DDS Medical Advisory #98-2
Guidelines for Management of Clients
with Vancomycin Resistant Enterococci
in DDS Operated or Funded Facilities or Services
(March 1998)

PURPOSE:

To provide guidance for personnel to provide the proper management for individuals infected with Vancomycin Resistant Enterococci (VRE) and to prevent its spread among individuals, personnel and the environment.

APPLICABILITY:

This advisory applies to individuals of the department who receive day and/or residential supports or services regardless of the facility or region in which they are served.

The department recognizes the special need to work with facilities which it does not fund or license to ensure the thorough understanding and implementation of medical advisories.

DEFINITIONS:

Cohorting: Placement of two or more individuals with Vancomycin Resistant Enterococci (VRE) in the same room or separation of VRE infected individuals from those who have not acquired VRE.

Colonized individual (carrier): Any person who is found to be culture-positive for VRE, but has no signs or symptoms of infection caused by the organism.

Decolonize: To administer topical and/or systemic antimicrobial agents for the purposes of eradication VRE carriage by an individual.

Endemic: The usual (baseline) frequency of VRE infection in a given facility.

Epidemic: An increase in the incidence of VRE infection above its expected endemic level of occurrence in a given facility.

Incidence: The number of new cases of VRE that occurred during a given interval of time divided by the population at risk during the given interval of time.

Infected individual: An individual who has laboratory and clinical evidence of disease (e.g. wound infection).

Nosocomial Infection: An infection acquired in the hospital.

Outbreak: An increase in the incidence of VRE above its expected endemic level of occurrence in a given facility. An outbreak is suggested if there are two or more new infections within a one month period.

Vancomycin resistant enterococci: A strain of Enterococci (including E. faecalis and E. faecium) resistant to vancomycin.

INTRODUCTION

Over the last several years the incidence of VRE in hospitalized patients has been increasing nationwide. In 1995, the Centers for Disease Control and Prevention (CDC), Hospital Infection Control Practices Advisory Committee (HICPAC) published Recommendations for Preventing the Spread of Vancomycin Resistance. These recommendations mostly applied to acute care hospitals. In May 1997, the Connecticut Department of Public Health (DPH) published Management of Patients/Residents with Vancomycin Resistant Enterococci in Acute Care Hospitals and Long Term Care Facilities.

With the increased incidence of VRE in health facilities, we can anticipate increasing numbers of individuals with VRE who receive services from DMR. In such instances, concerns are similar to those addressed by the DPH for people living in long term care facilities: proper management for infected individuals and prevention of the spread of infection to other individuals. This advisory, drawn from the 1997 DPH guidelines, will provide guidelines for such individuals and personnel.

BACKGROUND

(Information provided in the entire Background section was taken directly from DPH May 1997 Management of Patients/Residents with Vancomycin Resistant Enterococci in Acute Care Hospitals and Long Term Care Facilities.)

Enterococci are the second most common cause of nosocomial (hospital acquired) infections in the United States. They are estimated to be responsible for 10 to 20% of all such infections in the U.S. and for approximately 8% of all nosocomial bloodstream infections. In recent years, enterococci resistant to the antibiotic vancomycin have appeared with increasing frequency.

The emergence of vancomycin-resistant enterococci (VRE) as an important nosocomial pathogen in susceptible populations represents a significant challenge to infection control personnel. Concern about VRE is related to the potential for nosocomial transmission, the lack of antibiotics to treat infections caused by this organism, and the possibility that the vancomycin-resistant genes present in VRE can be transferred to other gram-positive microorganisms such as Staphylococcus aureus.

As the prevalence of VRE in hospitalized patients has been increasing nationwide, all health care facilities have the potential to be affected. Vancomycin-resistant enterococcal infection is a laboratory reportable finding in Connecticut. From 1994 through 1996, 64% of all laboratories that perform vancomycin-susceptibility testing of enterococci have identified VRE from sterile site specimens.

Enterococci are gram-positive cocci that are part of the normal flora of the gastrointestinal and female genital tracts. The two most common species causing human infection are Enterococcus faecalis, which causes 80% to 90% of all enterococcal infections, and Enterococcus faecium, which causes 5% to 15%. Other species include E. durans, E. avium, E. casseliflavus, E. gallinarum, E. raffinosus, and E. hirae.

These organisms were traditionally susceptible to penicillin, vancomycin, aminoglycosides and quinolones. As a consequence of widespread use and misuse of antimicrobial agents, enterococcal resistance to these antibiotics has emerged. Between 1989 and 1993, the percentage of nosocomial enterococcal infections reported to the CDC that were vancomycin resistant increased form 0.3% to 7.9%.

