Supplemental Infection Control Guidelines for the Care of Patients Colonized or Infected with Vancomycin-Resistant Enterococci (VRE) in Hospitals, Long-Term Care Facilities and Home Health Care

Series: Health Facilities Series: RHCF-7, D&TC-7, HMO-6, H-10, HHA-4 95-14
Subject: Supplemental Infection Control Guidelines for the Care of Patients Colonized or Infected with Vancomycin-Resistant Enterococci (VRE) in Hospitals, Long-Term Care Facilities and Home Health Care
Date: October 10, 1995

Purpose.

These guidelines provide infection control information for hospitals, long term care facilities, and home care agencies on strategies to prevent transmission of vancomycin-resistant enterococci (VRE) from colonized or infected patients. These supplement recommendations published by the Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee (HICPAC)¹, which have been endorsed by the Department of Health and its Infection Control Advisory Committee. Guidance for long-term care facilities and home health agencies, which was not covered by the HICPAC document, is included.

This document solely addresses infection control. Recommendations for surveillance, antibiotic utilization, and other aspects of an institutional plan for VRE prevention and control are covered in the HICPAC guidelines referenced at the end of this communication.

Background.

Enterococci are part of the normal flora in the intestinal tract and are a common cause of nosocomial infections. In recent years, enterococci, like many other organisms, have developed resistance to certain antibiotics. Although VRE is not especially virulent, the lack of effective therapy for invasive infection and the potential for transfer of vancomycin resistance to other bacteria (i.e., Staphylococcus aureus) has made the control of VRE a public health concern. Also, VRE infections tend to occur in critically ill patients in whom the outcome is more frequently fatal.

In the next few years, most health care facilities and agencies can expect to encounter VRE in their patient population. In New York State, VRE is endemic in many hospitals. All areas of the state are affected. Although a health care facility or agency may not have had a recognized case of VRE, this organism may be present in the patient population. Patients can be colonized with VRE and remain undetected.

VRE does not pose an infection risk to health care workers. However, health care workers can transiently carry this organism and serve as vehicles for transmission to other patients.

Admission and Transfer of Patients With VRE.

The admission or transfer of patients should not be affected by VRE infection or colonization. All health care facilities and home care agencies must be prepared to implement the appropriate infection control measures for patients infected or colonized with VRE and other resistant organisms. It is inappropriate to refuse admission of a patient based solely on the fact that VRE is present. Such action negatively affects patients by limiting access to the desired level of care, including hospitalization, and unnecessarily extends hospital stay beyond the period of medical need.

Today's health care environment must be viewed as a continuum where patients move back and forth across levels of care according to need. Open communication and sharing of information is therefore essential to the provision of quality care. The infection control office in a receiving facility should be notified when a patient with VRE is being considered for admission or transfer so that preparations can be made, including reinforcing staff education on control of VRE.

Principles of Controlling VRE Transmission.

Strategies for controlling VRE transmission are very basic: confine the organism and control the vehicles that can contribute to spread. Scrupulous handwashing, appropriate use of barrier precautions, and careful attention to environmental sanitation are the three most important elements of a control strategy. Health care workers should always treat stool and urine as if they contain potential pathogens. Beyond this, the nature of the control measures will be dictated by the type of facility in which care is provided and the vulnerability of its patient population. Patients vary in their susceptibility to becoming colonized with resistant organisms; exposure to antibiotics and invasive or indwelling devices are important risk factors. For these reasons, certain hospitalized patients appear to be at particular risk. Recommendations for control of VRE consider these variations in risk and consequently hospital guidelines are more restrictive than those for other health care settings. In addition, because VRE may be transmitted by contact with contaminated surfaces, greater attention is placed on recognizing where the patient or health-care worker may have contact which could result in transmission.

Factors that should routinely be considered when making decisions about infection control measures and room assignments include:

• intensity of care needs and degree of anticipated contact with excretions/secretions or wound drainage;
• the patient's ability to control secretions and excretions;
• the patient's level of activity and mobility, including expected interaction with other patients in a facility;
• presence of other patients who are infected or colonized with VRE;
• potential risk to roommates; and
• room availability.

