Outline the predisposing factors, consequences and management of the critically ill patient with Vancomycin Resistant Enterococcus (VRE).
Previous treatment with anti-microbials (especially vancomycin, cephalosporins and broad-spectrum antibiotics)
Increased length of stay
Long-term IV access
Enteral tube feeding
Prevalence of VRE colonized patients in the ICU
Resident of long-term care facility
Decreased staff : patient ratios
Potential transmission of resistance to Staph aureus
Determined by site of infection if present (eg UTI, bloodstream including endocarditis and rarely respiratory infection)
Need for isolation
Specific antibiotics if infected rather than colonized depending on sensitivities (Van A resistant to vancomycin and teicoplanin; Van B sensitive to teicoplanin) – options include linezolid, daptomycin, quinupristin-dalfopristin, tigecycline.
Probiotics may have a role.
Infection control including isolation, contact precautions and PPE, and general infection control measures including surface and environmental cleaning, antibiotic stewardship, screening of contacts and patient surveillance until swabs are negative.
Precautions should continue on discharge from ICU
VRE comes up often in this exam. One should become intimately familiar with its behaviour and temperament.
- Proximity to other VRE patients - especially those with diarrhoea
- Advanced age
- Severe underlying illness
- Inter-hospital transfer
- Nursing home residency
- Extended hospitalization
- Specialized nutritional support
- Central venous catheterization
- Haematologic malignant tumours
- Solid organ allograft
- Chronic haemodialysis
- Antibiotic exposure to vancomycin, third-generation cephalosporins, metronidazole, and any antibiotics with anti-anaerobic activity.
- Exposure to multiple antibiotics
- Prolonged duration of antibiotic therapy
Consequences of VRE colonisation
- Need for isolation
- Potential for clinically significant VRE infection
- Potential for transmission of vancomycin resistance to S.aureus
Management of the colonised patient
- Protective equipment
- Scrupulous attention to cleaning areas where the patient has been
- Surveillance swabs until the patient tests negative
Management of the clinically relevant VRE infection
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