE and other enterococci can be transmitted directly by patient-to-patient contact or indirectly by transient carriage on the hands of personnel or by contaminated environmental surfaces and patient care equipment.
In 1994, the subcommittee on the Prevention and Control of Antimicrobial-Resistant Microorganisms in Hospitals of the CDC�s Hospital Infection Control Practices Advisory Committee (HIPAC) and representatives from multiple health care-associated agencies developed recommendations for the prevention and control of the spread of vancomycin resistance, with special focus on VRE.� These were ratified on November 13, 1994.� These recommendations were grouped into the following areas:
HIPAC REPORT:� PREVENTING THE SPREAD OF VANCOMYCIN
RESISTANCE:
� Prudent vancomycin use
� Education program
� Microbiology laboratory role in the detection, reporting and control of VRE
� Prevention and control of nosocomial transmission of VRE
� Detection and reporting of vancomycin-resistant Staphylococcus aureus (VRSA) and vancomycin-resistant Staphylococcus epidermis (VRSE)
TREATMENT
Enterococci, even non-VRE strains, are resistant to most antibiotics.� For sensitive strains intravenous ampicillin and gentamicin are the drugs of choice.� Vancomycin can be used in the penicillin allergic patient.� When resistance to these antibiotics is present, treatment of enterococcal infections is difficult.� Many of them are virtually untreatable.� Some strains of resistant enterococci may be treated with synergistic antibiotic combinations, but this varies from strain to strain.� Treatment is bases on the sensitivity pattern.
The use antibiotics for decolonization of BRE is generally not recommended.� Once a person becomes colonized, eradication of VRE is difficult if not impossible.
PRUDENT USE OF VANCOMYCIN
Vancomycin use is consistently reported as a risk factor for the acquisition of VRE.� Therefore, it is recommended that the facility develop a comprehensive plan for the appropriate use of vancomycin.� The plan should include guidelines for the proper use of vancomycin, education for the medical staff, and other methods of influencing prescribing practices.� For guidelines on appropriate vancomycin use, see "Recommendations for Preventing the Spread of Vancomycin Resistance� (see appendix A) by HICPAC.
ADMISSION AND DISCHARGE
The issue of VRE status (negative culture, colonized, or infected) with regard to hospital and non-acute care facility admission and discharge warrants attention.� This issue is of great practical significance in the light of the current misinformation, fear, and inadequacy of control measures to prevent infection and colonization.
A system should be established to highlight the record of infected or colonized patients.� This will facilitate prompt implementation of contact precautions.
An institution should
not deny admission to a VRE colonized or infected person if adequate facilities
are available.
HOSPITAL ADMISSION
Admission Rationale: Hospital admission because of VRE infection is acceptable medical practice.� However, VRE colonization does not, by itself, warrant hospital admission.� Treatment for infection with VRE is usually accomplished in an acute care setting.� However, treatment for infection can be accomplished in a non-acute care facility or at home.� This decision is based on the clinical judgement of the attending physicians.
Room Assignment: A private room is preferred if at all possible for VRE-infected or colonized patients.� Patients with VRE can be placed together (cohort).
Infection Control: Minimum infection control guidelines (see pages 7-10) should be followed.� The facility may employ a more stringent infection control policy.
HOSPITAL DISCHARGE
Upon completion of appropriate therapy for VRE infection and
when the clinical manifestations have resolved (even if the patient has a
positive culture), hospital discharge may be indicated.� A patient colonized with VRE while
hospitalized for another illness may be discharged once the patients is
medically stable.� In other words, a
patient may be discharged from an acute care setting with a positive VRE
culture.� When this occurs, the hospital
should notify, in advance, an institution/agency receiving the patient who is
colonized/infected with VRE.� A negative culture should not be a prerequisite
for dismissal to another facility for care.
NON-ACUTE CARE
FACILITY ADMISSION
Admission Rationale: An institution should not deny admission to a person colonized or infected with VRE if adequate facilities are available.� A person colonized/infected with VRE should be allowed admission to a non-acute care facility.
Under special circumstances, treatment for a VRE infection can be accomplished in a non-acute care facility.� This decision is based on clinical judgement of the attending physician and capabilities of the institution.
Room Assignment: A private room is preferred for VRE-infected or colonized patients.� The patient with VRE can be placed with other patients with VRE (cohort).� If cohorting is not available, the patient with VRE can be placed with non-VRE patient; but the roommate may run an increased risk of acquiring VRE.� The patient with VRE should not be placed in a room with a person with at high risk for infection (i.e., a patient with a tracheotomy, gastrotomy, central line, urinary, catheter, open wound, or one who is immunocompromised).� A private room is desirable to prevent direct- or indirect-contact transmission when the VRE patient has poor hygienic habits, contaminates the environment, or cannot be expected to comply with precautions.
