Prevent transmission: Isolating vancomycin-resistant Enterococci (VRE) and breaking the chain of contagion

Abstract

BACKGROUND: In July 2003, VRE prevalence on a 25-bed medical unit and 10-bed medical intensive care unit (MICU) was 27% (7/24) and 57% (4/7), respectively. Environmental contamination was 37% (3/8) and 25% (1/4). Pulsed-field gel electrophoresis (PFGE) was used to analyze VRE cultures. Findings suggested cross-transmission between patients and environment. Two of three positive environmental cultures were highly related to five of seven positive medicine patient cultures. One positive MICU environmental culture was highly related to one MICU patient culture. METHODS: A root cause analysis (RCA) team compiled of housekeeping, nursing, medicine, supply, and infection control analyzed causes of VRE cross-transmission. The team addressed the role of environmental contamination, compliance to contact precautions, and other risks for transmission applying SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains of <i>Staphylococcus aureus</i> and Enterrococcus (May 2003). Actions included: 1) Use disposable wipes to clean and disinfect hard nonporous environmental surfaces. 2) Track VRE in the electronic medical record. 3) Improve the use of and accessibility to waterless alcohol hand rub. 4) Install glove dispensers next to hand rubs at the entrance to patient rooms. 5) Implement disposable perineal wash clothes. 6) Improve availability of personal protective equipment. 7) Educate staff. 8) Simplify contact precaution signage. 8) Evaluate alternatives to computer keyboards to improve disinfection. RESULTS: In December 2003, after implementation of the disposable equipment wipes, improved accessibility to hand rub and gloves, staff education, and simplified isolation signs, a repeat prevalence survey was conducted. There were no positive cultures found from 10 environmental swabs, a significant improvement in decreasing environmental contamination. (p < 0.01) The VRE prevalence rate in the medical unit decreased to 22% (6/26) and in the MICU to 20% (2/10) (p>0.05). Daily compliance monitoring of hand antisepsis and disposable washcloths was recently implemented. Results of January 2005 prevalence study are pending. CONCLUSION: VRE prevalence rate decreased following the multidisciplinary RCA actions, and an environment free of VRE contamination was achieved. Antisepsis compliance monitoring may further decrease VRE prevalence.