Vancomycin-Resistant Enterococcus Infection (VRE): Causes, Symptoms and Treatments

Definition:

Vancomycin-resistant enterococcus (VRE) is a mutation of a very common bacterium that spreads by direct person-to­person contact. Facilities in more than 40 states have reported VRE infections, with rates as high as 14% in oncology units of large teaching facilities. Patients most at risk for VRE infection include:

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

Causes of Vancomycin-Resistant Enterococcus Infection:

VRE enters health care facilities through an infected or colonized patient or a colonized health care worker. The microbe is spread through direct contact between the patient and caregiver or between patients. It can also be spread through patient contact with contaminated surfaces such as an overbed table. VRE is capable of living on surfaces for weeks, and has been detected on patient gowns, bed linens, and handrails.

Signs and symptoms of Vancomycin-Resistant Enterococcus Infection:

No specific signs and symptoms are related to VRE infection. The causative microbe may be found incidentally when culture results show the organism.

Diagnosis of Vancomycin-Resistant Enterococcus Infection:

Asymptomatic individuals are considered colonized if VRE can be isolated from stool or a rectal swab. Once colonized, a patient is more than 10 times as likely to become infected with VRE-for example, through a breach in the immune system.

Treatment of Vancomycin-Resistant Enterococcus Infection:

No specific treatment exists for eradicating VRE. The Centers for Disease Control and Prevention and the Hospital Infection Control Practices Advisory Committee have proposed a two-level system of precautions to simplify isolation. The first level calls for standard precautions, incorporating features of universal 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 on patients who have been transferred from a long­term-care facility. Any colonized patient is then in contact isolation until culture­negative or until discharged. Colonization can last indefinitely, and no protocol has been established for the length of time a patient should remain in isolation.

Because no single antibiotic currently available can eradicate VRE, the doctor may, in some cases, opt not to treat an infection at all. Instead, he 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.

Special considerations of Vancomycin-Resistant Enterococcus Infection:

* Hand washing before and after care of the patient is crucial.
* Use an antiseptic soap such as chlorhexidine; bacteria have been cultured from workers' hands after they've washed with milder soap.
* Use contact isolation precautions when in contact with the patient. Provide a private room and dedicated equipment for the patient. Disinfect the environment.
* Change gloves when contaminated or when moving from a dirty area of the body to a clean one.
* Do not touch potentially contaminated surfaces, such as a bed or bed stand, after removing gown and gloves.
* Be particularly prudent in caring for a patient with an ileostomy, colostomy, or draining wound that is not contained by a dressing.
* Instruct family and friends to wear protective garb when they visit the patient, and teach them how to dispose of it.
* Provide teaching and emotional support to the patient and family members.
* Consider grouping (cohorting) infected patients together and having the same nursing staff care for them.
* Do not lay equipment used on the patient on the bed or the bed stand. Wipe equipment with appropriate disinfectant before leaving the room.
* Ensure judicious and careful use of antibiotics. Encourage doctors to limit the use of antibiotics.
* Instruct patients to take antibiotics for the full prescription period, even if they begin to feel better.