The following recommendations are distinguished by the type of health care setting to which they apply. However, each facility or agency will need to adapt these guidelines on a case-by-case basis according to the situation and their previous experience with VRE.

Hospital Guidelines.

(These guidelines summarize the isolation precaution section of the HICPAC guidelines endorsed by the Department of Health and its Infection Control Advisory Committee.)

1. Room Selection.
   • Private or isolation rooms are preferred and should be used in units caring for highly vulnerable or immunocompromised patients, i.e., intensive care, burn, transplant, AIDS and oncology units.
   • If other known VRE positive patients are in the facility, and their placement as roommates is otherwise appropriate, then cohorting is an option to placement in a private room.
   • If private room or cohorting is not an option, VRE patients may be placed in multiple-bed rooms. (This maybe the preferred option for facilities in which VRE has become endemic.) However, roommates should not be immunocompromised or have open wounds, multiple lines, or highly invasive equipment (i.e., central or arterial line, respirator, wound suction.)
2. Handwashing.
   • It is recommended that an antimicrobial agent be used in areas where VRE patients receive care (soap is not as effective in removing transient carriage). The need for strict compliance with handwashing recommendations should be frequently reinforced. Hands should be carefully washed after any contact with the patient or contact with articles or equipment used in the care of patient and after removal of gloves and other barriers.
3. Gloves.
   • Where patients are in private rooms or cohorted, gloves should be donned when entering the room and removed prior to leaving. Where patients are in multiple-bed rooms, they should be worn for all interactions with the VRE-positive patients.
4. Gowns.
   • If there is likely to be substantial contact with the patient or the environment where the patient sleeps, or the patient is incontinent or has uncontained drainage, gowns should be worn.
5. Dedicated equipment.
   • Several epidemiological studies have shown that fomites may have a role in VRE transmission. Therefore, equipment which is frequently shared, e.g., blood pressure cuff, electronic thermometer, IV pole, should be dedicated for use on the VRE positive patient and thoroughly cleaned and disinfected prior to use on another individual. (In hospitals where VRE is endemic, this may not be practical. In such cases, decisions about dedicated equipment should be made on a case-by-case basis as circumstances permit.)
6. Signs.
   • An isolation sign in keeping with the system currently used by the institution should be placed on the door or at the bedside to alert staff and visitors to the need for appropriate precautions.
7. Housekeeping and laundry.

   • Members of the custodial staff have an important role in controlling VRE transmissions. They should be educated about VRE and taught to clean and disinfect environmental surfaces in the immediate vicinity of the patient, i.e., bed rails, door knobs, sinks, toilets, etc. (This does not apply to areas where the patients may be temporarily present, i.e., lounge, waiting area). Cleaning of these surfaces should be performed daily and cleaning materials changed after use in that room.

   • If patient care equipment is cleaned and disinfected by persons other than housekeeping staff, they too should be educated. Equipment that is typically cleaned only when the patient is discharged, (i.e., IV poles, pumps), should be placed on a schedule for routine cleaning. No specific cleaning interval is currently recommended, therefore, facilities should establish a schedule based on frequency of use, intensity of contact, and other factors that may be relevant to the situation.

   • In most settings, it will not be necessary to change linen and laundry handling practices as long as all such materials are treated as contaminated. However, personnel who are involved with stripping beds or otherwise having direct contact with these materials should wear gloves and gowns.

8. Discontinuation of Isolation Precautions.

   1. Criteria for discontinuing isolation have not been scientifically defined. Development of such criteria are confounded by the fact that: 1) enterococci are expected bowel flora, 2) VRE may persist indefinitely and be shed intermittently, 3) measures to eradicate VRE carriage are not currently known, 4) screening cultures may not reliably indicate the presence or absence of VRE, 5) cultures are expensive and may not be cost effective in this instance, and 6) many patients will be discharged or expire before precautions are discontinued. In addition, variations in the prevalence of VRE makes it difficult to issue a recommendation that will fit all settings. Based on the available science, the Department of Health believes all patients who ever have had a positive culture for VRE should be considered chronically colonized. Modification of precautions should be decided on the basis of risk factors for transmission, as outlined at the beginning of this guideline, and not on the basis of culture results.

