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|Title:||Guidelines for the Management of Patients with Vancomycin Resistant Enterococci (VRE) Colonisation / Infection in a Haemodialysis Unit|
|Document ID:||Operational Circular OP 2101/06|
|Date of issue:||Monday, 11 September 2006|
|Status:||NO LONGER APPLICABLE|
|Description:||Sets out the necessary steps to be taken to reduce the transmission of VRE infection within outpatient haemodialysis units. Complements often existing OC's. This is an important infection control guide.|
|Applicable to:||All haemodialysis units|
|Period of effect:||from 11 September 2006|
|Authorised by:||Dr Neale Fong, Director General, DEPARTMENT OF HEALTH, 11-Sep-2006|
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
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
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
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
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
Patients without risk factors for VRE dispersal
Patients with risk factors for VRE dispersal
INFECTION CONTROL MEASURES
Staff must strictly practise standard precautions at all times.
Hand Hygiene and Glove use
Equipment and supplies
Dialysis toilet (toilet not dedicated for use by VRE carrier)
* 0.125% sodium hypochlorite is available in WA in a pre-diluted form.
MICRO ALERT SYSTEM
Dr Neale Fong
This circular last updated: Monday, 11 September 2006 at 11:54am