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Strategies to prevent the spread of vancomycin-resistant enterococci in your facility


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Vancomycin-resistant enterococci (VRE) spends far less time in the spotlight than multidrug-resistant organisms (MDROs), particularly MRSA. Although this organism may be less pathogenic than some of its more famous counterparts, it still poses a serious concern for healthcare facilities.

Not only does VRE cause complications for already sick patients, resulting in longer stays and higher costs, but there is another concern-chiefly that it will meet with MRSA in a co-colonized patient and mutate, spreading vancomycin-resistant Staphylococcus aureus (VRSA), says Connie Steed, RN, BSN, CIC, manager of IC at the Greenville (SC) Hospital System.

Some rare cases have surfaced already. "Most VRSA-positive patients had a history of infections caused by both VRE containing vanA and MRSA," according to the CDC.
With this in mind, it's important to ensure that your facility is doing everything it can to prevent the spread
of VRE.

Assessing your facility's risk

VRE was first reported in U.S. hospitals in 1989. By 2004, data showed that VRE caused about one-third of infections in hospital ICUs, the CDC states.
According to the CDC, VRE infections most commonly occur in patients who:

  • Are treated with vancomycin and combinations of other antibiotics, such as penicillin and gentamicin
  • Receive antibiotic treatment for long periods of time
  • Have weakened immune systems, such as patients in ICUs or in cancer or transplant wards
  • Have had surgery, such as abdominal or chest surgery
  • Use medical devices, such as urinary catheters or central intravenous catheters, that stay in for a long period of time

"VRE is usually passed to others by direct contact with stool, urine, or blood containing VRE. It can also be spread indirectly via the hands of healthcare providers or on contaminated environmental surfaces," according to the CDC.

A facility's patient population may have a lot to do with whether VRE is a significant problem. "A small community hospital that doesn't have hematology, oncology, or transplant patients probably isn't going to have a problem with this organism," says Mary Alice Lavin, RN, MJ, CIC, IC and prevention manager at Northwestern Memorial Hospital (NMH) in Chicago.

Therefore, not every facility necessarily needs to screen patients for VRE, she says. However, all ICPs should be assessing their facility's patient population
and risk factors for VRE to decide whether to begin a screening program.

When Illinois adopted new mandatory screening and reporting requirements for MRSA, it prompted NMH to screen those patients for VRE to eliminate any confusion associated with ordering population-specific cultures.

As a result, the facility now performs active surveillance on hematology, oncology, and bone marrow transplant patients, in addition to adult ICU patients and patients in its two solid-organ transplant units, says Lavin.

Identifying high-risk patients

Steed says staff members at Greenville perform active surveillance on their renal failure patients, as well as those in the pulmonary nursing unit, medical surgical, and neurotrauma unit. The facility identified its high-risk patients by performing a point-prevalence survey, says Steed. A point-prevalence survey provides a snapshot of MDRO colonization by culturing all patients on a predetermined day to identify potentially high-risk populations for certain organisms.

Performing a point-prevalence survey can help you identify the populations you should target with your VRE surveillance efforts, says Steed. Some facilities rely
exclusively on clinical cultures instead of active surveillance to track VRE, but these cultures will not show you everything, says Steed. If your facility is serious about reducing its infection rate, active surveillance is the best strategy.

Enforcing contact precautions

Once your facility has determined which patients are colonized with VRE, those patients should be put on contact precautions to prevent the spread of the organism, says Steed.

Northwestern has an automated system that alerts clinical staff members to put a patient on isolation precautions when he or she tests positive for certain organisms, says Lavin.

"When the result fires from the lab system, it sends a message to the electronic medical record and automatically generates an order to place the patient on isolation precautions," Lavin says.

The system not only cuts down on paperwork and processing for nursing staff members, but it also identifies prior MRSA or VRE patients who have been readmitted and should be put back on contact precautions, she adds.

Although putting VRE patients on contact precautions has had a beneficial affect on infection rates, says Steed, it's not the only measure facilities need to be following.

Hand hygiene and environmental cleaning

A solid hand hygiene program and proper environmental cleaning are critical to mitigating VRE. Like MRSA, VRE is spread by contact, but it survives more easily on environmental surfaces, says Steed. Standard cleaning agents will kill VRE, but ICPs should pay close attention to ensure that housekeeping staff members are doing a thorough job cleaning potential hot spots in patient rooms, she says.

"What a lot of hospitals find is that, sometimes, housekeepers don't clean the highest-risk surfaces," says Steed. Cleaning staff members need to focus on bathrooms, sinks, bedrails, and any horizontal and frequently touched surfaces, she adds.

A checklist should be created for housekeeping staff members to help ensure that they have done a thorough job, Steed says. Many facilities use two checklists-one outlines the cleaning protocols when the patient is still in the room, and the other outlines terminal cleaning of the room, says Steed.

Managing antibiotic prescribing, usage

A focus on antibiotic use is also a key issue when it comes to VRE, says Steed. "All hospitals should be focused on antibiotic stewardship," she adds, noting that facilities should be monitoring the use of vancomycin for VRE to ensure it is only being used when appropriate.

At Greenville, officials recently purchased a new computer system that will help them more aggressively monitor antibiotic use at the facility, says Steed. There are several of these systems on the market, and although they are costly, they allow facilities to monitor antibiotic use and compare it to the prevalence of certain organisms at the facility, she adds.

The system will also allow ICPs to see which departments are ordering vancomycin and other antibiotics. If a certain drug is causing a problem, staff members can try to change prescribing behavior, says Steed.

For more information on VRE, visit www.cdc.gov/ncidod/dhqp/ar_lab_vre.html.