Question 9

Outline the causes, consequences and management of Vancomycin Resistant Enterococcus in the critically ill patient.

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College Answer

Enterococci are intrinsically resistant to many antibiotics, but acquired resistance has more recently become a major problem. A genetic modification in the bacteria occurs, presumably as a result of exposure to vancomycin (more widespread recent use, including for penicillin resistant pneumococcus and its oral use for clostridium difficile). Resistance is readily transmitted between strains, with risk factors identified being previous treatment with anti- microbials (especially vancomycin, cephalosporins, and broad-spectrum antibiotics), increased length of stay, renal insufficiency, enteral tube feeding, prevalence of VRE colonised patients in the unit, and residents of long-term care facilities.

Consequences are determined by the presence of infection (UTI, bloodstream including endocarditis, and rarely respiratory infection), or just colonisation (main consequence being requirement for isolation and associated factors). Patients usually have significant pre- existing co-morbidities.

Management involves specific antibiotics if infected rather than colonised (depend on sensitivities: regimens may include one or more of ampicillin, tetracyclines, teicoplanin, quinolones, and quinupristin-dalfopristin), infection control related to the patient (isolation [avoiding direct contact], aggressive infection control, limiting broad spectrum antibiotics if possible, surveillance of patient until clear).


This question is identical to Question 2 from the second paper of 2012 and closely resembles Question 26 from the first paper of 2007. The only difference is, in later years the examiners demonstrated an attachment to accuracy when they changed "causes" into "predisposing factors".