Ipcd policy number 13

CARDIFF AND VALE NHS TRUST
VANCOMYCIN RESISTANT ENTEROCOCCUS
POLICY AND PROCEDURE
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Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
CONTENTS
Transfer of colonised or infected patients Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
1. SUMMARY
Enterococci commonly colonise the human bowel, skin, wounds and the female genital tract. They can cause infections especially in high-risk patients such as those in ICU, neonatal, haematology, renal and oncology units. The organisms are mainly transmitted via hands after contact with infected or colonised patients, contaminated surfaces or other objects. Infections caused by Vancomycin-resistant Enterococci (VRE) may be difficult to treat because of the limited range of effective antibiotics. The most important measure to control the spread of VRE is proper hand washing. This should be undertaken before and after any contact with patients or any potentially infected materials. Single room isolation is preferred - if no single room is available, the implementation of contact precautions at the bedside can be effective in preventing spread. Patients with diarrhoea pose a higher risk of transmission and single room isolation is required. Gloves should be worn if there is a risk of contact with blood or body fluids. Plastic aprons must be worn when soiling is likely, or when close contact with the patient or patient equipment is anticipated. screening for VRE is not normally recommended. It should only be done if directed by the Infection Prevention and Control Department. Attempts at decolonisation are generally unsuccessful. There is no standard regimen and is therefore not recommended. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
2. INTRODUCTION
Enterococci are common human commensals, found in the large bowel, female genital tract, skin, throat, wounds and vascular catheter sites (1-3). E. faecalis followed by E. faecium are by far the most common species isolated from human specimens. Enterococcal resistance to glycopeptides (vancomycin and teicoplanin) emerged in the 1980’s, coinciding with the global increase in the use of glycopeptides for treatment of methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative Staphylococci and Clostridium difficile infections(4). The terms glycopeptide-resistant enterococci (GRE) and vancomycin-resistant enterococci (VRE) are used interchangeably. Unlike MRSA, VRE are of limited virulence. Even in vulnerable patients, their isolation is usually associated with colonisation rather than infection(5,6). However, enterococci are among the most common causes of hospital-acquired infections, especially infections of the urinary tract, wounds and vascular catheter sites. 2.3 Most enterococcal infections are endogenous, but cross-infection between hospitalised patients does occur. In hospitals, enterococci causing colonisation and infection are transmitted mainly via hands contaminated by contact with colonised or infected patients, contaminated surfaces or other objects. Environmental contamination increases significantly when patients have diarrhoea(7). Risk factors for VRE colonisation and infection include glycopeptide, cephalosporin or multiple antibiotic therapy(3,7-10), prolonged hospital stay(11) and admission to intensive care, renal, haematology or liver units (3,12-17). In England and Wales, vancomycin resistance in E. faecalis has increased from ≈ 3% in 1996 to 5% in 1998. In E. faecium the figure has increased from 6.3% in 1993 to 24% in 1998(18). This rise in glycopeptide resistance is a cause of major concern. Apart from limiting available therapeutic options, glycopeptide resistant genes can potentially be transferred to staphylococci seriously complicating the current problems with MRSA(19). The single most important measure in the containment of VRE, as indeed the vast majority of hospital acquired infections, is proper hand washing. This policy document gives advice on dealing with VRE, however, each situation should be dealt with on its own merits. More detailed advice can be obtained from the Infection Prevention and Control Department (IPCD) as needed. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
3. POLICY STATEMENT
VRE are common human commensals but can cause infection especially in vulnerable patients. The rise in glycopeptide resistance is a major cause for concern not only because of the limited therapeutic options but the potential of gene transfer to more virulent organisms such as Staphylococci. In order to prevent the possible spread of VRE amongst patients and staff it is recognised that the Trust requires a policy/procedural document to ensure effective management of the infection. This is especially necessary in the case of an infectious incident/outbreak, as detailed in the Trust Infectious Incident and Outbreak Plan (2002), 4. AIMS
To provide a structure and appropriate advice to staff on the management of VRE at all Trust locations. 5. OBJECTIVES
To provide advice on action required on the admission of a patient known or suspected to have VRE. To provide advice on action required when a case develops in a Trust institution. To provide advice on action required during an infectious incident or outbreak situation caused by VRE. To provide advice on the communications necessary whenever a cluster of cases of VRE develops. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
6. CONTROL MEASURES

