|Title:||Guidelines for the Management of Patients with Vancomycin-Resistant Enterococci (VRE) Colonisation/Infection in Acute Care Facilities|
|Document ID:||Operational Circular OP 1801/04|
|Date of issue:||Thursday, 27 May 2004|
|Status:||NO LONGER APPLICABLE|
|Description:||This Operational Circular is to provide information in the absence of adequate infection control measures. The introduction of Vancomycin-Resistant Enterococci (VRE) strains into an acute care facility can result in spread to other patients and sometimes cause infection. Evidence to date suggests there is much less chance for VRE strains to spread in long term care facilities and there should be less concern about the transfer of patients carrying VRE from acute care facilities to long term care facilities for convalescent rehabilitation or long term care.|
|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 Patients with Vancomycin-Resistant Enterococci (VRE) Colonisation/Infection in Acute 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.
In the absence of adequate infection control measures, the introduction of Vancomycin-Resistant Enterococci (VRE) strains into an Acute Care Facility can result in spread to other patients and sometimes cause infection. Evidence to date suggests there is much less chance for VRE strains to spread in Long-Term Care Facilities (LTCF) and to cause disease. This means that there should be less concern about the transfer of patients carrying VRE from Acute Care Facilities to LTCFs for convalescent, rehabilitation or long-term care.
Enterococci are bacteria normally found in the bowel and the female genito-urinary 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 the 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 1990's 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 enivronment.3 Recovery of enterococci from the hands of health care workers indicates hand contact may be an important means of transmission.4
The emergence of VRE poses problems:
Colonisation is the presence, growth and multiplication of micro-organisms without observable clinical signs or 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 infection.
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, 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 who are colonised are more likely to suffer infections such as bacteraemia with VRE:
Certain patients are at increased risk of acquisition and colonisation with VRE:
Certain colonised patients are more likely to contaminate the environment and staff hands with VRE:
ROUTES OF TRANSMISSION
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 via contaminated environmental surfaces and patient care equipment.
RESERVOIRS OF VRE
Enterococci are part of the normal flora of the gastro-intestinal tract and the female genito-urinary tract. Most infections with these micro-organisms are attributable to the patient's own flora. VRE are capable of prolonged survival on hands, gloves and environmental surfaces such as door handles, stethoscopes, over-bed tables, call bells and toilet areas.
Additional Transmission-Based Precautions are designed for patients with documented or suspected infection with highly transmissible or epidemiologically important pathogens, for whom additional precautions beyond Standard Precautions are needed to interrupt transmission.4
In the context of VRE colonisation/infection, Additional Contact Precautions are required. Contact Precautions are designed to reduce the risk of transmission by direct contact with the patient or by indirect contact with environmental surfaces or patient care items in the patient's environment. Contact Precautions involve the routine use of personal protective clothing and the appropriate decontamination of patient care equipment to reduce transmission of VRE.
The Infection Control Team shall be informed of all VRE cases, carriers and contacts and Additional Contact Precautions implemented (Appendix).
MANAGEMENT OF VRE PATIENTS
All facilities shall have policies and procedures for the prevention of spread and management of VRE in addition to the policy for Standard Precautions, which must be strictly complied with by all hospital personnel. Policies should include microbiological surveillance, notification, management of colonised and infected patients, waste management, cleaning and disinfection. There should be protocols for the use of antibiotics to reduce the use of vancomycin and broad-spectrum agents including ceftriaxone, timentin and metronidazole.
Appropriate staff education on VRE, infection control and antibiotic use is required.
In the case of isolation of VRE from a cluster of patients an Outbreak Management Group may be necessary and this may include a wide variety of personnel as specified in an Outbreak Management Plan including, for example, Medical, Nursing and Administrative Executives, the Infection Control Team, Infectious Disease Physicians, Specialists caring for infected or colonised patients, nurse managers, bed managers, human resource management, patient support service managers, pharmacists, information management, medical records personnel, staff development/education personnel and media relations. It will be necessary to notify Public Health as VRE is a notifiable disease, Infection Control personnel at other institutions and Health Bureaucrats. In the case of a developing outbreak, notification of patient contacts, relatives and general practitioners should be considered. The Outbreak Management Group will determine patient placement and movement, screening and clearance of colonised/infected patients and contacts based on the outbreak situation.
All facilities should consider an appropriate screening program for VRE. This may include testing of all significant enterococcal isolates for vancomyin sensitivity, use of media selective for VRE in examination of all faecal specimens from in-patients submitted for culture and targeted surveillance by collection of faeces, rectal or perianal swabs from high risk areas such as Haematology/Oncology, ICU, transplant and renal dialysis patients.
