Vancomycin-resistant enterococcus
Vancomycin-resistant enterococcus (VRE) is a mutation of a very common bacterium that is spread easily by direct person-to-person 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 or those with severe underlying disease
❑ patients with a history of taking vancomycin, third-generation cephalo-sporins, 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 cancer 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
❑ patients exposed to contaminated equipment or to a VRE-positive patient.
Causes
VRE enters health care facilities through an infected or colonized patient or a colonized health care worker. VRE 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. It’s capable of living for weeks on surfaces. It’s been detected on patient gowns, bed linens, and handrails.
Signs and symptoms
There are no specific signs and symptoms related to VRE. The causative agent may be found incidentally when culture results show the organism.
Diagnosis
Someone with no signs or symptoms of infection is 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
There’s no specific treatment at this time for eradicating VRE. 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 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 to be implemented when a particular infection is suspected.
To prevent the spread of VRE, some facilities perform weekly surveillance cultures on at-risk patients on intensive care or oncology units and on patients who have been transferred from a long-term care facility. A colonized patient is then placed in contact isolation until he’s culture-negative or 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 physician may 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 infection’s source.
Special considerations
❑ Hand washing before and after care of the patient is crucial.
CLINICAL TIP: Good hand washing is the most effective way to prevent VRE from spreading.
❑ Use an antiseptic soap such as chlorhexidine; bacteria have been cultured from worker’s 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’s 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 infected patients together and having the same nursing staff care for them (known as cohorting).
❑ Do not lay equipment used on the patient on the bed or the bed stand; wipe it with appropriate disinfectant before leaving the room.
❑ Ensure judicious and careful use of antibiotics. Encourage physicians to limit the use of antibiotics.
❑ Instruct patients to take antibiotics for the full prescription period, even if they begin to feel better.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
Other Book Chapters Related to Infection
Read excerpts from these other book chapters related to Infection:
Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
More About Causes of Infection
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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