Vancomycin ( Glycopeptide ) Resistant Enterococci Guideline

Publication: 01/03/2010  --
Last review: 26/09/2019  
Next review: 26/09/2022  
Clinical Guideline
CURRENT 
ID: 2014 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Vancomycin (Glycopeptide) Resistant Enterococci

 

Summary of Guideline

This guideline describes the measures that need to be taken by Leeds Teaching
Hospital NHS Trust (LTHT) clinical teams when a patient has suspected or confirmed vancomycin/ glycopeptide resistant enterococcus (VRE/GRE) infection or colonisation.

The terms vancomycin resistant enterococci (VRE) and glycopeptide resistant enterococci (GRE) are used interchangeably.

Patients infected or colonised with VRE should be placed into source isolation.

The topics covered are:

Transmission of VRE
Risk factors for VRE
Symptoms of VRE
Management of VRE
Discharge of patients with VRE
Deaths related to VRE

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Background

Enterococcus spp. are typically commensal organisms, common in the human gastrointestinal tract, but in some circumstances can cause serious infections including bacteremia, particularly among hospitalized patients with underlying
comorbid conditions (Prematunge C et al 2016). Enterococci are well known
antibiotic-resistant opportunistic pathogens commonly recovered
from patients who received multiple courses of antibiotics (Manamenot A 2018).
Enterococci are not very virulent, usually causing colonisation rather than actual symptomatic infection. Most enterococci remain susceptible to glycopeptides, suchasvancomycin or teicoplanin, however the emergence of vancomycin/glycopeptide resistant enterococci is a major concern as therapeutic options can then be very limited.

VRE are difficult to eradicate from the bowel and faecal carriage of VRE can persist for a very long time. Attempts at decolonisation using oral therapy are usually unsuccessful and not recommended (Mondy KE et al 2001). Enterococci are also exceedingly hardy in the environment, and can tolerate a variety of growth conditions. Most enterococcal infections are endogenous (part of the patient’s own flora) but cross infection between hospitalised patients can and does occur.

The use of vancomycin and certain other antibiotics e.g. quinolones (ciprofloxacin) encourage the emergence of VRE therefore prudent use of antibiotics is essential in the prevention of VRE spreading.

The potential transfer of vancomycin resistance genes to other Gram positive bacteria such as Staphylococcus aureus is a major public health concern and another reason for controlling their emergence and spread.

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Diagnosis

In critically ill and immuno-compromised patients, enterococci may become opportunistic pathogens. The symptoms depend on the site of the VRE infection and include the following conditions:

Urinary tract infection
Bacteraemia (including vascular catheter derived)  Endocarditis
Intra-abdominal/pelvic infections
Skin and soft tissue infections
Neo-natal infections
Meningitis (rare)
Lower respiratory tract infection (rare)

VRE are more likely to occur if the patient has certain risk factors.
These include;

  • previous treatment with glycopeptides, cephalosporins or multiple antibiotic therapies
  •  prolonged hospital stay and admission to certain units, such as intensive care, renal, liver or haematology.
  • indwelling devices, such as urinary and intravascular catheters.

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Investigation

Enterococci can be isolated from a range of routine clinical samples including blood cultures, urine, wound swabs, line tips and respiratory samples (this is not an exhaustive list). Susceptibility testing will determine whether the isolate is resistant to glycopeptides. If the isolate is glycopeptide-resistant this will be highlighted on the laboratory report.

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Management of Patients with VRE Infections

Enterococci causing colonisation and infection are transmitted mainly via hands contaminated through contact with colonised or infected patients, via contaminated surfaces or equipment.

Environmental contamination increases when patients have diarrhoea. During outbreaks, VRE has been found on staff uniforms, bed linen, beds, commodes, floors, blood pressure cuffs, stethoscopes, locker tops, chairs and in bathroom environments.

VRE is not usually spread through the air by cough or sneezing.

In Outbreak settings, the use of glycopeptides is often formally restricted (on the advice of Microbiology / Infection Prevention and Control Team).

