Quality Monitoring Program Resources

Infection Control: Vancomycin Resistant Enterococcus

Overview

Enterococci are naturally found in the gastro-intestinal (GI) tract and in the female genital tract.[1] Sources of enterococci include those naturally occurring in the body, direct contact with a carrier, or indirect contact with contaminated objects such as equipment or environmental surfaces. Treatment for enterococcal infections requires antibiotics.[2] Enterococci have developed antibiotic resistance over time, and strains resistant to vancomycin (VRE) have emerged. The number of VRE infections increased from 0.3% in 1989 to 7.9% in 1994, and VRE is now endemic in many US healthcare facilities.[2] In Texas, during 1999, VRE accounted for 4% of all Enterococcus isolates reported to the Texas Department of State Health Services. While VRE is neither more infectious nor more virulent than non-resistant strains, they survive for long periods on hands, gloves, and environmental surfaces.[1,3]

VRE colonization is common in nursing homes; 10% of nursing home residents may become VRE carriers.[4,5] VRE infections are difficult to treat because VRE is not only resistant to vancomycin but is also resistant to antibiotics such as erythromycin, tetracycline, rifampin, fluoroquinolones, and beta-lactams (the chemical class that includes penicillins and cephalosporins), particularly the beta-lactam ampicillin which is the drug of choice for severe enterococcal infections in susceptible strains.[6] The antibiotic treatment options for VRE are extremely limited, and attempts to decolonize the stool of carriers are not productive. VRE is also implicated in emerging antibiotic resistance because vancomycin resistance genes can transfer from VRE to other gram-positive organisms causing bacteria such as Staphylococcus aureus to develop vancomycin resistance (VRSA).[2] Therefore, halting the spread of antibiotic resistance is an infection control priority for all healthcare facilities. For more information on VRE and antibiotic resistance, see the Centers for Disease Control Fact Sheet on VRE Infection and CDC information on VRSA infection.

Outbreak Prevention and Control

VRE infections are most likely when the following events occur: [1,2,5,6]

VRE is introduced into the facility. Residents admitted from an acute care or LTC facility are often the initial source of newly introduced VRE strains.
LTC staff transfer VRE to other residents by direct or indirect contact during routine caregiving.
Residents have specific risk factors that increase the likelihood of VRE colonization or infection.

Therefore, preventing VRE infections involves the following steps:[9]

Knowing the VRE status of newly admitted residents at the time of admission: Use hospital or current LTC records to identify VRE carriers during their preceding acute care or LTC stay before admission.
Practicing proper hand hygiene: VRE is primarily transmitted by hand-to-hand contact during routine caregiving. Strict adherence to hand hygiene polices are a must. Always wash your hands before and after resident contact - no exceptions.
Reducing opportunities for transmission: Do not place residents who carry VRE in rooms with residents who have risk factors for colonization or infection. Dedicate equipment (e.g., stethoscope, thermometers, etc.) specifically for use in caring for persons that carry VRE for as long as they are affected.
Following contact precautions: Wear gloves when handling infectious material, and wear a gown if soiling is likely.

Risk Factors for VRE Infection

Any skin break such as a wound, sore or the site of an invasive device is a potential portal for VRE entry and subsequent infection. Reduce cross-infection by recognizing the following risk factors that increase a resident's risk of VRE colonization and infection:[1,4,6,8,9,10,11]

Recent hospitalization;
Recent treatment with antibiotics - especially with vancomycin, extended-spectrum penicillins or third-generation cephalosporins (see the CDC recommendations for appropriate use of vanocomycin and Antibiotic Use, Selection and Resistance framework);
Known colonization with other antimicrobial resistant bacterial strains such as MRSA or VRSA;
Severe acute or chronic disease or immunosuppression;
Abdominal or thoracic surgery;
Indwelling urinary or central venous catheter;
Presence of a pressure sore; and
Presence of a feeding tube.

