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Vancomycin-Resistant Enterococci (VRE)

General Information

What is VRE?

VRE is Vancomycin-Resistant Enterococcus.

Enterococcus are bacteria that live in the digestive and genital tracts. They are normally benign and don't cause any problems in healthy people.

Vancomycin is a powerful antibiotic that is often the antibiotic of last resort. It is generally limited to use against bacteria that are already resistant to penicillin and other antibiotics.

Vancomycin-Resistant Enterococcus is a mutant strain of Enterococcus that originally developed in individuals who were exposed to the antibiotic. It was first identified in Europe in 1986, and in the U.S. in 1988.

Why is it dangerous?

It is not dangerous in healthy people with strong immune systems, where the balance of healthy flora in their digestive tract helps keep VRE from getting out of control.

VRE is dangerous because it cannot be controlled with antibiotics, and it causes life-threatening infections in people with compromised immune systems - the very young, the very old, and the very ill.

It is especially dangerous because it can easily transmit the resistance genes to other, more dangerous bacteria, such as staph and strep. Two cases of vancomycin-resistant staph have been identified in the U.S. in the last two months. These could cause serious infections even in otherwise healthy people.

How can it affect me?

Although VRE generally doesn't affect healthy people, anyone who comes in contact with the bacteria can become a carrier. Once you become a carrier, you can easily spread the bacteria to friends and family. In addition, if you become a chronic carrier of VRE, you could easily become infected when you are older or in declining health.

The spread of VRE isn't thoroughly documented or understood, but estimates from Europe are that 3.5% to 5% of the population may be carriers of VRE. VRE first appeared in the U.S. on the East Coast and spread to the West Coast. It is likely that carrier rates in those areas will take a couple of years to catch up to the European carrier rates.

It's particular important to avoid becoming a carrier if you share a home with those at risk - the very young, the very old or the very ill.

How can I be exposed to it?

You can be exposed to VRE by coming in contact with a contaminated object or person, or by eating contaminated food.

In Hospitals - The most likely place to pick up VRE is in hospitals, since this is where VRE tends to originate. In the U.S., all reported cases of VRE were acquired in a hospital. (This is according to the information currently publicly available - this information changes rapidly.)

VRE has been cultured from hospital equipment, doorknobs, and bedrails. It has also been cultured on the hands of hospital personnel. Anyone who frequents hospitals should be considered at risk for carrying VRE.

Of course, you can be exposed to VRE by a single visit to the hospital, but people who work in hospitals (even administrative personnel) are at much higher risk for being exposed and becoming a carrier.

How can I avoid it?

Fastidious hygiene is the best way to avoid ingesting VRE and becoming a carrier. VRE is a robust bacteria and has been found on hospital personnel's hands after five seconds of hand washing. It is recommended that you wash your hands for twenty seconds with an antibacterial soap every time before you eat. (Note that this means right before you eat. If you are eating in a restaurant and have been handling the menu, you could have picked up VRE. Wash your hands thoroughly before you pick up that piece of bread.)

Note that the most likely place to pick up VRE is probably the door handle of the rest room. Consider using the towel you dried your hands with as a protective shield when you open the door.

Avoid hospitals, as this is the only documented source of VRE in the U.S. If you do go to a hospital to visit someone, maintain fastidious hygiene throughout your visit. Avoid eating while at the hospital, and especially avoid eating hospital food.

In general, avoid taking antibiotics. You don't want to become a breeding ground for an antibiotic-resistant infection.

What if I need hospital treatment?

First, consider your options. Is it possible to receive treatment in the caregiver's office or in an outpatient surgery center?

If a hospital stay is absolutely necessary, it is probably wise to ask thorough questions about the hospital infection situation. Request written information about the hospital's record regarding VRE - how many infections have there been? When was the most recent infection? How many people were infected? How often are hospital personnel tested for VRE carrier status? How many staff are known to be VRE carriers?

It's best to request that this information be provided in written form, and dated and signed by your caregiver. This way your caregiver will know that you are serious about getting accurate information.

Consider asking all the hospitals in your area. You may be surprised at the variance of infection rates. In particular, university and teaching hospitals have much higher rates of infection than community hospitals, and it may be possible to arrange to stay at the hospital with the lower infection rate.