If a patient is suspected/known to be colonised/infected with VRE the following actions/policies/guidelines must be followed:

  • Source Isolation - patients must be admitted to a single room and remain there for the duration of their admission and subsequent admissions. It is important to separate the patient from other vulnerable patients. Patients with diarrhoea are more likely to transmit VRE (see LTHT Isolation Guideline)
  • Standard Precautions (see LTHT Standard Infection Control Precautions Guideline)
  • Hand Hygiene (see LTHT Hand Hygiene Policy)
  • Isolation cleaning (see LTHT Isolation Guideline)
  • Movement or transfer of patients colonised/infected with VRE should be kept to a minimum, however if deemed essential, the receiving area/ward/ unit/hospital must be informed (see LTHT Safe Placement of Patients with Suspected or Diagnosed Infection Policy).
  • Indwelling devices such as urinary catheters may act as a reservoir for VRE. Each indwelling device in patients colonised/infected with VRE should be reviewed to ascertain if it is still required. If not, they should be removed. If the device itself is colonised/infected with VRE it should be removed to help eradicate the colonisation/infection.Heavily colonised wounds may need debridement and abscesses should be drained as necessary.
  • Antibiotic treatment should be based on antimicrobial susceptibilities

(Refer to LTHT Antimicrobials Guidelines; and discuss with Microbiology as appropriate. However, please remember enterococci are usually colonisers rather than actually causing symptomatic infections - i.e. usually the presence of VRE is NOT in itself an indication for specific antibiotics to treat VRE. 

Screening of patients for VRE/GRE colonisation is not recommended routinely. In certain circumstances, such as during an outbreak of VRE, patient screening may be undertaken following discussion with Consultant Medical Microbiologist / IPCT.

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Discharge of VRE patients

VRE/GRE colonisation/infection by itself does not require the patient to remain in hospital. If the patient is to be discharged home, the patient’s relatives/significant others need to be reassured that VRE carriers do not need any special treatment once they are at home. There is no risk to healthy individuals outside the hospital. Patients should be advised to inform hospital staff that they are VRE positive if they are readmitted.

If the patient is to be discharged to another healthcare setting, nursing or residential home, staff there should be informed in advance.

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Death

No additional precautions other than Standard Infection Prevention and Control Precautions are required.

Audit and Monitoring Compliance

Method

Responsibility

Body/Individual Outcome Reported to for Action

Documented evidence of
isolation risk assessment on admission (nursing
documentation)

Sisters and Matrons

Clinical Service Unit Infection Prevention and Control group

Documented evidence of
daily re-assessment and
re-evaluation of each
patient in isolation
(nursing care plan)

Sisters and Matrons

Clinical Service Unit Infection Prevention and Control group

Audit of known or
suspected infected
patients achieving
isolation within two hours.(quarterly review)

Matrons;
ward/departmental
managers ; Clinical Leads

Clinical Service Unit Infection Prevention and Control group

Evidence of the escalation procedure being followed in the event that a patient cannot be isolated within two hours

Matrons;
ward/departmental
managers ; Clinical Leads

Clinical Service Unit Clinical Governance Group

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Definitions

Alert organisms and conditions are those identified as posing a public health risk to patients, staff or visitors as defined by the Department of Health (DoH 1995) and evidenced in LTHT Infections that require Isolation Protocol.

Antibiotics are chemical substances produced by micro-organisms which have the capacity, in dilute solutions, to inhibit the growth of or kill other micro-organisms. Antibiotics that are sufficiently non-toxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants.

Antimicrobial susceptibilities are those tests carried out by the microbiology laboratory that measure the growth response of an isolated micro-organism in relation to a particular antibiotic or a range of antibiotics. The results combined with clinical information and experience informs the selection of the most appropriate antibiotic.

Cephalosporins are any natural or synthetic antibiotics developed from Cephalosporium fungi.

Colonisation is the presence, growth and multiplication of an organism without observable clinical symptoms or immune reaction in a patient. Colonisation occurs when a microbe establishes itself in a particular environment such as a body surface without producing disease.

Diarrhoea is defined as stool loose enough to take the shape of the container it is being collected in or as Type 5-7 of the Bristol Stool Chart.

MRSA (Meticillin resistant Staphylococcus aureus) is a type of Staphylococcus aureus that is resistant to certain antibiotics including meticillin and the more common antibiotics such as flucloxacillin, co-amoxiclav and most cephalosporins..

Opportunistic pathogens are infectious micro-organisms that do not usually harm their host but can cause disease when the host’s resistance is low.

An outbreak is a situation where the observed number of cases of an organism in a particular ward or department exceeds the expected number for that area

Pathogens are organisms that are capable of causing disease.