Infection Control: Minimum infection control guidelines (see pages 7-10) should be followed.� The facility may employ a more stringent infection control policy.
NON-ACUTE CARE
FACILITY DISCHARGE
A patient may be discharged to home or transferred to a hospital while colonized/infected with VRE.� When the patient is transferred to an acute care setting, the receiving institution/agency should be notified, in advance, of the patient�s status.
DISCHARGE TO HOME
If the patient is discharged from an acute or non-acute care facility to a private home, there will be a need to educate about VRE.� The patient�s family/caregiver will invariable have noted the extraordinary attention to infection control practices while the patient was hospitalized or in the non-acute area and may be concerned with (1) that they will be required to duplicate these infection control practices in the home setting and (2) that they themselves will be at high risk of acquiring VRE if they bring the patient home.� Information should be conveyed that infection control practices are often employed in the health care facility to reduce the risk of transmission of VRE to highly susceptible patients,� especially those who have open wounds, invasive devices, or sever underlying diseases.
The patient/caregiver should be taught that they rarely need to practice extraordinary infection control measures in the home beyond good handwashing, careful handling of soiled dressings, and good environmental hygiene (bathroom cleaning)� Gloves may be worn when performing patient cares involving VRE contaminated areas.� Handwashing must follow the removal of gloves.� If there is a highly susceptible family member, more extensive precautions might be requested for that individual by his/her family physician.
Interfacility Communication During Admission and Transfer
of the VRE Patient:
Communication between transferring facilities is essential to provide information on patients so appropriate arrangements (i.e., room assignment, cohorting) can be coordinated.� It is preferred practice to notify the receiving facility about a patient know to have VRE (i.e., either colonized or infected.)
KEY ISSUES
The following statements summarize key issues regarding discharge/admission management of VRE patients in acute and non-acute care facilities:
� Colonization with VRE alone is not grounds for admissions to a hospital.
� Colonization with VRE should not be grounds for refusing admission to a hospital if other acute conditions exist.
� Colonization with VRE does not require extension of hospitalization.� Arrangements for discharge to home or a non-acute care facility can proceed as the patient�s condition warrants.
� Colonization with VRE alone should not be grounds for exclusion from a non-acute care facility, if adequate facilities are available.
� Hospital discharge may occur when a VRE infection has been adequately treated.� A hospitalized patient who is colonized with VRE may be discharged whenever he/she is medically ready.
� Patients infected with VRE, who may be ready for discharge except for completion of antibiotic therapy, may be discharged to another facility such as a long-term care facility or rehabilitation center as long as the required care/treatment is available at that facility.
� The receiving facility should request and the transferring facility should inform the receiving facility of the patient�s condition upon transfer.� This should include medical diagnoses, medication, therapies, and activities of daily living as well as pertinent information on any infection or colonization of the patient.� This information should be shard to insure appropriate and adequate care of patient.� This will also assist facilities in placing the patient in the appropriate room with appropriate roommate and allow for any special arrangements regarding patient care.
� Negative VRE cultures should not be required for transfer.
INFECTION
CONTROL MEASURES TO PREVENT VRE TRANSMISSION
Education of staff and ancillary departments on VRE is critical for strict adherence with infection control measures (see Education section and Appendix B).
Handwashing for a minimum of 10-15 seconds with an antiseptic soap or a waterless antiseptic agent is recommended (bland soap does not always completely remover VRE from hands).� Proper technique is another important factor.� Generally, hands should be washed (a) before and after contact with the patient, (b) after personal hygiene of staff, (c) before eating or handling food, (d) before invasive procedures and (e) after handling contaminated items.� (See Appendix D for technique).
Upon transfer to another facility or visit to a doctor�s office/clinic, inform the receiving health care facility prior to the transfer of the patient�s VRE status.� It is important to keep all agencies informed of the patient�s VRE status so necessary precautions can be maintained.
Implement infection control precautions specific to setting.
ACUTE CARE SETTING
A private room is preferred for both infected and colonized patients.� Cohorting patients with VRE is a option.� As soon as VRE is identified, room arrangements should occur.
When VRE is identified after the patient has had a roommate, notify the roommate�s physician about possible exposure and CDC�s recommendation to obtain a stool culture or rectal swab to rule out VRE transmission.
