|Title:||Guidelines for the Management of Residents with Vancomycin-Resistant Enterococci (VRE) in Residential Care Facilities|
|Document ID:||Operational Circular OP 1802/04|
|Date of issue:||Thursday, 27 May 2004|
|Status:||NO LONGER APPLICABLE|
|Description:||This Operational Circular is to provide guidelines based on a risk assessment approac that outline infection control measures for the management of residents colonised/infected with Vancomycin-Resistant Enterococci (VRE) in residential care facilities, including nursing homes, hostels, psychiatric facilities, hospices and rehabilitation facilities.|
|Period of effect:||from 27 May 2004|
|Authorised by:||Dr Shirley Bowen, Director, Communicable Disease Control Directorate, 18-May-2004|
|Print version:||View print version|
Guidelines for the Management of Residents with Vancomycin-Resistant Enterococci (VRE) in Residential Care Facilities
This Operational Circular is designed to advise Department of Health staff on Departmental policies and procedures and may contain advice that is not appropriate in other circumstances.
To provide guidelines based on a risk assessment approach that outline infection control measures for the management of residents colonised/infected with Vancomycin-Resistant Enterococci (VRE) in Residential Care Facilities (RCF), including nursing homes, hostels, psychiatric facilities, hospices and rehabilitation facilities.
Enterococci are bacteria normally found in the bowel and the female genitourinary tract. They are of relatively low virulence but they may cause urinary tract infections and other infections such as wound infection or bacteraemia after contamination of the peritoneal cavity by bowel contents.
When exposed to antibiotics, drug-resistant strains of these bacteria may survive and multiply, resulting in overgrowth of drug-resistant enterococci in the bowel. VRE refers to vancomycin-resistant enterococcal species, Enterococcus faecium and Enterococcus faecalis. VRE is neither more infectious nor more virulent than sensitive enterococci.
The first detection of a VRE infected patient in Australia occurred in Victoria in 1994.1 In the late 1990s colonisation and infection of patients with VRE has spread as in the United States and Europe. Enterococci are known to contaminate hands, equipment2 and the patient care environment.3 Recovery of enterococci from the hands of health care workers indicates hand contact may be an important means of transmission.4
Colonisation is the presence, growth and multiplication of micro-organisms without observable clinical signs and symptoms of infection. For example, enterococci are not a cause of diarrhoea, so when they are isolated from a rectal swab or faecal specimen collected from a patient with diarrhoea, this isolation should be considered as colonisation and not infection5.
Infection refers to invasion of bacteria into tissues with replication of the organism. Infection is characterised by isolation of the organism accompanied by clinical signs of illness such as fever, inflammation (warmth, redness, swelling), pus formation and an elevated white blood cell count.
Patients can be colonised or infected with VRE. In Western Australia, the majority of VRE isolates to date have been from colonised patients.
RISK FACTORS FOR VRE ACQUISITION
Certain patients are at increased risk of VRE infection or colonisation, such as those who:
Most VRE infections have been attributable to the patient's own flora, although cross infection has been clearly documented. VRE are capable of prolonged survival on hands, gloves and environmental surfaces such as door handles, stethoscopes, over-bed tables and call bells.
The most likely routes of transmission from patient to patient are either by direct contact through transient carriage of VRE on the hands of personnel, or indirectly by contaminated environmental surfaces and patient care equipment.
Residents colonised or infected with VRE and who have diarrhoea, faecal incontinence, an ileostomy or colostomy, open wounds, or in whom basic personal hygienic practices maybe compromised by cognitive or functional impairment are more likely to contaminate their own environment. Health care workers providing direct care to these residents may be at increased risk of transient acquisition of VRE if Standard and Additional Precautions (where indicated) are not adhered to.
ADMISSION OF RESIDENTS WITH VRE TO RCFs
Admission to RCFs should not be denied on the basis of VRE status alone. Available evidence suggests that there is little risk to residents in these facilities from other residents colonised/infected with VRE.6-8
Before transfer of a resident to a RCF there should be full communication between the transferring and receiving personnel. The transfer documents accompanying the resident should clearly state details relating to the person's VRE colonisation/infection history, level of hygiene and faecal continence.
Standard Precautions apply at all times.9 However, each VRE positive resident should be individually assessed on admission for risk factors that increase dissemination and/or transmission of VRE. Additional Contact Precautions (Appendix) may be indicated for a resident with diarrhoea, faecal incontinence and in whom basic hygiene practices are compromised.
Some residents may require fewer precautions than others depending on identified risk factors. Additional Precautions can be modified if the resident's symptoms or medical condition is stable.
All staff should be educated about infection control and VRE prior to the admission of the resident, wherever possible.
There is no role for routine VRE screening of residents prior to admission/re-admission. However, in certain at risk populations a screening program may be appropriate e.g. residents receiving renal dialysis. This screening will usually be performed by the acute health care facility where the resident is receiving treatment.
Surveillance cultures of rectal swabs and wounds for VRE may be appropriate if an outbreak of infection is suspected. Otherwise, surveillance cultures are unlikely to be cost effective and are not recommended.
Every effort should be made to encourage prudent use of antimicrobials. Vancomycin should only be prescribed in consultation with a Clinical Microbiologist.
ADDITIONAL CONTACT PRECAUTIONS
*Only required if resident has diarrhoea, faecal incontinence and in whom basic hygiene practices are compromised.
Department of Human Services. (1999). Guidelines for the management of patients with Vancomycin-Resistant Enterococci (VRE) colonisation/infection. Victoria: Public Health Division, Department of Human Services, Government of Victoria.
Department of Human Services. (1999). Part 3: Guidelines for the management of patients in long-term care facilities (LTCF) and rehabilitation units. Victoria: Public Health Division, Department of Human Services, Government of Victoria.
Health Canada. (1997). Infection control guidelines. Preventing the spread of Vancomycin-Resistant Enterococci (VRE) in Canada. Canada: Author.
MMWR. (1995). Recommendations for preventing the spread of vancomycin resistance: Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). Washington: Author.
Steele, L. (2000). Limiting the spread of VRE: An educational program for long term care. Washington: Association for Professionals in infection Control and Epidemiology, Inc.
Dr Shirley Bowen
BIBLIOGRAPHY / REFERENCES:
This circular last updated: Thursday, 27 May 2004 at 12:00am