As a patient in a hospital, you have to decide how paranoid you want to be about the possibility of exposure to VRE. It's probably safest to avoid eating any raw vegetables from the hospital kitchen. Wash your hands thoroughly before eating, and avoid eating any foods with your hands.

It's certainly safest to have anyone who touches you put on sterile gloves first, but this is unlikely to be their standard procedure.

Request a copy of their guidelines for avoiding hospital-acquired infections, and remind hospital personnel to abide by those guidelines.

What if I've been in a hospital recently?

You might want to call the hospital and ask about the infection situation there prior to and during your stay.

If the hospital has a history of VRE, consider the possibility that you might have been exposed during your stay, and you might now be a carrier.

Those who are VRE carriers are unlikely to know it. It is possible to be cultured to find out if you are a VRE carrier, but this is unlikely to be covered by a health plan.

If you think there's a possibility that you were exposed to VRE and might be a carrier, you should maintain fastidious hygiene in order to avoid spreading the bacteria. It is important to wash your hands for twenty seconds with an antibacterial soap every time after using the toilet. This will reduce the chance that you will spread VRE to others with whom you come in contact. Be especially fastidious if you are regularly in contact with those at risk - the very young, the very old, or the very ill.

If you are certain that you were exposed to VRE or suspect that you may have become a carrier, it is essential to maintain your own good health in order to avoid developing a serious infection.

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What is VRE (Vancomycin-Resistant Enterococci)?

Enteroccocci are bacteria that are normally present in the human intestines and in the female genital tract and are often found in the environment. These bacteria can sometimes cause infections. Vancomycin is an antibiotic that is often used to treat infections caused by enterococci. In some instances, enterococci have become resistant to this drug and thus are called vancomycin-resistant enterococci (VRE). Most VRE infections occur in hospitals.

What types of infections does VRE cause?

VRE can live in the human intestines and female genital tract without causing disease. However, sometimes, it can be the cause of urinary tract infections, blood stream infections and wound infections.

 Possible Contributing Factors

Hand-washing
Cold water
Bed-Side Commode sharing
Equipment sharing
Room cleaning
Decreased access to Personal Protective Equipment
Line labeling & Capping
Primary and secondary IV lines
Dirty utility room
Supply room

Possible solutions
Hot water and soap
Bed-Side Commode or Bathroom in all patient’s rooms
Cleaning equipment between patients use of disposable equipment
Cleaning all rooms as if pt was isolated
Isolation carts/supply carts outside of rooms not in rooms
Labeling of IV tubing and capping
Gloves and Latex free gloves

Assignment of isolation patients
Are certain people at risk of getting VRE?

The following persons are at an increased risk becoming infected with VRE:

• Persons who have been previously treated with vancomycin and combinations of other antibiotics such as penicillin and gentamicin
• Persons who are hospitalized, particularly when they receive antibiotic treatment for long periods of time
• Persons with weakened immune systems such as patients in Intensive Care Units, or in cancer or transplant wards
• Persons who have undergone surgical procedures such as abdominal or chest surgery
• Persons with medical devices that stay in for some time such as urinary catheters or central intravenous catheters.

How common is VRE?

VRE was not reported in U.S. hospitals until 1989. Data reported to the Centers for Disease Control and Prevention during 2004 showed that VRE caused about 1 of every 3 infections in hospital intensive care units.

What is the treatment for VRE?

Most VRE infections can be treated with antibiotics other than vancomycin. The treatment of VRE is determined by laboratory testing to determine which antibiotics are effective. For persons who get VRE infections and have urinary catheters, removal of the catheter when it is no longer needed can help getting rid of the infection. People who are colonized (bacteria are present, but have no symptoms of an infection) with VRE do not usually need treatment.

How is VRE spread?

VRE is usually passed to others by direct contact with stool, urine or blood containing VRE. It can also be spread indirectly via the hands of healthcare providers or on contaminated environmental surfaces. VRE usually is not spread through casual contact such as touching or hugging. VRE is not spread through the air by coughing or sneezing.

How can I prevent the spread of VRE?