6.1 Outline

6.1.1 The primary objective of infection prevention and control is the prevention of
acquisition and spread of infection in patients, visitors and staff. There is no evidence that chronic staff carriage (e.g. bowel colonisation in staff with VRE) plays an important role in the spread of enterococci. 6.1.2 Infection prevention and control is the responsibility of all staff associated with patient care. A high standard of infection prevention and control is required in all areas and is an important part of the concept of total patient care. Priority areas for control are high-risk units such as intensive care and special care baby units and other areas where patients are particularly susceptible to infection such as haematology and nephrology. Standard infection prevention and control measures should be instituted at all times even if a patient is not known to be colonised with resistant organisms. INFECTION PREVENTION AND CONTROL MEASURES − Strict compliance with hand washing procedures. − Wearing of appropriate personal protective equipment e.g.; aprons, − High standards of aseptic techniques. − Careful handling of clinical waste and linen. − Minimisation of inter- and intra- ward transfer of patients. − Maintaining adequate and appropriately skilled nursing and other
6.2 Control
measures

6.2.1 Hands must be decontaminated by either washing with liquid soap and applying an
alcohol gel or washing with another approved hand disinfectant. Hand washing should be performed: • before entering an isolation room and before leaving; • before and after contact with the patient; and • after contact with potentially infected materials. If gloves have been worn, hands must be washed following removal of the gloves. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
6.2.2 All infected waste should be disposed of into a yellow “clinical waste” bag. 6.2.3 All linen should be placed in the appropriate bag for contaminated linen and returned to the laundry. Curtains adjacent to VRE positive patients should be sent to the laundry if visibly contaminated. 6.2.4 Whenever possible, instruments and equipment such as writing materials, sphygmomanometers, and stethoscopes should be designated for VRE patients. If this is not possible, such items should be cleaned and disinfected before use on another patient. For more information, see Cardiff and Vale NHS Trust Decontamination Policy (2002).
6.2.5 If the patient is in a single room, the nurse-in-charge must ensure that appropriate
cleaning is carried out. If the patient is not in a cubicle, the ward area where the patient is present should be cleaned to the highest standard.
6.2.6 The patient's room must be cleaned thoroughly with detergent and water and then
decontaminated with a phenolic disinfectant (e.g. Stericol® 2%). It is not necessary
to clean the walls and ceilings. All hospital furniture (e.g., bed, tables) and any
dust collecting ledges should be wiped with a phenolic disinfectant. After
terminal cleaning following discharge of a patient with VRE, the room should be
allowed to dry thoroughly before a new patient is admitted. The mattress should be
decontaminated with a hypochlorite solution (1,000ppm). Phenolics should NOT be
used as they will damage the mattress.

6.3 Contact
isolation

6.3.1 Contact precautions/isolation are used for the control of MRSA and VRE because
the mode of transfer of these organisms is principally by contact (usually via hand contact). If a patient is colonised with VRE, a single room is preferred. Decisions on individual cases are made by risk assessment after discussion with the IPCD. A single room is essential if the patient has diarrhoea. Individual rooms should preferably have their own toilet facility. The door of the room should be kept closed unless the clinical need of the patient dictates otherwise. 6.3.2 Prior to transferring the patient to a single room, the implications of VRE colonisation, infection and treatment should be clearly explained to the patient or relative. Contact IPCD for assistance if necessary. 6.3.3 Cohorting of a group of patients may be considered on discussion with IPCD. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
If isolation on a standard ward is used for a patient with VRE, the
following procedures should be observed:
• Careful compliance with hand hygiene • Gloves should be worn if there is any risk from contamination with blood • Plastic aprons must be worn when soiling is likely, or when direct contact with the patient / patient equipment is anticipated • Facial protection e.g. visors, goggles must be worn if there is a risk of splashing from blood or body fluids and secretions If isolation in a single room is used for a patient with VRE, the
following procedures should be observed:
• Careful compliance with hand washing procedures • Visitors and members of staff from other departments must report to the nurse-in-charge before entering the room • The door of the room should be kept closed at all times unless the clinical need of the patient dictates otherwise contact isolation sign (orange) should be displayed on the door.
• Patients should not leave the room/ward area to attend other departments without prior arrangement/notification of the receiving department • Gloves should be worn if there is any risk from contamination with • Plastic aprons must be worn when soiling is likely, or when direct contact with the patient / patient equipment is anticipated • Facial protection e.g. visors, goggles must be worn if there is a risk of splashing from blood or body fluids and secretions It is the responsibility of the nurse-in-charge to ensure that all the materials required for the isolation room are readily available. Only items for immediate use should be taken into the isolation area. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
Screening

6.4.1 Screening for VRE is not normally recommended, however, it may be appropriate in
outbreak situations on advice from Infection Prevention and Control Department. 6.4.2 The preferred specimen for detection of VRE on screening is faeces(1). The clinician requesting the investigation must sign all forms and provide the relevant clinical information.
6.4.3 There is no evidence that staff screening is of benefit even during outbreaks.