Additional measures include wearing clean, non-sterile gloves when entering the patient�s room.� Gloves should be removed before leaving the room followed by hand washing.� During the course of caring for a patient, a change of gloves and hand washing may be necessary after contact with material that may contain high concentrations of VRE, such as stool or wound dressings.
Wear a clean, non-sterile gown when entering the patient�s room if contact with patient or environmental surfaces in patient�s room is anticipated or if the patient is incontinent, has diarrhea, an ileostomy, or colostomy, a wound drainage not contained by dressings.� Remove the gown before leaving the room followed by handwashing.� Assure that staff clothing, hands and the environment are not contaminated from gown and glove removal.
After removal of gloves/gowns and handwashing, do not contact contaminated surfaces in patient�s room, such as repositioning call light for patient, moving bedside stand closer to patients, or touching inside door knob to open door.
Handwashing for a minimum of 10-15 seconds with an antiseptic or a waterless antiseptic agent is recommend (bland soap does not always completely remove VRE from hands).� See educational section on technique.
Dedicated equipment should remain in patient�s room during the patient�s stay, such as thermometers, stethoscope, and blood pressure cuff.� If this is not feasible due to supply inventory, adequate cleaning with an EPA approved disinfectant must occur before removal from the patient�s room.
Extensive daily and discharge room cleaning with approved EPA disinfectant (contact time according to manufacturer�s recommendations) is required (see Environmental Cleaning section).
PHYSICIAN
OFFICE/CLINIC/AMBULATORY SETTINGS
Clinic staff may consider scheduling a patient with VRE at a time that would reduce the possibility of transmission to other patients.
Wear and remove clean, non-sterile gloves and gown as outlined in the acute care setting recommendations.
Disposable equipment, when available is ideal.� When reusable equipment must be used due to supply inventory, reprocess/disinfect equipment with an EPA approved disinfectant (contact time according to manufacturer�s recommendations).
Handwashing for minimum of 10-15 seconds with an antiseptic soap or a waterless antiseptic agent is recommended (bland soup does not always completely remove VRE from hands).� See educational section on this technique.
At the completion of the exam, clean the examination room with an EPA approved disinfectant (contact time according manufacturer�s recommendations).� Pay special attention to the surfaces that came in contact with patient, such as the examination table and chair.
HOME HEALTH CARE
SETTING
Home health staff members should wear clean, non-sterile gloves and a gown as described in the acute care setting recommendations.
Family/caregivers may want to wear gloves when caring for areas that have high concentrations of the organism.� It is advisable to have the caregivers wear a protective outer garment (i.e., loose fitting shirt or a fluid resistant barrier), if soilage of caregiver�s clothing is anticipated, such as cleaning up diarrhea.� The outer shirt can then be removed and washed with other laundry.� Use the hot water cycles of the washer and dryer if possible.
Handwashing for a minimum of 10-15 seconds with an antiseptic soap or a waterless antiseptic agent is recommended (bland soap does not always completely remover VRE from hands).� See educational section on this technique.
Dedicated equipment is recommend.� When equipment removal is necessary or service are completed, the equipment should be adequately cleaned and disinfected with an EPA approved disinfectant (contact time according to manufacturers� recommendations).� Follow the agency policy regarding removal of contaminated equipment from the home.
Persons already defined as high risk may want to check with their health care provider prior to having direct contract with the patient (see page 7-10).
LONG-TERM CARE
SETTING
A private room is recommended if the patient has poor hygienic habits, contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of VRE.� If a private room is not feasible, cohorting with another VRE positive patient is acceptable.� A semi-private room is acceptable if the roommate has not invasive devices, such as an indwelling urinary catheter or a central intravenous device.
Handwashing for a minimum of 10-15 seconds with an antiseptic soap or a waterless antiseptic agent is recommended (bland soap does not always completely remover VRE from hands).� See educational section on this technique.
Staff should wear clean, non-sterile gloves upon entering the room of a VRE patient.� Wear a gown or apron if substantial contact with the patient or environmental surfaces in patient�s room is anticipated or the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage that is not contained by a dressing.� Remove jackets, sweaters, etc., that might become contaminated if not covered by a gown.� Linen and gowns are handled according to facility policy.� Place non-porous disposable gowns (isolation gown) in the trash.
Dedicated equipment should remain in the patient�s room during the patient�s stay, such as thermometers, the stethoscope, blood pressure cuff.� Upon discharge, reusable items should be reprocessed/disinfected with an EPA approved disinfectant (contact time according to manufacturer�s recommendations) according to the facility policy.� Extensive daily and discharge room cleaning with an approved EPA disinfectant is required, contact time per manufacturer�s recommendations.