If you or someone in your household has VRE, the following are some measures to prevent spread of VRE:

• Always wash your hands thoroughly after using the bathroom and before preparing food. Clean your hands after close contact with persons who have VRE. Wash with soap and water (particularly when visibly soiled) or clean with alcohol-based hand cleaner.
• Frequently clean areas of your home such as your bathroom that may become contaminated with VRE. Use a household disinfectant or a mixture of one-fourth cup bleach and one quart of water to clean those areas and surfaces that are touched frequently.
• Wear gloves if you may come in contact with body fluids that may contain VRE, such as stool. Always wash your hands after removing gloves.
• Be sure to tell any healthcare providers that you have VRE so that they are aware of your infection.
  What should I do if I think I have VRE?

What can be done to prevent or control transmission of these pathogens in my facility?

CDC's recommendations for preventing transmission of MRSA / VRE in hospitals consist of standard precautions, which should be used for all patient care. In addition, CDC recommends contact precautions when the facility (based on national or local regulations) deems the multidrug-resistant microorganism to be of special clinical and epidemiologic significance.

The components of contact precautions may be adapted for use in non-hospital healthcare facilities, especially if the patient has draining wounds or difficulty controlling body fluids.

In addition to standard and contact precautions, the following procedures also may be considered for non-hospital healthcare facilities:

• Patient placement - Place the patient in a private room, if possible. When a private room is not available, place the patient in a room with a patient who is colonized or infected with the same organism, but does not have any other infection (cohorting). Another option is to place an infected patient with a patient who does not have risk factors for infection.
• Patient placement in dialysis facilities - Dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the unit).
• Group activities - It is extremely important to maintain the patients' ability to socialize and have access to rehabilitation opportunities. Infected or colonized patients should be permitted to participate in group meals and activities if draining wounds are covered, bodily fluids are contained, and the patients observe good hygienic practices.

The following are recommended for prevention of VRE / MRSA in hospitals and may be adapted for use in non-hospital healthcare facilities:

• Obtain stool cultures or rectal swab cultures of roommates of patients newly found to be infected or colonized with VRE, and nasal swabs for MRSA.
• Adopt a policy for deciding when patients can be removed from isolation, e.g., VRE-negative results on at least three consecutive occasions, one or more weeks apart.
• Consult health departments regarding discharge requirements for patients with MRSA or VRE.

If a patient in a facility is colonized or infected with MRSA or VRE, what do their visitors members need to know?

In general, healthy people are at low risk of getting infected with MRSA or VRE. Therefore, casual contact - such as kissing, hugging, and touching - is acceptable. Visitors should wash their hands before leaving an infected person's room. Also, disposable gloves should be worn if contact with body fluids is expected. (If excessive contact with body fluids is expected, gowns should also be worn.) It is also acceptable for infants and children to have casual contact with these patients.

What precautions should family caregivers take for infected persons in their homes?

Outside of healthcare settings, there is little risk of transmitting organisms to persons at risk of disease from MRSA / VRE, therefore, healthy people are at low risk of getting infected. In the home, the following precautions should be followed:

• Caregivers should wash their hands with soap and water after physical contact with the infected or colonized person and before leaving the home.
• Towels used for drying hands after contact should be used only once.
• Disposable gloves should be worn if contact with body fluids is expected and hands should be washed after removing the gloves.
• Linens should be changed and washed if they are soiled and on a routine basis.
• The patient's environment should be cleaned routinely and when soiled with body fluids.
• Notify doctors and other healthcare personnel who provide care for the patient that the patient is colonized/infected with a multi-drug-resistant organism.

These measures to limit VRE spread, however, have failed on occasion. Not all hospitals can or are willing to perform active surveillance. Because more patients are typically colonized with VRE (3% to 47%) than are infected, and because intestinal colonization can be prolonged, passive surveillance by routine cultures allows colonized inpatients to go unidentified and serve as point sources for continued spread of VRE. Even if all colonized inpatients are successfully identified, VRE may be spread by health-care workers through either inadequate hand washing or through contact with items such as bedrails, sinks, faucets, and doorknobs (enterococci can persist for weeks on environmental surfaces). Decontamination efforts must be rigorous.

At a minimum, a successful program for control of MDR enterococci requires effective passive and active surveillance to identify colonized and infected patients, absolute adherence to contact isolation by health-care workers, rigorous decontamination of patient-contact areas and judicious use or restriction of vancomycin and other broad spectrum antibiotics.

 

Special Implications for New Mothers and Babies

N.B. About 4% of Group B streptococcus (GBS) isolates demonstrate penicillin tolerance (from Merck Manual).  Consider alternative treatment aimed at reducing colonization without relying on antibiotics.