Care Planning

Care planning for VRE carriers should focus on preventing transmission within the facility. The table below shows which infection control measures are important for preventing MRSA transmission.

Infection Control Technique	Relevance	Comments and Links
Barriers to entry		The presence of VRE colonization or infection is not a reason to deny admission to a resident. Follow the isolation precautions below.
Screening
Immunization / Vaccination
Chemoprophylaxis
Treatment		To treat VRE infection consult with an infectious disease specialist, if necessary. For more information on symptomatic treatment, see the Commonwealth of Massachusetts VRE Infection Control Guidelines
Eradication of carrier state		Treatment for asymptomatic VRE colonization is rarely warranted and can prolong VRE carriage.[6,11] Most persons colonized with VRE will clear the bacteria without treatment.
Handwashing		VRE is transmitted from person to person - typically from the contaminated hands of caregivers to residents. Some experts recommend using antibacterial soaps or alcohol-based rubs rather than detergent soaps for hand hygiene when caring for persons with known VRE infections.[1,12,13] Always wash your hands before and after resident contact to reduce transmission. For more information on VRE prevention and control, see: CDC Information on VRE Infections Commonwealth of Massachusetts VRE Infection Control Guidelines For general information on handwashing, see: CDC hand hygiene information CDC hand hygiene guidelines fact sheet
Universal precautions
Wearing gloves		Wear gloves when caring for residents colonized or infected with VRE - even if only contact with a contaminated item or surface is possible.[1] Always wash your hands before putting gloves on and after taking them off. Never reuse gloves, not even for the same resident. For more information on glove use see CDC Information on VRE Infections.
Face and eye protection		Wear masks and eye protection if blood or body fluid splashes are likely. For more information about face and eye protection see CDC Information on VRE Infections.
Aprons or gowns		Gowns are indicated when a resident has diarrhea or a draining wound or when body fluid splashes are possible. Wear gowns when changing linens. For more information about apron and gown use see CDC Information on VRE Infections.
Resident isolation		Place residents with symptomatic VRE infection in a private room.[1] If one is not available, place the resident in a semi-private room with another resident who has symptomatic VRE infection but no other infection. Do not place persons who carry VRE in the same room as residents who have invasive devices, open wounds, or who are immunocompromised.[13] The duration of VRE colonization can be lengthy. Isolate residents until at least two cultures taken from the rectum on separate days are negative for VRE.[12] All newly admitted residents who carry VRE should be identified on admission based on their current medical and laboratory record data. Assign residents with VRE infection to a:[1,12] Private room, if possible, or Semi-private room with another resident who carries VRE and does not have risk factors for VRE infection. For more information see: CDC Information on VRE Infections Commonwealth of Massachusetts VRE Infection Control Guidelines Speak candidly with persons who visit affected residents. Require that such visitors adhere to facility infection control practices (e.g., handwashing, gloves, and gowns).
Employee health		VRE carriage on the hands of nursing home staff is common. All staff must wash their hands before and after every resident contact - no exceptions.[1,12] Employees with cuts, sores or abrasions are at increased risk of VRE colonization and infection. Provide staff specific instructions on how to keep such injuries clean and protected.
Employee education		Employee education should address at least the following facts: Staff can carry VRE. VRE will as likely be spread by staff as by residents. Hand hygiene for all staff is essential to halt VRE spread. While other infection control steps are also important, they do not substitute for proper hand hygiene.
Cleaning / Disinfection		Thoroughly clean the room daily or more often if needed. Clean and disinfect residents' care items, bedside equipment, and frequently touched surfaces daily and as needed when visibly soiled.[14] Bag soiled linen and laundry in the residents room to prevent transmission of VRE to other residents. VRE is capable of prolonged survival on hands and environmental surfaces.[1] Conduct daily cleaning. Cleaning supplies for residents with VRE should be dedicated to their room. Furniture should be plastic, vinyl, or leather coated and be capable of being wiped down with disinfectant. Bath tubs, whirlpools, and hydrotherapy should be disinfected after each use. Handle soiled linens the minimum possible.[1] Use gloves and gowns when changing linens AND bag soiled linen in the resident's room. When possible, dedicate non-critical items such as a stethoscope and other examination tools to a particular resident for the duration of VRE illness. Otherwise, thoroughly disinfect reusable equipment before removing it from the room.