6.5 Treatment
infection and decolonisation
6.5.1 Careful assessment is required to distinguish clinical infection from colonisation. Clinical infections should be treated as appropriate (e.g. removal of prosthetic devices if possible). Antimicrobial therapy should be guided by results of antimicrobial susceptibility testing. For further advice contact the medical microbiologist on duty. 6.5.2 Faecal carriage of VRE can persist for a very long time(14). Attempts at decolonisation using oral therapy are usually unsuccessful(20-22) and are not recommended neither are tests for clearance following successful antimicrobial therapy. Transfer of infected or colonised patients
6.6.1 The ward manager or nurse-in-charge of the ward has the responsibility to ensure that the necessary information regarding an infected/colonised patient is passed on to a senior member of staff of the receiving ward/department or other healthcare establishment prior to transfer. 6.6.2 Unnecessary movement within the ward area should be avoided if at all possible, as should transfers to other wards. If transfer has to be effected, then the receiving
ward should be informed of the current status of the patient. Lesions should be
occluded with an impervious dressing. Staff involved in transferring the patient
should wear gloves and an apron only if they come into direct close contact with
the patient. After transfer, all linen should be treated as contaminated and the
trolley/chair should be wiped down with detergent and water and disinfected with
2% stericol or 70% alcohol solution.
6.6.3 Visits to other departments by patients colonised with VRE should be kept to a minimum. When visits are essential, prior arrangements should be made with the senior staff of the receiving department concerned. Patients may be seen at any time during the normal working session but should spend the minimum time in the receiving department. They should be sent for when the receiving department is ready and not left in a waiting area with other patients. Equipment used and the Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
number of staff attending the patient should be kept to a safe minimum, and the equipment should be decontaminated after use. 6.6.4 Patient that require surgery should placed at the end of the list or session whenever possible and should be sent for so that they spend the minimum amount of time in the theatre area. Theatre equipment should be disinfected following use as per current theatre protocols. 6.6.5 Surgical antibiotic prophylaxis may need to be adjusted for patients colonised or infected with VRE, particularly in high-risk surgery such as implant surgery. Further advice can be obtained from a medical microbiologist. 6.6.6 The ambulance service should be notified prior to transfer. Further information for the ambulance service should be obtained from the Consultant in Communicable Disease Control (029 20402478). 6.6.7 Inter-hospital movements should be kept to the minimum possible. It is the responsibility of the transferring ward to identify the patient as VRE positive and to flag the patient's notes. Patient transfer need not be delayed as long as the receiving unit is aware of the patient’s status. 6.6.8 Colonisation with VRE should not delay patient discharge from the Trust to a nursing home. The Consultant in Communicable Disease Control (Bro Taf Health Authority) has advised long-term community care facilities that they should accept VRE positive patients. 6.6.9 The General Practitioner, other health care and relevant social agencies involved in the patient's care should be informed of any relevant information they require to provide that care. Patients should be informed that there is no risk to healthy relatives. 6.6.10 In the case of deceased patients inform the mortuary of their status. Precautions taken should be the same as when the patient was alive. Any lesions should be
covered with impermeable dressings. Plastic body bags are not necessary.
Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
7. RESPONSIBILITIES
The Trust Board is responsible for the approval of the Vancomycin Resistant Enterococcus Policy and Procedure. will be responsible for the implementation of the policy The Infection Prevention and Control Department will be responsible for the distribution of the document throughout the Trust. Infection prevention and control is the responsibility of all staff associated with patient care. 8. RESOURCES
Adequate supplies of the materials required to control the spread of VRE at ward level must be available at all times. 9. TRAINING
Mandatory Infection and Prevention and Control training updated every two years. based training as identified by training needs analysis. 10. AUDIT