In addition to the increase in VRE, the potential spread of vancomycin resistance to Staphylococcus aureus or Staphylococcus epidermidis is a serious public health concern.. The genes for vancomycin resistance are frequently plasmid-borne and have been transferred in vitro from enterococci to staphylococci. Clinical strains of vancomycin-resistant Staphylococcus haemolyticus and S. epidermis have already been reported. Spread of vancomycin resistance must be controlled to prevent the development of untreatable staphylococcal infections.

Epidemiology and Transmission of VRE

The epidemiology of vancomycin resistant enterococci (VRE) has not yet been elucidated completely. Populations found to be at increased risk for VRE include:

  1. Those who have received vancomycin and/or multi-antimicrobial therapy;
  2. Those with severe underlying disease or immunosuppression;
  3. Those who have had intra-abdominal or cardiothoracic surgical procedures;
  4. Those who have an indwelling urinary catheter or central venous catheter.

Because enterococci are part of the normal flora of the gastrointestinal and female genital tracts, most infections with these bacteria have been attributed to the patient's endogenous (own) flora. However, recent reports have documented spread of VRE by direct patient-to-patient contact and via carriage on the hands of personnel. Transmission of VRE may also occur through indirect spread since contamination of the environment around the colonized or infected person has been demonstrated. Organisms have been recovered from bedrails, sheets, call buttons, telephones, horizontal surfaces, doorknobs, and patient care equipment such as stethoscopes and thermometers.

Therefore, VRE infection can be transmitted from contaminated articles via direct contact with such articles by an at risk individual or indirectly by a staff person who does not comply with thorough handwashing and other infection control measures.

Individuals with VRE in the stool may continue to shed organisms for weeks to months and treatment may not successfully eradicate the organism.

PROCEDURE;

I. Management of the Infected Individual

When an individual living in or receiving services from a DDS operated or funded facility or program, is diagnosed with VRE, the following shall occur:

  1. The person's physician shall complete required reporting to DPH and shall order treatment and follow-up surveillance as appropriate.
  2. The facility/agency nurse shall be notified immediately and the DDS regional health service director shall be notified as soon as possible.
  3. The facility/agency nurse with the person's interdisciplinary team (IDT) including the physician, shall review the health issues specific to the individual and make recommendations and/or decisions regarding home, work, and other activities as appropriate. Participation in normal living activities shall be encouraged as appropriate for the individual. In making such decisions, the IDT shall consider:
    1. the body sites from which VRE has been cultured and whether drainage from such sites can be contained;
    2. the person's competence regarding personal hygiene and whether these factors relate to the potential spread of VRE; 
    3. the type of direct care the person requires; and
    4. the ability of staff to comply with strict hand washing and infection control procedures (physical plant and training issues).
  4. The IDT recommendations/decisions regarding the person's living, day and social situations shall be based upon the following considerations:
    1. Individuals infected with VRE may share a bedroom with a low-risk roommate (i.e., one who does not have tubes, catheters, wounds or decubiti, intravascular lines, and/or is not immuno-compromised) or with another VRE positive individual (cohorting).
    2. VRE positive individuals should be considered for a private room and should not ambulate or socialize without one-to-one supervision if the person
      1. has VRE isolated in stool and has uncontrolled diarrhea;
      2. has VRE isolated from stool and does not understand or cannot/will not cooperate with basic hygiene;
      3. has VRE isolated from a wound that cannot be covered or has drainage that cannot be contained; and/or
      4. as determined by the nurse, physician, or facility or regional infection control committee.
    3. The availability of direct supervision (one-one) if necessary to minimize direct physical contact with other individuals.
  5. The agency/facility nurse or other appropriate manager shall ensure that staff receive inservice training regarding VRE infection including issues and concerns specific to the individual with VRE.

II. Communication and Confidentiality

  1. The agency or facility nurse shall ensure that required reporting to DPH as occurred.
  2. Information regarding the individual's infection or colonization of VRE shall be handled in the same manner as any other medical information.
    1. As with all medical information, diagnosis and treatment of VRE shall be released to the individual's health providers. Standard medical consent to release information shall be maintained in the individual's record (medical record or master file).
    2. Information regarding VRE infection shall be released to others on a need to know basis, only after obtaining the consent of the individual or his or her guardian.
    3. If information cannot be shared due to lack of consent and concerns include potential risk to other individuals, the DDS health service director shall notify the DDS central office director of health and clinical services who shall seek the advice of the Office of the Attorney General.
  3. When the person is being transferred to another setting, advance notification shall be given to ensure appropriate planning.

III. Precautions

Although the mechanism of VRE transmission has not yet been completely defined, it is known that spread can occur by direct contact (e.g. touching VRE colonized stool) or by indirect contact (e.g. touching the contaminated hands of health care workers or contaminated environmental surfaces).