Practical Guide to Quality Improvement

This section is specific for VRE. For general infection control quality improvement steps (including infection surveillance and tools for tracking trends), refer to the Key Components for a Successful Infection Control Program. Effective infection control is essential for preventing transmission and outbreaks of VRE infection.

Organizational Strategy for Treatment and Outbreak Control[1,8,14]]

Use the following outbreak control measures when dealing with VRE:

Review all available microbiologic results as part of the surveillance routine in order to identify VRE carriers.
1. Determine the baseline number of VRE carriers (both colonized and infected persons).
2. Use the number of known VRE infections to calculate the VRE infection rate.
Use medical records to identify newly admitted residents with VRE colonization or infection.
1. Do not conduct routine culture for residents on admission to determine VRE status; use only readily available information (e.g., recent culture results).
2. Review the medical record of each resident admitted from another LTC facility or hospital to determine VRE status.
3. Determine whether the resident is colonized or infected:
  1. Colonized residents have a positive VRE culture without clinical symptoms of infection.
  2. Infected residents have a positive VRE culture with clinical symptoms of infection at the culture site.
4. Base your decision to use isolation precautions on the likelihood of VRE transmission:
  1. Does the resident have an open wound with poorly controlled drainage?
  2. Does the resident have the cognitive ability to understand and follow instructions to avoid VRE transmission during activities that involve person to person contact?
  3. Is there fecal incontinence?
5. Do not assume that a resident known to have had VRE colonization or infection is free of VRE until three separate cultures of the affected site are shown to be negative for VRE.
Keep a record of all VRE carriers, including:
1. Known body sites of colonization or infection.
2. Date(s) of positive culture.
3. Room location or number.
4. Documentation concerning the treatment of VRE infection.
5. Contacts with staff and fellow residents.
Isolate the resident who has symptomatic infection and a high risk of VRE transmission.
1. Place the resident in a private room.
2. If a private room is unavailable, the resident may share a semi-private room with another resident known to carry VRE who does not have risk factors for developing VRE infection.
3. Thoroughly wash your hands before and after caring for the resident.
4. Institute contact precautions (e.g., use gloves, gowns, and face protection)
5. Provide VRE treatment as warranted. Contact an infectious disease specialist, if necessary.
6. Clean and disinfect the resident's room daily to control VRE contamination. Dedicate cleaning supplies to the resident's room. Clean:
  1. Bedside equipment.
  2. Frequently touched surfaces.
  3. Bathrooms and toilet facilities.
  4. Any other potentially contaminated surfaces (e.g., handrails, telephones, or doorknobs).
7. Disinfect and clean bathtubs, whirlpools, and hydrotherapy tubs after each use.
8. Only allow plastic, vinyl, or leather-coated furniture that can be wiped down with disinfectant in the resident's room.
9. Allow minimal handling of soiled linens.
10. Wear gloves and gowns when changing linen.
11. Bag soiled linens in the resident's room.
Advise visitors of the outbreak and limit the exposure of visitors to affected residents. Require visitors seeing affected residents to adhere to facility infection control practices (e.g., handwashing, gloves, and gowns).
Allow residents colonized with VRE to live as normally as possible. Residents having neither fecal incontinence nor a draining wound may share a room with non-VRE carriers, provided that the unaffected resident does not have exceptional risk factors for VRE infection and is not an MRSA or VRSA carrier.

Additional Resources (including online resources)

The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit, and non-profit sources. Some of these sources may have financial ties to industry. DADS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.

Online

Clinical Corner: Infection Control. Issues related to admission and pre-admission screening of individuals with VRE or MRSA.