Environmental
Cleaning
Environmental cleaning is a key element in the prevention and control of nosocomial transmission of VRE.� An individual facility assessment should be completed and followed by the development of individualized facility specific policies for environmental cleaning.
Recommendations for healthcare facility policies for VRE patients are as follows:
Dedicate use of patient care equipment to a single patient.� Clean and disinfect items before use on another patient.� Examples of specific items are:
� Stethoscope
� Thermometers
� Blood pressure cuff
� IV pumps
� Other non-critical items
Daily routine cleaning and disinfecting of the patient�s environment with a disinfectant solution (EPA registered) is important.� Follow manufacturer�s recommendations for wet contact time.� Clean the environment around the patient, such as where the patient can touch or where contaminated items are placed.� Specific area to include are:
� Door knobs
� Bed rails
� Carts
� Faucet handles
� Bedside commodes
� Telephones
� Bedside stands
� Chairs or wheel/chairs
EPIDEMIC
(OUTBREAK)
DEFINITION OF AN
OUTBREAK
An epidemic is an excess over the usual level of a disease within a geographic area; however, one case of an unusual disease (e.g. VRE) may constitute an epidemic.� Each facility must decide the criteria to define an outbreak.
EPIDEMIOLOGIC
INVESTIGATION
In an epidemic, the investigation should include collection of the following data:
1. Patient�s location in the institution (before and after cohorting).
2. Date of admission and recent previous admissions.
3. Age, sex, and race.
4. Diagnosis, especially conditions with negative impact on patient�s immune status.
5. Severity of illness, presence of, and history of invasive devices or other special procedures.
6. Body site of infection or colonization.
7. Date, body site, and results of cultures.
8. Which caregivers had direct contact with patient.
9. Treatments given, especially antibiotics.
MANAGEMENT OF A VRE
OUTBREAK
Education:
When an outbreak is recognized, immediate reinforcement of infection control procedures (e.g., handwashing and standard precautions/contact precautions) for all staff is necessary.� See the section on Infection Control Measures to Prevent VRE Transmission.
Cultures:
Patients: When an epidemic is recognized, patients in the unit or units where cases have occurred may need to be cultured.� Cultures should be done simultaneously; sites to consider include stool or rectal swabs, perineum, axilla, umbilicus, wounds, foley catheter, and or colostomy sites if present.� Notify the laboratory to screen for VRE.
Patients-care-personnel: Patient-care personnel should be cultured only if epidemiologically implicated in transmission.� If an employee is cultured, hand and rectal swabs cultures should be obtained.� Multiple specimens may be required in order to identify the organism.� An epidemiologically implicated culture-positive caregiver should be counseled regarding infection control precautions and any deficiencies in technique should be corrected.� Other measures, such as removal of the employee from care of high-risk patient, may be considered if these initial steps fail.
Cohorting:
During an outbreak and when extra control measures are required, all VRE positive patients should be physically separated with no staff crossover to VRE negative patients (i.e., if feasible and necessary, a cohort should be established).� As much as possible, staff assigned to the cohort should work with cohort patients.
Immediate review of basic standard and contact precautions should be done.� Careful surveillance for additional infected or colonized patients should be undertaken.
Decolonization:
Decolonization of patients or staff is not routinely recommended.� This has not proven to be an effective control measure because recolonization usually occurs.
Admission and
Discharge:
During an outbreak, there is usually no reason to close the non-acute care facility or hospital to new admissions.� The facility should not be prevented from discharging patients, provided the guidelines for admissions/discharge are followed.
Resources
An internal working group should be organized to assist the person primarily responsible for investigation the epidemic.� In addition to the internal group, assistance may be sought from physicians who specialize in infectious diseases, infection control specialist, microbiology, reference laboratories, and/or local or state health departments, as needed.� The local or state health department may need to be notified of the epidemic.
COMMUNICATION
Facts concerning the epidemic, such as the severity of the epidemic, the methods of transmission, and prevention measures as well as a general account of what direction the investigation is taking, should be clearly communicated to all necessary personnel.� A written report of the epidemic should be completed promptly after the investigation is over.
EDUCATION
Control of VRE requires a collaborative informed effort on the part of the patient, caregivers, and institution employees.� Continuing education programs for health care workers should include information concerning the Epidemiology of VRE, the potential impact of the pathogen on the cost and outcome of patient care, and the transmission and control of VRE.� Education remains one of our best defense mechanisms.� This subject requires continuous education as new developments and research date become available.� Guidelines to assist with teaching efforts are found in the appendices.