VRE is not generally dangerous to healthy individuals with fully functioning immune systems. However, it is very dangerous to newborn babies because they have an immature immune system that cannot cope with many different types of germs.

In the U.S., most women give birth in hospitals. Unfortunately, the emergence of VRE as an increasingly common pathogen can make the hospital a very dangerous place for your baby. Hospitals have always recommended that newborns be kept away from hospitals because of the increased danger to their immature immune systems. This danger becomes even more serious when the hospital germs cannot be treated with antibiotics.

The Center for Disease Control warns that the primary concern about VRE is that it could easily share its resistance with staph bacteria, which can easily infect a baby's skin. Two strains of staph resistant to vancomycin were reported in the U.S. in the summer of 1997, and it is expected that this number will increase rapidly.

What are the dangers to my baby?

There are two primary dangers.

The first is that your baby may be exposed to VRE or resistant staph through contact with hospital equipment or personnel.

The second is that you may become a VRE carrier and take the bacteria to your home, where you may spread it to other family members, including your new baby. Your own body might become an incubator for resistant strep or staph, which could cause serious infection in your baby.

What are the dangers to me?

In addition to the risks of becoming a carrier, you are at increased risk for exposure every time the integrity of your skin is broken by an IV or injection. An unnecessary episiotomy or Cesarean wound puts you at particular risk.

Germs introduced vaginally are particularly dangerous because if they migrate to the placenta site, they can move directly into the larger vessels in the mother's bloodstream and cause systemic infection quite rapidly.

How can I minimize the dangers?

The best way to avoid hospital-acquired infections is to avoid hospitals. Consider the possibility of an out-of-hospital birth:

Birth Centers - Birth Centers are different from hospitals in that they are much less likely to harbor antibiotic-resistant germs. This is because Birth Center clients aren't typically taking antibiotics. However, as a public place, birth centers do have a lot of people passing through, which increases the risk of introduction of antibiotic-resistant germs in the environment. In particular, if the birth center personnel also work in hospitals, there is an increased risk that they may be carriers of antibiotic-resistant germs.

At home - The best way to protect your baby from dangerous germs is to give birth at home. It's very unlikely that VRE is present in your home, unless you or someone else in your family became a carrier through previous exposure to VRE. In addition, a baby born at home is always kept very close to the mother, thereby ensuring that the mother is exposed to the same germs the baby is exposed to. This allows the mother's body to customize the antibodies in her breastmilk to be exactly the ones her baby needs.

If your pregnancy is complicated by high-risk factors that limit your out-of-hospital options, you can still make choices that minimize your exposure to hospital germs:

• When you are deciding on a childbirth education class, ask the instructor about their knowledge of hospital infections and how to avoid them.
• Learn as much as possible about pregnancy and birth so that you can make informed choices about your care and decline procedures that increase your risk of exposure without providing benefits. Get a copy of A Guide to Effective Care in Pregnancy & Childbirth by Enkin, Keirse, Renfrew and Neilson. This excellent book provides an easy-to-read guide to all the tests and procedures that might be recommended by your care provider. The authors have evaluated all the available research and categorized everything in simple tables: Beneficial forms of care, Forms of care likely to be beneficial, Forms of care with a trade-off between beneficial and adverse effects, Forms of care of unknown effectiveness, Forms of care unlikely to be beneficial, Forms of care likely to be ineffective or harmful. With this knowledge, you can make better decisions about choosing or declining invasive procedures that might introduce infection.
• Choose out-of-hospital providers for prenatal diagnostic tests such as ultrasound and bloodwork.
• Plan to labor at home as long as possible. By using the services of a professional labor assistant, you can have the benefits of professional care in your home without the dangers of the hospital.

When you go to the hospital, follow these safety guidelines:

Maintain Fastidious Hygiene - Wash your hands frequently, and use the paper towel as a shield on the door handle. Consider wearing gloves.

Minimize Interventions - Any intervention that causes a break in your skin could result in a serious infection. Avoid these risks by declining unnecessary IVs or injections.

Avoid an Epidural - Epidurals are especially dangerous because a pathway for germs is created from the outside directly into your spinal space; a spinal is even more dangerous, as it could introduce germs into your spinal column and cause meningitis. In addition, 15% of women who have an epidural develop an epidural fever. This usually necessitates the baby's being admitted to the Neonatal Intensive Care Unit (NICU) for a number of tests and observations. The most dangerous infections are generally found in the NICU.