Because there is currently a lack of treatment options for VRE, prevention through the use of effective infection control measures is extremely important. The three most important components are

  • thorough handwashing;
  • appropriate use of protective equipment; and
  • careful attention to environmental sanitation.
  1. Handwashing is the most important procedure to prevent the spread of VRE. Proper technique includes:
    1. washing hands before contact with each individual and before donning gloves;
    2. washing hands after caring for the individual or touching potentially contaminated environmental surfaces;
    3. washing hands after removing gloves and before leaving the person's room;
    4. using an antimicrobial soap or disinfectant solution (e.g. chlorhexidine);
    5. using paper towels with proper disposal. Disposal shall be done according to local infection control procedures for infectious waste (not biomedical waste); and
    6. avoiding touching potentially contaminated surfaces such as bedside rails and doorknobs after washing hands.
  2. Glove use is required as follows:
    1. Gloves must be worn
      1. before entering the VRE infected person's room;
      2. when contact with the person or environmental surfaces is expected;
      3. when caring for the person.
    2. Gloves should be changed between caring for different anatomical sites (e.g. between oral care, dressing changes, peri care, etc.).
    3. Gloves should be not be worn for prolonged periods.
    4. Gloves should be changed between caring for different individuals.
  3. Gowns should be worn if clothing is likely to come into contact with body secretions, stool, urine or drainage.
  4. Masks and eye protectors or face shields should be worn if it is likely that eyes and/or mucous membranes (e.g. nasal passages, etc.) may be splashed with body substances such as when suctioning a person with copious secretions.
  5. Cleaning equipment
    1. Equipment should be dedicated for the infected person whenever possible (e.g. thermometers, commodes, etc.), especially when use of disposable equipment is not feasible.
    2. Non-dedicated or non-disposable equipment shall be disinfected with an EPA-approved Hospital Grade disinfectant-detergent prior to use for another individual.
  6. Laundry
    1. Soiled linen shall be bagged near the location where used.
    2. Laundry should not be sorted or rinsed in common living areas (e.g. shared bathrooms).
    3. Linen heavily soiled with body fluids (urine, stool, etc.) that may soak through a linen bag shall be placed in an impervious bag to prevent leakage.
    4. Linen handlers shall wear appropriate protective equipment.
    5. Soiled linen does not have to be washed separately.
  7. Housekeeping
    Because VRE can survive for prolonged periods on environmental surfaces, careful attention to proper disinfection is essential and shall include:
    1. Environmental surfaces shall be routinely cleaned (daily) with a hospital grade disinfectant detergent in accordance with the manufacturer's instructions. Environmental surface include but are not limited to bedrails, tables, wheelchairs and other assistive devices, and commodes. (Consider all surfaces touched by the affected individual or staff who have provided direct care to the individual.)
    2. Shared equipment shall be cleaned prior to use by another individual.
    3. When possible, a normally shared "common area" such as a second bathroom, shall be dedicated to the person infected with VRE.

IV. Surveillance

  1. DDS Operated Facilities/programs
    1. DDS regional infection control committee shall determine region specific infection control policies and practices. Such committees shall identify a responsible person(s) who shall:
      1. determine baseline incidence rates for VRE in DDS campus facilities and other settings as deemed appropriate by the committee;
      2. monitor new cases of VRE infection/colonization, identify increased incidences of infection above the expected endemic (baseline) level, determine if possible, whether the new case was generate "in house" or in another facilityor hospital, and ensure reporting to, or seek advice from the DPH Epidemiology unit or infectious disease specialists as appropriate.
      3. determine if additional incidences of VRE constitute an outbreak as previously defined and ensure appropriate responses such as DPH notification, re-inservicing of infection control procedures, and other appropriate actions.
    2. The DDS regional health service director shall ensure that appropriate measures are taken including placement decisions, inservice training, and infection control practices.
  2. Private Agencies Funded by DDS
    1. Private agency policies and procedures shall address infection control issues including VRE infections as appropriate.
    2. Private agencies shall report each new occurrence of VRE infection or colonization to the DDS regional health service director.
  3. The DDS regional health service director shall notify the DDS central office director of health and clinical services as appropriate.
  4. The central office director of health and clinical services shall notify the commissioner and other individuals as appropriate.

NOTE: The State of Connecticut Department of Public Health (DPH) Management of Patients/Residents with Vancomycin Resistant Enterococci In Acute Care Hospitals and Long Term Care Facilities is available upon request from the DPH, DMR regional health service director, the DDS central office director of health and clinical services.

Connecticut Developmental Services

460 Capitol Avenue
Hartford Connecticut 06106