Appendix A
HICPAN Report
PREVENTING THE
SPREAD OF VANCOMYCIN RESISTANCE
Report from the Hospital Infection Control
Practices Advisory Committee
The report recommended the prudent use of vancomycin by clinicians.
A. Situations in which the use of vancomycin is appropriate or acceptable:
1. Treatment of serious infections due to beta-lactam resistant gram-positive organisms.� Clinicians should be aware that vancomycin may be less rapidly bactericidal than beta-lactam agents for beta-lactam susceptible staphylococci.
2. Treatments of infections due to gram-positive organisms in patients with serious allergy to beta-lactam antibiotics.
3. When antibiotics-associated colitis (AAC) fails to respond to metronidazole therapy or if AAC is severe and potentially life-threatening.
4. Prophylaxis, as recommended by the American Heart Association, for endocarditis following certain procedures in patients at high risk for endocarditis.
5. Prophylaxis for surgical procedures involving implantation of prosthetic materials or devices at institutions with a higher rate of infections due to MRSA or Methicillin-resistant Staphylococcus epidermis.� A single dose administered immediately before surgery is sufficient unless the procedure lasts more than six (6) hours, in which case the dose should be repeated.� Prophylaxis should be discontinued after a maximum of two (2) doses.
B. Situations in which the use of vancomycin should be discouraged:
1. Routine surgical prophylaxis.
2. Empiric antimicrobial therapy for a febrile neutropenic patient, unless there is strong evidence at the outset that the patient has an infection due to gram-positive organisms (e.g., inflamed exit site of Hickman catheter) and the prevalence of infections due to beta-lactam resistant gram-positive organisms (e.g., MRSA) in the hospital is substantial.
3. 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, i.e., if contamination of the blood culture is likely.� Because contamination of blood cultures with skin flora, e.g., S. epidermis, may cause vancomycin to be inappropriately administered to patients, phlebotomizes and other personnel who
obtain blood cultures should be properly trained to minimize microbial contamination of specimens.
�����������
4. Continued empiric use for presumed infections in patients whose cultures are negative for beta-lactam resistant gram-positive organisms.
5. Systemic or local prophylaxis for infection of colonization of indwelling central or peripheral intravascular catheters or vascular grafts.
6. Selective decontamination of the digestive tract.
7. Eradication of MRSA colonization.
8. Primary treatment of antibiotic-associated colitis (AAC).
9. Routine prophylaxis for very low-birth-weight infants.
10. Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis.
REFERENCE: Federal Register (May 17, 1994)
����������������������������������� CDC
Preventing the Spread of Vancomycin Resistance
Appendix B
Staff Education
VANCOMYCIN-RESISTANT
ENTEROCOCCI (VRE) INFORMATION
What are Enterococci?
Enterococci are gram-positive cocci initially classified as Streptococci and reclassified as Enterococci in 1984.� Enterococci are found in the normal gastrointestinal or female genital tract.� An example of where Enterococci are normally found is in the feces (stool) of humans.
What disease role does Enterococci play?
Enterococci can cause community acquired infections and are having an increasing role in nosocomial infection.� Examples of infections include urinary tract, bacteremia, abdominal or pelvic (usually polymicrobial), wounds, and neonatal infection.� Enterococci are rarely implicated in respiratory or central nervous system infections.
What antibiotics are Enterococci resistant to?
Enterococci are intrinsically resistant to cephalosporins, some penicillins, clindamycin and aminoglycosides.� Some Enterococci have acquired resistance to chloramphenicol, erythromycin, ampicillin, tetracycline, fluoroquinolones, aminoglycosides, and vancomycin.� Enterococci are remarkable resistant to most antibiotics.
Who is at risk?
Patient population of increased risk for VRE infection or colonization include: critically ill patients or those with sever underlying disease or immunosuppressions, those who have had an intra-abdominal or cardio-thoracic surgical procedures, those with an indwelling urinary or central venous catheter, and those who have had a prolonged hospital stay or received multiple antibiotics an/or vancomycin therapy.� A patient may have VRE in his/her intestine or on the skin without any complications (colonization), or may have a VRE infection such as a urinary tract infection, wound infection, pneumonia, or bacteremia.