Avoid Being Catheterized - Urinary tract infections are the most commonly acquired infections in hospitals; they are usually caused by catheterization.

Avoid Ingesting VRE - Eat only cooked hospital food, and wash your hands thoroughly before eating.

Breastfeed Your Baby - By breastfeeding your baby, you protect your baby in a number of ways. You minimize the number of times the baby is handled by hospital staff, and you prevent the introduction of VRE through bottle equipment or formula. In addition, your breastmilk provides antibodies that protect your baby against infection. Even if your baby is primarily fed artificial human milk (formula), occasional breastfeeding can still offer a significant immunity boost to your baby. This is especially important while you are in the hospital. Once you are away from the hospital, continue to breastfeed as much as possible. Babies who do not receive the immune boost from breast-milk are ten times more likely to develop an infection that requires hospitalization.

Wash Your Hands Fastidiously Before Breastfeeding so that your baby doesn't ingest germs along with the breast-milk. This will also reduce the risk of mastitis and other breast infections in cracked nipples.

Avoid Procedures that Break the Baby's Skin - One quarter of newborns in hospitals acquire a staph infection. Every injection or heel-stick breaks the baby's skin and can become an avenue for serious infection. Although the vitamin K shot is best given close to the time of birth, other breaks in the skin can sensibly be delayed. (Some progressive hospitals are offering oral vitamin K, which doesn't require breaking the baby's skin; you can request vitamin K.)  In particular, vaccines can often be delayed for some months, and the newborn screen (PKU heel-stick) can be done by a health care provider after the baby is safe at home. (In any case, the PKU is most accurate when done at six days; newborn screens performed before the baby is a couple of days old miss 10-15% of cases of hypothyroidism.  It is also significantly less traumatic to do a heel-stick on a six-day-old baby than a day-old baby since newborns are often dehydrated in the first couple of days.  The task of "getting blood from a stone" requires significant and repeated stabbing of the baby's heel.)  If you are unable to find a CNM, Licensed Midwife or pediatrician who makes house-calls to do the newborn screen heel-stick at 6 days, it is still safer to have the PKU heel-stick done in the pediatrician's office than in the hospital.

Insist everyone (yes, even the doctors) wash their hands in your presence for at least 30 seconds before touching you or your baby.

If someone comes in your room already wearing gloves, make them take them off, wash their hands and reapply.

Minimize Handling of Your Baby by Hospital Personnel - Insist that the staff maintain fastidious hygiene and handle your baby only with fresh, clean gloves. One way to ensure that the staff doesn't touch the baby with bare hands is to decline to have the baby bathed after the birth. You might choose to do a little spot cleaning here and there, but if the baby is not bathed, then the staff will be careful about handling the baby for their own protection. In addition, this will protect the baby from the germs found in the bath water.

Keep Your Baby in Your Room - This reduces handling of your baby by hospital staff, and ensures that your body will produce the antibodies to the germs your baby is exposed to.  The World Health Organization's discussion of Umbilical Cord Care offers clear advice about keeping your baby in your room in order to minimize infection.

Return Home as Soon as Possible - Leaving the hospital as soon as possible after the birth will reduce your chance of acquiring a hospital infection or being exposed to antibiotic-resistant germs. In California, the law to reduce so-called "drive-through deliveries" requires HMOs and health insurers to cover at least a 48-hour hospital stay for a mother and newborn or to provide for a follow-up exam within two days after discharge. Astute consumers can use this law to negotiate for care to be provided in their home. You can arrange for an in-home visit by a Licensed Midwife and a week of household help for less money than it costs for a single day in the hospital. This will allow you to recover in the comfort and safety of your own home, surrounded by the people of your choice, while providing access to the health care and practical help you may need.

Avoid Returning to the Hospital or a Doctor's Office Where Your Child Can Be Exposed to Nasty Germs - Once you've successfully brought a healthy baby home from the hospital, it's important to remember that hospitals and medical offices filled with sick children continue to be a threat to your child.  A child's immune system doesn't develop completely until around 5 years of age.  It's important to minimize your child's exposure to other sick children, especially the very sick children in a doctor's office.  Develop a good relationship with the phone nurse, instead, and develop skills at caring for minor problems at home.

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