Quinolones are a class of antibiotics that act by interrupting the replication of deoxyribonucleic acid (DNA) molecules in bacteria. Examples are ciprofloxacin and levofloxacin

Source isolation is the physical separation of a patient with a suspected/identified alert organism/condition into a single room away from other vulnerable patients in order to prevent the spread of infection

Vancomycin resistant enterococcus is the name given to a group of bacterial species of the genus Enterococci that are resistant to the antibiotic vancomycin

Provenance

Record: 2014
Objective:

Aims

The aim of this guideline is to outline the prevention and control measures that need to be taken by LTHT clinical teams when a patient within LTHT has a suspected/ confirmed VRE infection or colonisation.

Objectives

Clinical teams must ensure a safe environment for all LTHT patients in order to prevent and control the spread of communicable infections.

Clinical condition:

VRE/GRE colonization or infection

Target patient group: All patients at LTHT
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

Evidence Base:   

De Angelis G, Cataldo M, De Waure C, et al (2014) Infection control and prevention measures to reduce the spread of vancomycin-resistant enterococci in hospitalized patients: a systematic review and meta-analysis.
Journal of Antimicrobial Chemotherapy 69: 1185-1192

Cookson BD, Macrae MB, Barrett SP et al (2006) Guidelines for the control of glycopeptides resistant enterococci in hospitals.
Journal of Hospital Infection 62, 1: 6-21.

Kirst HA, Thompson DG, Nicas TI (1998) Historical yearly usage of vancomycin.
Antimicrobial Agents Chemotherapy 1998; 42:1303-1304 (letter).

Agegne M , Abera B Derbie A  Yismaw G, and Shiferaw (2018) Magnitude of Vancomycin-Resistant Enterococci (VRE) Colonization among HIV-Infected Patients Attending ART Clinic in West Amhara Government Hospitals.
International Journal of Microbiology Vol 2018,

Mondy KE, Shannon W, Mundy LM. Evaluation of zinc bacitracin capsules versus placebo for enteric eradication of vancomycin resistant Enterococcus faecum.
Clinical Infectious Diseases (2001) August 15; 33(4): 473-6. E-pub 2001 July 6.

Prematunge C, MacDougall C, Johnstone P, Adomako Lam F, Robertson J, Garber G, (2016) VRE and VSE Bacteremia Outcomes in the Era of Effective VRE Therapy: A Systematic Review and Meta-analysis.
infection control & hospital epidemiology vol. 37, no. 1

HICPAC (1994) Recommendations for Preventing the Spread of Vancomycin Resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR. Vol 44/NoRR-12 (1994)
Working Party Report. Guidelines for the control of glycopeptides resistant enterococci in hospitals.
Journal of Hospital Infection 2006; 62:6-21

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Definitions

Alert organisms and conditions are those identified as posing a public health risk to patients, staff or visitors as defined by the Department of Health (DoH 1995) and evidenced in LTHT Infections that require Isolation Protocol.

Antibiotics are chemical substances produced by micro-organisms which have the capacity, in dilute solutions, to inhibit the growth of or kill other micro-organisms. Antibiotics that are sufficiently non-toxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants.

Antimicrobial susceptibilities are those tests carried out by the microbiology laboratory that measure the growth response of an isolated micro-organism in relation to a particular antibiotic or a range of antibiotics. The results combined with clinical information and experience informs the selection of the most appropriate antibiotic.

Cephalosporins are any natural or synthetic antibiotics developed from Cephalosporium fungi.

Colonisation is the presence, growth and multiplication of an organism without observable clinical symptoms or immune reaction in a patient. Colonisation occurs when a microbe establishes itself in a particular environment such as a body surface without producing disease.

Diarrhoea is defined as stool loose enough to take the shape of the container it is being collected in or as Type 5-7 of the Bristol Stool Chart.

MRSA (Meticillin resistant Staphylococcus aureus) is a type of Staphylococcus aureus that is resistant to certain antibiotics including meticillin and the more common antibiotics such as flucloxacillin, co-amoxiclav and most cephalosporins.

Opportunistic pathogens are infectious micro-organisms that do not usually harm their host but can cause disease when the host’s resistance is low.

An outbreak is a situation where the observed number of cases of an organism in a particular ward or department exceeds the expected number for that area.

Pathogens are organisms that are capable of causing disease.

Quinolones are a class of antibiotics that act by interrupting the replication of deoxyribonucleic acid (DNA) molecules in bacteria. Examples are ciprofloxacin and levofloxacin.

Source isolation is the physical separation of a patient with a suspected/identified alert organism/condition into a single room away from other vulnerable patients in order to prevent the spread of infection.

Vancomycin resistant enterococcus is the name given to a group of bacterial species of the genus Enterococci that are resistant to the antibiotic vancomycin.

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.