How is VRE transmitted?�
Transmission of VRE is from person to person either via direct contact or indirectly via the hands of personnel or contaminated patient care equipment or environmental surfaces.� Once VRE colonizes a patient, it tends to remain in the intestine or on the skin for years.� Patients with VRE, especially if incontinent, can contaminate the environment heavily (e.g., room, floor, bed, side rails).
What can be done to prevent and/or control the spread of
VRE?
�
Education
�
Early detection and prompt reporting of VRE (i.e.,
obtaining good cultures, identify the organism, antimicrobial susceptibility
testing, and communication).
�
Implement appropriate infection control measure to
prevent transmission.� These measures
include:
-
Place the patients in a private room or in the same
room as other patients who have VRE.
-
Wear gloves when entering the patient�s room.
-
Wear a gown
-
Remove gloves and gown before leaving the patient�s
room and wash hands immediately with an antiseptic soap.
-
Order and use a stethoscope committed to a single
patient.
-
Maintain a high standard of environmental cleaning and
disinfecting, e.g., bed rails, charts carts, doorknobs, faucet handles,
bedsides commodes.
-
Follow aseptic procedures regarding patient care
equipment.
-
Highlight the records of VRE infected or colonized
patients so that they can be recognized and isolated promptly upon readmission.
�
Assist in prudent vancomycin use
�
Communication, cooperation, and concerted effort from
various departments will assist in the identification, prevention, and control
of infection and colonization with VRE.
What about treatment for VRE?
Few if any antibiotics are available to treat infections due to VRE.� Treatment options are often limited to antimicrobial combinations or experimental compounds with unproven efficacy.� These is also the possibility that the vancomycin resistance genes present in VRE may be transferred to other gram positive micro-organisms such as Staphylococcus aureus.
Will I take VRE home to my family?
Normal healthy people are not usually at risk.� Follow the prevention and control recommendations while at work.� Remember the importance of HANDWASHING as the single most important measure to prevent transmission.� Wash your hands after the care of each patient, after handling soiled items, after wearing gloves, before eating and before leaving work.
Appendix C
Patient and Care Giver Education
VANCOMYCIN-RESISTANT
ENTEROCOCCI
(VRE)
What
is VRE?
Enterococcus
is a bacteria that normally lives in the gastrointestinal tract and female
genital tract, by may cause infection in other parts of the body.� Enterococcus is normally found in the feces
(stool) of humans.
VRE
stands for vancomycin-resistant enterococci.�
It is a bacteria or germ that is not always killed by vancomycin
or most other antibiotics.� VRE can
affect people in different ways.�
Individuals may have VRE in their intestine or on their skin without
complications (carrier), or they may have a VRE infection such as a urinary
tract infection, wound infection, pneumonia, or bloodstream infection.
How
is VRE spread?
VRE
is spread from person to person by having direct contact with someone who is a
carrier or is infected with VRE or by indirect contact with contaminated
(soiled) environmental surfaces or other objects.
Why
are precautions used?
Precautions
are used for those who are carriers or infected to prevent the spread of the
VRE germ to others.
How
will your stay be different if you are suspected of carrying VRE of have VRE
infection?
1.
You
will need to stay in your room.
2.
Persons
caring for you will wear gowns and gloves to prevent them from carrying the VRE
germ to other patients.
3.
An
informational card is placed on your door to alert caregivers and visitors to
wear gowns and gloves before entering your room.
4.
It
is very important for all persons entering and leaving your room to wash their
hands.
5.
If
it is necessary for you to go to another part of the hospital (for example,
X-ray), you must first wash your hands, and a clean blanket/sheet will be
wrapped around you for transportation.
When
you go home, what you expect?
Normal
healthy people are not usually at risk for VRE infections.� At home, general good hygiene is the best
measure to follow.� Handwashing for
10-15 seconds following use of the toilet is always important, but especially
so with VRE.
If
home health care nurses come to the home, they will wear gloves and gowns to
reduce any chance of spreading VRE to others patients for whom they provide
care.
If
you are caring for your family member at home:
Remember,
HANDWASHIN is the single most important thing you can do to prevent the spread
of infections.
1.
Wash
you hands for 10-15 seconds with an antibacterial soap after:
�
Caring
for your family member
�
Removing
gloves
�
Handling
soiled or contaminated items such as dressings, clothing, linen, tissues, etc.
�
Skin
contact with blood or other body fluids
2.
Wear
gloves and a cover shirt when caring for your family member, especially if you
anticipate contact with blood or body fluids such as urine and stool.
3.
Remove
your cover shirt when finished and launder according to manufacturer�s
instructions.� Use the hot water cycle
of the washer and dryer if possible.
