Vancomycin-Resistant Enterococcus

Vancomycin-resistant enterococcus (VRE) is a mutation of a very common bacterium that is spread easily from person to person by direct contact. Facilities in more than 40 states have reported VRE, with rates as high as 14% in oncology units of large teaching facilities.

Patients most at risk for VRE include immunosuppressed patients and those with severe underlying disease; patients with a history of taking vancomycin, third-generation cephalosporins, or antibiotics targeted at anaerobic bacteria (such as Clostridium difficile); patients with indwelling urinary or central venous catheters; elderly patients, especially those with prolonged or repeated hospital admissions; patients with malignancies or chronic renal failure; patients undergoing cardiothoracic or intra-abdominal surgery or organ transplants; patients with wounds with an opening to the pelvic or intra-abdominal area, including surgical wounds, burns, and pressure ulcers; patients with enterococcal bacteremia, often associated with endocarditis; and patients exposed to contaminated equipment or to a VRE-positive patient.

Causes

VRE enters a health care facility by way of an infected or colonized patient or colonized health care worker. VRE is spread through direct contact betWeen the patient and caregiver or patient-to-patient. It can also be spread through patient contact with contaminat­ed surfaces, such as an over-bed table. The organism is able to live for weeks on surfaces and has been detected on patients' gowns, bed linens, and handrails.

Symptoms and Signs

There are no specific signs and symptoms of VRE. The causative agent may be found incidentally when culture results disclose the organism.

Diagnostic tests

Someone with no signs or symptoms of infection is considered colonized if VRE can be isolated from a stool sample or rectal swab. If colonized, a patient is more than 10 times more likely to become infected with VRE, such as through a breach in the immune system.

Treatment

There is no specific treatment at this time for eradicating VRE. Recently, the Centers for Disease Control and Prevention and the Hospital Infection Control Practices Advisory Committee proposed a two-level system of precautions to simplify isolation. The first level calls for standard precautions, which incorporate standard blood and body fluid precautions and body substance isolation precautions to be used for all patient care. The second level calls for transmission-based precautions, implemented when a particular infection is suspected.

To prevent the spread of VRE, some facilities perform weekly surveillance cultures on at-risk patients in intensive care units or oncology units and those who were transferred from long-term care facilities. Any colonized patient is then placed in contact isolation until cultures are negative or the patient is discharged. Colonization can last indefinitely, and no protocol is established for the length of time a patient should remain in isolation.

Because no single antibiotic currently available can eradicate VRE, the doctor may opt not to treat an infection at all in some cases. Instead, the doctor may stop all antibiotics and simply wait for normal bacteria to repopulate and replace the VRE strain. Combinations of various drugs may also be used, depending on the source of the infection.

Prevention

• Wash your hands.
• People with VRE must use proper toilet hygiene. Ample paper should be used for cleansing and good handwashing afterwards is essential.
• Equipment such as thermometers, blood pressure cuffs and articles for personal use must be left in the home and should not be shared with other people.

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