Specimens should be obtained from room mates of colonised patients or those in close proximity or sharing toilet facilities at the discretion of the Infection Control Team. Contacts who are being screened may be managed using Standard Precautions while awaiting results. However, the precaution system utilised will be assessed by the Infection Control Team. All isolates of VRE must be sent to the Gram Positive Bacteria Typing and Research Unit at Royal Perth Hospital. The Infection Control Team should determine when environmental swabbing is required, usually in the setting of an outbreak.
Notification of Key Personnel
When VRE is isolated from a patient the following personnel should be notified immediately:
When infected or colonised patients are identified, infection control personnel in conjunction with management, need to review admission to the ward and patient transfers from ward to other wards or units with the aim of preventing transmission of VRE.
Micro Alert System
Patients who are carriers of VRE will have a micro alert V attached to their medical record.
In a hospital outbreak, patients who have been identified as contacts of a VRE carrier will have a micro alert F attached to their medical record.
Patients who have been given a micro alert will be provided with information about VRE and the alert system.
Carriage of VRE can be prolonged and absence of VRE cannot be proven. V alerts will therefore remain in place. F alerts are for use in a hospital outbreak and criteria for clearance should be determined by the Infection Control team of the hospital, pending determination of clearance requirements by the Multi-Resistance Organism (MRO) Sub-Committee.
ADDITIONAL CONTACT PRECAUTIONS
The patient shall be cared for in a single room with dedicated toilet facilities.
Several patients who are VRE cases, carriers or contacts may be cohorted in two or four bedded rooms with dedicated toilet facilities if suitable single rooms are not available.
Patients who have risk factors for dispersal e.g. diarrhoea, faecal incontinence, stomas, urinary catheters, colonised or infected wounds should be confined to the room. Patients without risk factors can leave the room as long as they do not have patient contact.
Staff having contact with the patient or surfaces and equipment around the patient shall wear non-sterile disposable gloves. Hands shall be decontaminated after removal of gloves with an antiseptic handwash5 or alcohol based hand gel/rub.6
Patients shall be instructed on how to use alcohol gel hand gel/rub and given a container dedicated for their use only. They should use this after using the toilet.
Visitors shall be instructed to use the alcohol hand gel/rub on leaving the room.
All staff must strictly adhere to hand hygiene.
Personal Protective Equipment (PPE)
Staff having patient contact shall wear gloves and a long sleeve, impermeable disposable gown.
Gowns should be worn once only and disposed of in general waste.
Before leaving the room, gowns and gloves must be removed and hands washed with antiseptic handwash or alcohol gel/rub applied.
Masks as per Standard Precautions.
Equipment in the room shall be kept to a minimum.
Avoid excess stocks of gloves, kidney dishes etc. in the room.
Non-critical equipment should be dedicated to the room and decontaminated at least daily:
Disposable tourniquets should be used and left in the room.
Linen and Laundering
As per Standard Precautions and in accordance with AS/NZS 4146.7
Change bed linen daily.
Bag linen in the room.
As per Standard Precautions.
Horizontal surfaces and equipment shall be cleaned with detergent and water and disinfected daily with 0.1% (1,000ppm) to 0.125% (1,250ppm) sodium hypochlorite solution8 (Hypochlorite is corrosive to metals and advice should be sought from Infection Control Team if metal equipment is involved).
Toilet areas should be cleaned and disinfected as above preferably after use but at least once daily.
Dedicated cleaning items eg. mop, bucket should be used.
On discharge of the patient, the room and equipment shall be cleaned and disinfected and soft furnishings changed. Inform Infection Control Team who will advise on environmental swabbing requirements.
Crockery and Cutlery
Crockery should be processed using routine hot water dishwashing.
Nursing should be preferably 1:1 with a nurse dedicated to the patient. If this is not possible the minimum number of staff should have contact with the patient.
Agency staff should not look after these patients if possible.
Patients with VRE should be seen last on ward rounds and put last on theatre or procedure lists.
Patients Visiting Other Departments
Infection Control advice should be sought if the patient is to visit another department.
The department receiving the patient shall be informed of the patient's VRE status. Surfaces in contact with the patient and their clothing should be decontaminated with an alcohol wipe.
Dr Shirley Bowen
BIBLIOGRAPHY / REFERENCES:
This circular last updated: Thursday, 27 May 2004 at 12:00am