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Vancomycin Resistant Enterococcus

Vancomycin-resistant enterococcus (VRE) is a mutation of a very common bacterium that is spread easily by direct person-to-person contact. Facilities in more than 40 states have reported VRE, with rates as high as 14% in oncology units of large teaching facilities. Patients most at risk for VRE include:

immunosuppressed patients or those with severe underlying disease
patients with a history of taking vancomycin, third-generation cephalosporins, or antibiotics targeted at anaerobic bacteria (such as Clostridium difficile)
patients with indwelling urinary or central venous catheters
elderly patients, especially those with prolonged or repeated hospital admissions
patients with cancer or chronic renal failure
patients undergoing cardiothoracic or intra-abdominal surgery or organ transplants
patients with wounds with an opening to the pelvic or intra-abdominal area, including surgical wounds, burns, and pressure ulcers
patients with enterococcal bacteremia, often associated with endocarditis
patients exposed to contaminated equipment or to a VRE-positive patient.

Causes

VRE enters health care facilities through an infected or colonized patient or a colonized health care worker. VRE is spread through direct contact between the patient and caregiver or between patients. It can also be spread through patient contact with contaminated surfaces such as an overbed table. It is capable of living for weeks on surfaces. It has been detected on patient gowns, bed linens, and handrails.

Signs and symptoms

There are no specific signs and symptoms related to VRE. The causative agent may be found incidentally when culture results show the organism.

Diagnosis

Someone with no signs or symptoms of infection is considered colonized if VRE can be isolated from stool or a rectal swab. Once colonized, a patient is more than 10 times as likely to become infected with VRE, for example, through a breach in the immune system.

Treatment

There is no specific treatment at this time for eradicating VRE. Recently, the Centers for Disease Control and Prevention and the Hospital Infection Control Practices Advisory Committee proposed a two-level system of precautions to simplify isolation. The first level calls for standard precautions, which incorporate features of universal blood and body fluid precautions and body substance isolation precautions, to be used for all patient care. The second level calls for transmission-based precautions, which are implemented when a particular infection is suspected.

To prevent the spread of VRE, some facilities perform weekly surveillance cultures on at-risk patients on intensive care units or oncology units and on patients who've been transferred from a long-term care facility. Any colonized patient is then placed in contact isolation until culture-negative or until discharged. Colonization can last indefinitely, and no protocol has been established for the length of time a patient should remain in isolation.

Because no single antibiotic currently available can eradicate VRE, the doctor may, in some cases, opt not to treat an infection at all. Instead, he may stop all antibiotics and simply wait for normal bacteria to repopulate and replace the VRE strain. Combinations of various drugs may also be used, depending on the source of the infection.

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