Guidelines for the Management of Patients with Vancomycin Resistant Enterococci (VRE) Colonisation / Infection in a Haemodialysis Unit

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

INTRODUCTION

These guidelines complement related Operational Circulars in other settings, notably OP 1801/04 (management of VRE patients in acute care settings) and OP 1802/04 (management of VRE patients in residential care settings). 

Staff are also reminded of the guidance letter sent by the Chairman of the State Infection Control Advisory Committee to all public and private acute and residential care facilities in June 2002, which stated that “VRE-colonisation, or contact with a VRE-colonised person, is not a bar to inpatient or outpatient treatment at any acute health care facility, or admission to any residential care facility”.

These guidelines identify the minimum standard of practice to prevent transmission of VRE to other patients in the haemodialysis setting, and are based on the United States Centres for Disease Control (CDC) recommendations designed to prevent transmission of blood-borne viruses and pathogenic bacteria. The governing principle is that environmental and skin contamination is likely to be less in short stay settings compared with inpatient hospital settings where strict additional contact precautions are recommended.¹ A risk management approach is essential.

A recent Australian study of environmental and healthcare worker (HCW) contamination with VRE during haemodialysis concluded that, to minimise transmission of VRE, infection control measures for faecally continent carriers of VRE should focus on effective HCW and patient hand hygiene and environmental cleaning, especially of the dialysis chair. ²

BACKGROUND

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 and wound infections or bacteraemia after contamination of the peritoneal cavity by bowel contents. Most infections with these micro-organisms are attributable to the patient’s own flora.  Weakened hosts, who are colonised with VRE, are more likely to suffer infections with VRE (e.g. renal transplant patients, neutropenic Haematology/Oncology patients, critically ill patients and some surgical patients).

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 and since 1996 there have been a steady increase in cases throughout the country.  In the late 1990s colonisation and infection of patients with VRE had spread widely in the United States and Europe.  Enterococci are known to contaminate hands, equipment and the patient care environment. ^2,3 Recovery of enterococci from the hands of health care workers indicates hand contact may be an important means of transmission.^2,3 

RESERVOIRS OF VRE

VRE is found in the faeces of colonised people and can also colonise skin surfaces.  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. ^{3,4 5} 

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 by contaminated environmental surfaces and patient care equipment.

Patients who are infected or colonised with VRE and who have diarrhoea, faecal incontinence, an ileostomy or colostomy, poor personal hygiene, or open and oozing wounds are more likely to contaminate the environment and staff hands.^2,5,6

RISK MANAGEMENT

An individual risk assessment should be performed on each VRE positive dialysis patient to identify any of the risk factors that increase dissemination and/or transmission of VRE, i.e.diarrhoea or faecal incontinence, enterostomies or infected/colonised wounds that cannot be contained by a dressing.^1,5,6

PATIENT PLACEMENT

Patients without risk factors for VRE dispersal

• Standard precautions and CDC¹ recommendations for haemodialysis units apply.
  (Refer to section on Infection Control measures on Page 3.)
• Can be placed in the open dialysis area.
• Place a clean sheet on the dialysis chair.²
• Consider dialysing patient on the last session for the day to optimise cleaning time.
• Cohort several patients with VRE in adjoining bays and allocate the same nurse.

 Patients with risk factors for VRE dispersal

• Additional precautions apply –  (Refer to Appendix 1)
• Preferably place in a single room if available (with or without an ensuite).
• If a single room is not available there should be enhanced attention to patient separation and environmental cleaning,¹ e.g. an end or corner bay; a bay with as few adjacent stations as possible and also in close proximity to a hand basin.
  An individual management plan should be drawn up in consultation with Infection Control personnel and the Renal staff.
• Environmental contamination is especially increased with diarrhoea and faecal incontinence⁶ and these should take priority for a single room or a separated bay, with all options for placement carefully considered.  Consider dedicating one dialysis nurse to care for these patients.
• Consider dialysing patient on the last session for the day to optimise cleaning time.
• In facilities where transmission to patients at increased risk of infection can not be reasonably excluded, temporary transfer to a unit with more appropriate isolation facilities should be considered for patients with transitory risk factors for VRE dispersal.

INFECTION CONTROL MEASURES

Standard precautions

Staff must strictly practise standard precautions at all times.
In a dialysis setting this is the most important means of preventing cross transmission of VRE from carriers who do not have risk factors for dissemination of VRE. ^1,7
The CDC¹ recommendations designed for haemodialysis units are more stringent than Standard Precautions and are incorporated into the infection control measures outlined.

Hand Hygiene and Glove use

• Ensure alcohol +/-chlorhexidine based hand rub and gloves are available at each dialysis bay.^1,2
• Wear gloves for contact with the patient, patient equipment and the immediate bay environment.   Perform hand hygiene after removing gloves and before leaving the bay. ^1,2,4
• Educate staff on strict hand hygiene/glove use.
• Routine hand hygiene by the dialysis patient on presentation and departure should be performed. ^1,2

Equipment and supplies

• Ensure large alcohol wipes are available at every bay for decontamination of equipment.
• Dedicate equipment and items to patient for duration of dialysis, and consider disposable items where possible (e.g blood pressure cuffs and tourniquets)
• The bay should only stock essential supplies and equipment for the session.
  Unused medications or supplies (e.g. syringes) should not be returned to a common clean area or used for other patients.
• Appropriate decontamination of all patient equipment must occur before reuse on another patient i.e.
• Clean with large alcohol wipes or  0.125% sodium hypochlorite solution*
• heat-disinfection e.g a washer-sanitiser
• sterilisation if appropriate.

  Dialysis toilet (toilet not dedicated for use by VRE carrier)

• Close the toilet temporarily following use by a VRE carrier until the cleaners have completed a clean with 0.125% sodium hypochlorite solution (1250ppm).
• If visibly soiled, clean with detergent and warm water prior to hypochlorite use.

Wounds

• All wounds should be covered with a dressing at all times.  

Discharge cleaning

• Remove sheet from dialysis chair and place directly into a linen skip.
• Clean the dialysis chair and the immediate environment within the bay with 0.125% sodium hypochlorite solution (1250ppm)* paying attention to frequently touched areas.  If any area is visibly soiled, clean with detergent and warm water prior to use of hypochlorite.
• Clean the dialysis machine and any metal equipment with detergent and warm water  +/-wipe with large alcohol wipes
• Rinse mop bucket with hot water and detergent and allow to dry.  
  Mop head is to be cleaned as per institution policy prior to reuse.

* 0.125% sodium hypochlorite is available in WA in a pre-diluted form.

STAFF INSTRUCTION

• Conduct staff education about VRE transmission, infection control and cleaning measures.
• Ensure appropriate staff allocation of patients to allow optimal implementation of measures

PATIENT EDUCATION

• Instruct the VRE positive patient on the importance of handwashing after the toilet, and to perform hand hygiene on presentation and departure from dialysis.
• Ask the patient to report any episodes of diarrhoea or faecal incontinence to dialysis nurses.

VISITORS

• Instruct visitors to perform hand hygiene before leaving the dialysis bay.

MICRO ALERT SYSTEM

• Patients who are carriers of VRE will have a micro-alert V attached to their medical record.
• Patients who have been identified as contacts of a VRE carrier in a hospital outbreak will have a micro alert F attached to their medical record.
• Carriage of VRE can be prolonged, and absence of VRE cannot be proven with negative swab results.  Micro alert V alerts will therefore remain in place.

Dr Neale Fong
DIRECTOR GENERAL
DEPARTMENT OF HEALTH