Centers for Disease Control and Prevention recommendations for preventing the spread of vancomycin resistance. Recommendations of the hospital infection control practices advisory committee (HICPAC).

Department of Aging and Disability Services, Government of Victoria, Australia. Guidelines for the management of patients with vancomycin-resistant enterococci (VRE) colonisation/infection.

Commonwealth of Massachusetts vancomycin-resistant enterococci (VRE) infection control guidelines for long-term care facilities.

Health Canada infection control guidelines: preventing the spread of vancomycin-resistant enterococci (VRE) in Canada.

State of Minnesota guidelines for the management of antimicrobial resistant microorganisms in long-term care facilities.

State of North Carolina guidelines for control of antibiotic resistant organisms.

In Print

Crossley K. SHEA Position Paper: Vancomycin-resistant Enterococci in long-term care facilities. Infection Control and Hospital Epidemiology 1998;19(7):521-25.

Murray BE. Vancomycin-resistant Enterococcal infections. New England Journal of Medicine 2000;324(10):710-21.

Bibliography

[1] Commonwealth of Massachusetts vancomycin-resistant enterococci infection control guidelines for long-term care facilities. Accessed May 25, 2003.

[2] Morbidity and Mortality Weekly Report 1995:44(RR12);1-13.

[3] Department of Aging and Disability Services, Government of Victoria, Australia. Guidelines for the management of patients with vancomycin-resistant enterococci (VRE) colonization/infection. Accessed 3/17/2003.

[4] Tokars JI, Satake S, Rimland D et al. The prevalence of colonization with vancomycin-resistant Enterococcus at a Veteran's Affairs institution. Infection Control and Hospital Epidemiology 1999;20(3):171-75.

[5] Bonilla HF, Zervos MA, Lyons MJ et al. Colonization with vancomycin-resistant Enterococcus faecium: Comparison of a long-term care unit with an acute-care hospital. Infection Control and Hospital Epidemiology 1997;18(5):333-39.

[6] Murray BE. Vancomycin-resistant Enterococcal infections. New England Journal of Medicine 2000;324(10):710-21.

[7] Tenorio AR, Badri SM, Sahgal NB et al. Effectiveness of gloves on the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clinical Infectious Diseases 2001;32(5):826-29.

[8] Ostrowsky BE, Trick WE, Sohn AH et al. Control of vancomycin-resistant Enterococcus in health care facilities in a region. New England Journal of Medicine 2001;344(19):1427-33.

[9] Elizaga ML, Weinstein RA, Hayden MK. Patients in long-term care facilities: A reservoir for vancomycin-resistant Enterococci. Clinical Infectious Diseases 2002;34(15):441-46.

[10] Trick WE, Weinstein RA, DeMarais PL et al. Colonization of skilled-care facility residents with antimicrobial-resistant pathogens. Journal of the American Geriatrics Society 2001;49(3):270-76.

[11] Brennen C, Wagener MM, Muder RR. Vancomycin-resistant Enterococcus faecium in a long-term care facility. Journal of the American Geriatrics Society 1998;46(2):157-60.

[12] Crossley K. SHEA Position Paper: Vancomycin-resistant Enterococci in long-term care facilities. Infection Control and Hospital Epidemiology 1998;19(7):521-25.

[13] Wade JJ, Desai N, Casewell MW. Hygienic hand disinfection for the removal of epidemic vancomycin-resistant Enterococcus facecium and gentamicin-resistant Enterobacter cloacei. Journal of Hospital Infection. 1991;18:211-218.

[14] American Medical Directors Association. Clinical Corner: Infection Control. Issues related to admission and pre-admission screening of individuals with VRE or MRSA. Accessed 3/12/03.

Evidence Table

Reviewers

Peer Reviewer: James S. Lewis, Pharm.D.
Review Date: May 19, 2004

Dr. Lewis is the Infectious Diseases Pharmacy Specialist & Clinical Assistant Professor at the University Health System & University of Texas Health Sciences Center at San Antonio.

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