   2. Patients with a history of VRE colonization for infection should be identified and their charts flagged to alert clinical and clerical personnel in the event of readmission and placed on precautions commensurate with the risk of transmission.

Long Term Care Guidelines.

1. Room/roommate selection.

   Patient placement decisions need to consider the risk/benefit and degree of disruption from changes in room assignment (considering all patients affected by a decision), the fact that colonization can persist indefinitely, and the patient's level of interaction within the facility. Patients who are incontinent of stool or urine or have wound drainage are at greatest risk for being a source of cross-contamination.

   When placing patients with VRE in multiple-bed rooms, roommates should not be severely immunocompromised, have indwelling lines or open wounds. In addition, VRE-positive patients who are incontinent of stool or urine and are likely to significantly contaminate the environment, should be placed in a private room or cohorted with other VRE positive patients, whenever possible.

2. Activity modifications.

   A long-term care facility is generally considered a patient's home. Patients with VRE should be allowed to ambulate, socialize normally, and participate in group activities as long as contaminated body substances are contained. Where appropriate, enhanced barrier protection to contain a contaminated body substance is preferred over restriction of the patient.

3. Handwashing.

   Use of antimicrobial in the room in the patient's room is recommended. Hands should be carefully washed after all patient care activities. Hands do not need to be washed routinely after casual contacts, such as a handshake or hug. The need for strict compliance with handwashing recommendations should be frequently reinforced.

4. Gloves and Gowns.

   In long term care settings there is a need for greater flexibility regarding decisions about the use of gloves and gowns. This will depend in part on the level of patient mobility and general compliance with hygienic practices, and the ability to contain secretions, excretions or drainage. Patients who are bedridden require a greater intensity of care and guidelines described above for hospitals may need to apply. When patients are more socially interactive and ambulatory, the need for gloves or gowns is limited to those situations involving direct contact with the contaminated body site. Nursing and medical staff should determine the most effective application of barrier concepts, balancing the need for infection control with promoting an optimal lifestyle for the patient. In all cases, clear guidance, consistency in approach, and rigorous enforcement is necessary.

5. Dedicated equipment.

   Equipment that is more likely to become implicated in transmission of VRE is less frequently used in nursing homes. Therefore, the need for dedicated equipment is less critical in long term care settings and not routinely recommended. However, patients should be evaluated on a case-by-case basis to determine where dedicated equipment may be indicated, i.e., patients who require a commode and who cannot be relied on to prevent contamination should have such equipment assigned.

6. Signs.

   Notification of isolation for VRE should be in keeping with the system currently used by the facility.

7. Housekeeping and laundry.

   See hospital recommendations.

8. Discontinuation of Isolation Precautions.

   Because patients with VRE carry this organism indeterminently, long-term care facilities should not expect patients to have negative cultures for VRE before being accepted for admission. (For further information on this subject, see the preceding hospital recommendations.)

Home Care Guidelines.

Admission and transfer of patients with VRE to or from the home is not a concern, other than to alert the receiving facility or agency. In addition, there is no need to disrupt housing arrangements because a household member has VRE.

Efforts to control VRE transmission in the home should focus on preventing cross-contamination via the nursing bag, clothing, and equipment which is carried to and from the home by the health care professional. Hands should be washed before leaving the home.

Other persons in the home should be educated about VRE and instructed to clean and disinfect toilet facilities used by the patient and contain and dispose dressings and other disposable materials that may be contaminated. No special precautions for linen, dishes, or personal clothing is indicated. If persons in the home provide direct care, they too should be guided on the importance of handwashing, glove use, and other barriers as reasonable and appropriate to the situation.

Reference:
¹ Hospital Infection Control Practices Advisory Committee.
Recommendations for preventing the spread of vancomycin resistance.
Infection Control and Hospital Epidemiology 1995;16:105-113.

Dale Morse, M.D.
Division of Epidemiology

Endorsement: Dennis Whalen
Office of Health Systems Management

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