4.
Clean
soiled or dirty surfaces with a household disinfectant or bleach and water (1
1/12tsp. bleach/pint water) daily or as needed.� Bleach and water need to be mixed fresh every day rather than
stored for any length of time in order to maintain it�s germ-killing
capabilities.
Contact
your health care resource person for additional information.
HANDWASHING
Handwashing is the single most effective step in preventing the spread of germs and infection.� Germs which cause infection often travel from person to person simply through touching.� Anyone who has seen a family member come down with a cold or flu will tell you it is easy for infections to spread from one person to another.� Washing hands with soap and water helps scrub away disease causing germs before they enter the body or are spread to another person.
It is your responsibility to prevent passing germs to family members, visitor, and yourself.
Let�s learn about
handwashing:
To protect yourself and others, be sure to:
� Wash your hands often � remember, clean hands are key to infection control.
� Wash your hands after removing gloves.
� Wash your hands after touching items, which are dirty and may have germs on them.
� Wash your hands after using the rest room, blowing your nose, or covering a sneeze.
� Wash your hands before you eat, drink, prepare or handle food.
� Ask your visitors to wash their hands before having contact with you to protect against the spread of germs.
� Wash your hands if you get any blood or other body fluids on your skin.
� Wash your hands after handling soiled or contaminated items such as dressings, clothing, linen, tissues, etc.
� If VRE or a multiple drug resistant organism is present, an antibacterial soap is recommended.
Turn the page for the
correct way to wash your hands.
GLOSSARY
ANITSEPTIC SOAP: A soap with antimicrobial activity that is designed for use on skin or other superficial tissues; removes residents as well as transient organisms.
ASYMPTOMATIC: Without symptoms or producing no symptoms.
CARRIER: A person who is colonized with an organism.� A carrier may transmit the organism to another person either by direct or indirect contact.
COHORT: A group of VRE positive patients (infected or colonized) who are physically separated by grouped together and cared for by staff who do not care VRE negative patients.
COLONIZATION: Presence of VRE in the body without the presence of symptoms or clinical manifestation of illness or infection.� A carrier is colonized with VRE.
COMMUNITY ACQUIRED: Infection incubating or present at the time of admission to a healthcare facility.
ENDOGENOUS: Growing from within.� Endogenous organisms are organisms colonizing the host, either as transient flora or permanent resident flora.
EXPGENOUS: Developing or originating outside.� Exogenous organisms are organisms from a source other than the host.
EPA: Environmental Protection Agency.� A federal agency that tests and registers disinfectants.� The label on the disinfectant must state: a) where the product is to be used, b) type of surface, c) pre-cleaning instructions, d) dilution and directions, e) method of application, f) contact time, and g) how long prepared solution is good.
ENDEMIC: The usual rate or prevalence of persons infected and/or colonized with VRE in a facility.� Endemic rate in each facility will be unique.
EPIDEMIC: An excess over the expected occurrence of disease within a geographic area.
ENTEROCOCCUS: Gram-positive cocci which are normal flora of the gastrointestinal tract and female genital tract.� There are numerous species with E. faecalis and E. faecium being the most clinically significant species.
INFECTION: The condition in which organisms capable of causing disease enter the body and elicit a response from the host�s immune defenses.
IMMUNOSUPPRESSED: A condition in which the immune system is not functioning normally, e.g., severe cellular immunosuppressions resulting from HIV infection or immunosuppressive therapy.
NORMAL FLORA: The population of microorganisms inhabiting the internal and external surfaces of humans which usually do not produce disease.
NOSOCOMIAL AQUIRED: Colonization or infection noted in persons in whom the colonization or infection was not present or incubating at the time of admission for care, or related to a previous stay at the same facility.
POLICY: An overall plan embracing general goals and acceptable procedures which reflect the facility�s standards and principles.
RESERVOIR: The non-clinical source of infection such as the alternate host or the passive carrier of a pathogenic organism.
RESISTANCE TESTING: A laboratory test to determine if an organism is resistant to various antibiotics.
RISK FACTOR: A characteristic behavior or experience that increases the probability of developing a negative health status.
STANDARD PRECAUTIONS: A system of barrier techniques designed to reduce the risk of transmission of bloodborne and other pathogens from moist body substances.� Standard precautions applies to all patients receiving care regardless of their presumed infection status.
STAPHYLOCOCCUS AUREUS: Gram-positive bacteria which grow in colonies that look like grapes.
SUBSTANTIAL CONTACT: Contact with the patient or environmental surfaces in the patient�s room or contact with a patient who is incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing.