10.1 Audit of the distribution of the document and compliance will be carried out by the Infection Prevention and Control Department as part of their policy audit programme. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
11. DISTRIBUTION
11.1 The document will be distributed by the Infection Prevention and Control Department for inclusion in the Cardiff and Vale NHS Trust Infection Prevention and Control manual. 11.2 The name and signature of the staff member receiving the document will be obtained and entered in the Infection Prevention and Control Department policy database. 11.3 The document will be available on Public Folders and the Trust Intranet. 12. REFERENCES
12.1 Beezhold DW, Slaughter S, Hayden MK et al. Skin colonisation with among hospitalised patients with bacteraemia. Clin Infect Dis 1997;24:704-6. 12.2 Bonten MJM, Hayden MK, Nathan C et al. Epidemiology of colonisation of patients and environment with vancomycin-resistant enterococci. Lancet 1996;348: 1615-9. 12.3 Handwerger S, Raucher B, Altarac D et al. Nosocomial outbreak due to Enterococcus faecium resistant to vancomycin, penicillin, and gentamicin. Clin Infect Dis 1993; 16:750-5. 12.4 Kirst HA, Thompson DG, Nicas TI. Historical yearly usage of Vancomycin. Antimicrob Agents Chemother 1998; 42:1303-4 (letter). 12.5 Morris JG, Shay DK, Hebden JN et al. Enterococci resistant to multiple Antimicrobial agents, including vancomycin. Ann Intern Med 1995; 123:250-9. 12.6 Jordens JZ, Bates J, Griffiths DT. Faecal carriage and nosocomial spread of vancomycin resistant Enterococcus faecium. J Antimicrob Chemother 1994; 34:516-28. 12.7 Boyce JM, Opal SM, Show JW et al. Outbreak of multi-drug resistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol 1994;32: 1148-53. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
12.8 Karanfil LV, Murphy M, Josephson A et al. A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol 1992;13:195-200. 12.9 Feldman RJ, Paul SM, Silber JL, Cody RP, Noveck H, Weinstein MP. An analysis of treatment of patients with vancomycin-resistant enterococcal bacteremia. Infectious Diseases in Clinical Practice 1996;5:440-5. 12.10 Rax GG, Ojo F, Kolokithaw D. Vancomycin-resistant gram-positive cocci: Risk factors for faecal carriage. J Hosp Infect 1997;35:63-9. 12.11 Montecalvo MA, Shay DK, Patel P et al. Bloodstream infections with vancomycin- resistant enterococci. Arch Intern Med 1996;156:1458-62. 12.12 Chadwick PR, Oppenheim BA, Fox A et al. Epidemiology of an outbreak due to vancomycin-resistant Enterococcus faecium on a leukemia unit. J Hosp Infect 1996;34:171-82. 12.13 Edmond MB, Ober JF, Weinbaum DL et al. Vancomycin resistant Entrococcus faecium bacteraemia: risk factors for infection. Clin Infect Dis 1995;20:1126-33. 12.14 Henning KJ, Delencastre H, Eagan J et al. Vancomycin resistant Entrococcus faecium on a paediatric oncology ward: duration of stool shedding and incidence of clinical infection. Paed Infect Dis J 1996;15:848-54. 12.15 Livornese LL, Dias S, Samel C et al. Hospital-acquired infection with vancomycin- resistant Entrococcus faecium transmitted by electronic thermometers. Ann Intern Med 1992;117:112-6. 12.16 Papanicolaou GA, Meyers BR, Meyers J et al. Nosocomial infection with vancomycin-resistant Entrococcus faecium in liver transplant recipients: risk factors for acquisition and mortality. Clin Infect Dis 1996;23:760-6. 12.17 Uttley AHC, George RC, Naidoo J et al. High level vancomycin-resistant enterococci causing hospital infections. Epidemiol Infect 1989;103:173-81. 12.18 Reader MH, Shah A, Livermore DM et al. Bacteraemia and antibiotic resistance of its pathogens reported in England and Wales between 1990 and 1998: trend analysis. BMJ 2000;320:213-6. 12.19 Noble WC, Virani Z, Cree RGA. Co-transfer of vancomycin and other resistance genes from Entrococcus faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol lett 1992;93:195-8. 12.20 Chia JKS, Nakata MM, Park SS et al. Use of bacitracin therapy for infection due to vancomycin-resistant Entrococcus faecium. Clin Infect Dis 1999;29:361-6. Vancomycin resistant Enterococcus Policy and Procedure CARDIFF AND VALE NHS TRUST
12.21 Weinstein MR, Dedier H, Brunton J et al. Lack of efficacy of oral bacitracin plus doxycycline for the eradication of stool colonization with vancomycin-resistant Entrococcus faecium. Clin Infect Dis 1999;29:361-6. 12.22 Whiteman Ms, Pitsakis PG, DeJesus E et al. Gastrointestinal tract colonization with vancomycin-resistant Entrococcus faecium in an animal model. Antimicrob Agent Chemother 1996;40:1526-30. Vancomycin resistant Enterococcus Policy and Procedure

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