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Canada Communicable Disease Report
- Supplement INFECTION CONTROL GUIDELINESPreventing the Spread of Vancomycin-Resistant Enterococci (VRE) in CanadaGuidelines for Preventing the Spread of VRE (adapted from HICPAC) Situations in which the use of vancomycin is appropriate or acceptable
Situations in which the use of vancomycin should be discouraged
Information about VRE and other antibiotic- resistant organisms and their potential impact Information regarding the emergence of VRE as a significant nosocomial pathogen in Europe and the United States should be provided to all hospital staff. This may be done in the context of education about other antibiotic-resistant organisms. Special emphasis should be placed on providing continuing education programs to the medical, nursing, pharmacy, and administrative staff. Information about the epidemiology of VRE, risk to patients, and VRE's impact on antimicrobial prescribing practices and on hospital and financial resources should be emphasized. Information about the influence of antimicrobial usage on the emergence of VRE and other antibiotic-resistant organisms Many health care facilities throughout the United States and Canada are facing the increasing emergence of antibiotic-resistant organisms (AROs). The emergence of VRE is but one example of many AROs that are a problem in our population. There are several reasons for the emergence of these AROs(72), but paramount has been the selective pressure of intense antimicrobial use, much of it excessive and inappropriate, over the past decade or two. C. Enhancing the Detection and Reporting of VRE in the Microbiology Laboratory The ability of the microbiology laboratory to accurately identify Enterococcus species and detect vancomycin resistance is an integral component in recognizing the emergence of VRE colonization and infection in health care facilities. Cooperation and communication between the laboratory and those responsible for infection control is equally important (see Figure 1 for information on response to a report of VRE).
A system for presumptive identification of enterococci on primary isolation media is required in the microbiology laboratory. For laboratories not familiar with identifying VRE, additional tests for motility and pigment production may be required to distinguish E. gallinarum and E. casseliflavus from E. faecium and E. faecalis. For those laboratories not familiar with these methods or if financial resources do not permit such identification, a mechanism should be in place for the prompt referral of organisms to provide an appropriate level of identification with a rapid turnaround time. Susceptibility testing Routine testing Confirmatory testing Susceptible - MIC <= 4 µg/mL Intermediate - MIC 8-16 µg/mL Resistant - MIC >= 32 µg/mL Immediate infection control (IC) notification During performance of confirmatory susceptibility tests, IC and appropriate patient care personnel should be notified regarding the presumptive identification of VRE. The infection control practitioner should assess whether isolation is required until species identification and vancomycin resistance are confirmed. This preliminary report should be followed by the (final) result of the confirmatory test. Routine surveillance procedures for detecting VRE where VRE has not been previously detected Antimicrobial susceptibility survey of clinical isolates Culture survey of stools or rectal swabs Screening procedures for detecting VRE when a first isolate of VRE has been detected The finding of a first isolate of VRE should prompt fecal screening (stool survey or rectal swabs) for the identification of other colonized patients in an effort to establish the optimal and timely application of isolation precautions and control measures. It must be emphasized that the use of screening surveys are merely a tool to elucidate the epidemiology of VRE within a given ward, patient population or facility and are not considered a mandatory component of an infection control program. The optimal timing and extent of screening procedures remains unknown. Currently, there are no data available on cost-effectiveness. Consideration of patient populations, risk factors for acquisition of VRE, and the costs and resources available within the facility must be taken into consideration when implementing screening procedures. As a minimum, stools or perirectal swabs may be obtained from roommates and other close contacts of patients found to be newly colonized with VRE. Additional screening of patients on the same ward or unit may also be considered. In outbreak situations, it may be necessary to screen patients outside of the ward to avoid missing colonized patients. The utility of massive screening efforts directed at all possible contacts, entire health care facility patient populations and staff is unknown at this time and such efforts are not currently recommended. D. Infection Control Precautions to Prevent the Transmission of VRE in the Health Care Setting The infection control practitioner or other responsible individual must be aware that there are several different Enterococcus species. However, E. faecalis and E. faecium represent the species most often associated with disease and nosocomial transmission. Laboratories unfamiliar with speciation and susceptibility testing of enterococci may not correctly differentiate E. faecalis and E. faecium from other VRE that do not warrant the same infection control precautions. Practitioners must confirm that their laboratory uses methods that will reliably identify these other species of Enterococcus (e.g., gallinarum, casseliflavus) that are intrinsically resistant to low levels of vancomycin. Enterococcus gallinarum (E. gallinarum) and E. casseliflavus are less likely to be pathogens, their resistance has never been observed to transfer to other bacteria, and they do not require isolation, as do other VRE. If the laboratory identifies a VRE, the practitioner must confirm that it has been identified to species level, by a reference laboratory if necessary. VRE isolates should be confirmed as such by laboratories experienced in enterococci identification and genotyping. The presence of any isolate of VRE other than E. gallinarum and E. casseliflavus (VRE positive) from a single patient should receive prompt attention by infection control or other responsible personnel, and the ensuing guidelines should be initiated (Figure 1). [Previous]
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Last Updated: 2002-11-08 | ![]() |