SUSCEPTIBLITY TESTING: A laboratory test to determine if an organism can be effectively treated with a particular antibiotic.
TRANSMISSION: The spread of an infectious agent from one person to another.
UNIVERSAL PRECAUTIONS: A system of barrier techniques and practices used by healthcare workers for contact with blood and body fluids.� Universal Precautions are used when providing care for all patients to prevent the transmission of bloodborne pathogens such as HIV or HBV.
VANCOMYCIN: An antibiotic used most commonly to treat infections caused by gram positive bacteria.
VANCOMYCIN-RESISTANT ENTEROCOCCI (VRE): Gram-positive bacteria which are resistant to vancomycin as well as most other antibiotics.
REFERENCES
1. Association for Professionals in Infection Control and Epidemiology, Inc. (APIC).� APIC Infection Control and Applied Epidemiology: Principles and Practice.� Mosby, 1996.
2.
Association for Professionals in Infection Control and
Epidemiology Inc. Greater Omaha Area and The State of Nebraska Department of
Health: Guidelines for the Control of Methicillin-Resistant Staphylococcus aureus 1994.
3.
Edmond, M. B., Ober, J. F., Weinbaum, D. L., Phaller,
M. A., Hwang, T., Sandford, M.D., Wenzel, R.P. Vancomycin-Resistant
Enterococcus faecium Bacteremia: Risk Factors for Infection.� Clinical Infectious Diseases 1995;
20:1126-1133.
4.
Hospital Infection Control Practices Advisory Committee
(HIPAC).� Recommendations for preventing
the spread of vancomycin resistance.�
American Journal of Infection Control 1995;23:87-94: Infect Control Hosp
Epidemiol 1995;16:105-113.
5.
Hospital Infection Control Practices Advisory
Committee (HIPAC), Centers for Disease Control and Prevention (CDC), Public
Health Service, U.S. Department of Health and Human Services.� Recommendation for Isolation Precautions in
Hospitals.� American Journal of Infection Control 1996;24:32-45
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7. Montecalvo, M., Horowitz, H., Gedris, C., Carbonaro, C., Tenover, F., Issah, A., Cook, P., Wormser, G. Outbreak of Vancomycin-, Ampicillin-, Aminoglycoside-Resistant Enterococcus faecium Bacteremia in an Adult Oncology Unit.� Antimicrobial Agents and Chemotherapy 1994;38:1363-1367
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9. Murray, B. Editorial Response: What Can We Do About Vancomycin-Resistant Enterococci?� Clinical Infectious Diseases 1995;20:1134-1136.
10. Noskin, G.A., Cooper, I., Peterson, LR. Vancomycin-Resistant Enterococcus faecium Sepsis Following Persistent Colonization.� Arch Intern Med 1995;155:1445-1447.
11. Noskin, G.A., Stosor, V., Cooper, I., Peterson, L. R. Recovery of Vancomycin-Resistant Enterococci on Fingertips and Environmental Surfaces.� Infect Control Hosp Epidemiol 1995;16:577-581
12. Strausbaugh, L.J., Crossley, K.B., Nurse, B.Z., Thrupp, L.D., SHEA Long-Term-Care Committee.� SHEA Position Paper, Antimicrobial Resistance In Long-Term Care Facilities. Infect Control Hosp Epidemiol 1996;17:129-140.
13. Wade, J., Casewell, M. The evaluation of residual antimicrobial activity on hands and its clinical relevance.� Journal of Hospital Infection 1991; Supplement B, 23-28
14. Wade, J., Sedai, N., Casewell, M.� Hygienic had disinfection for the removal of epidemic vancomycin-resistant Enterococcus faecium and gentamicin-resistant Enterobacter cloacae.� Journal of Hospital Infection 1991; 211-218.
15. Weinstein, J., Roe, M., Towns, M., Sanders, L., Thorpe, J., Corey, G., Sexton, D.� Resistant Enterococci: A Prospective Study of Prevalence, Incidence, and Factors Associated With Colonization in a University Hospital. Infect Control Hosp Epidemiol 1996;17:36-41.
16. Wells, C.L., Juni, B.A., Cameron, S.B., Mason, K.R., Dunn, D.L., Ferrieri, P., Rhame, F.S. Stool Carriage, Clinical Isolation, and Mortality During an Outbreak of Vancomycin-Resistant Enterococci in Hospitalized Medical and/or Surgical Patients.� Clinical Infectious Diseases 1995;21:45-50.