This document discusses Vancomycin Resistant Enterococcus (VRE). It begins by explaining that antimicrobial resistance occurs naturally as microbes evolve, but is exacerbated by inappropriate antibiotic use. The overuse and misuse of antibiotics in both wealthier and developing nations has contributed to the rise of resistant strains. VRE is transmitted through direct contact and can cause difficult to treat infections. Risk factors include recent antibiotic use, hospitalization, and weakened immunity. Laboratories test for VRE and hospitals implement precautions like isolation, protective equipment, cleaning, and surveillance to control outbreaks. Treatment options for VRE infections are limited to antibiotics like linezolid and daptomycin.

1. Vancomycin Resistant
Enterococcus (VRE)
Dr. Abhijeet Mane

2. What is antimicrobial resistance?
– Microbes cause infectious diseases
– Antimicrobial agents combat severity and spread
– Emergence of resistance is natural biological
phenomenon
– “Selective Pressure”
– Majority microbes killed, but mutants may resist
– Lead to treatment failure

3. Why is antimicrobial resistance a
problem?
• Failure to respond to treatment
• Lead to prolonged illness
• Greater risk of death
• Patient remains infective for a longer time
• Resistant strain may spread to other people

4. Most important cause of
“Antimicrobial Resistance”?
• Inappropriate use of antimicrobials
• What is that?
• It occurs when antimicrobials are taken for too
short a time, at too low a dose, at inadequate
potency, or for wrong disease.
• Wealthier nations – over use
• Developing nations – under use

5. Introduction to Enterococci
• Bacteria which are normally present in Human
intestinal tract, female genital tract and often
found in environment
• Vancomycin often used to treat infections
caused by Enterococci
• Sometimes, resistance!!!!
• Vancomycin Resistant Enterococcus (VRE)

6. Contd…
• VRE spread by direct contact with infected
person, usually with hands
• Enterococci, per se, not very harmful or
virulent.
• Applies to sensitive and resistant strains.
• But, if infect urinary tract, surgical wounds,
blood stream, difficult to treat, sometimes life
threatening!

7. Some terminologies
• Carrier: refers to any patient who has had VRE
isolated from any site
• Colonization: presence, growth and
multiplication of micro organisms without
observable clinical signs / symptoms of infection
• Contact: any patient who has been in close
contact with VRE carrier
• Infection: invasion of bacteria into tissues with
replication

8. Causative agents of VRE
• Enterococcus faecium
• Enterococcus faecalis

9. Risk factors
• Enterococci growing (colonising) in body (mostly intestines)
• Contact with infected person or contaminated fomite
• Previous treatment with vancomycin or another antibiotic
for a long time
• Being hospitalised (eg. ICU, etc.) or long term care facility
• Weak immune system
• Treated with corticosteroids, parenteral feeding,
chemotherapy
• Having chest or abdominal surgery
• Having urinary catherter
• Undergoing dialysis

10. Infections caused by VRE
• UTI (most common)
• Intra abdominal and pelvic infections (common)
• Surgical wound infection
• Bacteremia
• Endocarditis
• Neonatal sepsis
• Meningitis (infection of membranes that
surround the brain and spinal cord)

11. Role of laboratory…
• Send samples to laboratory
• Culture: Sample inoculation
• Incubation
• Isolation
• ABST: Antibiotic Sensitivity Testing

12. What next…?
• Isolate patient
• Or Cohort with other VRE patient
• Contact precaution sign on door of room
• Equipment used for patient remains in same
room
• Kill germs by frequent hand hygiene especially
after using toilet
• Avoid touching open sores
• Any gross contamination of body fluids should be
cleaned up ASAP

13. Treatment
• Common antibiotics used are:
– Linezolid
– Quinpristin – Dalfopristin
– Daptomycin
– Tigecycline
– Nitrofurantoin

14. Standard precautions
• Gowns / gloves:
– Gloves changed when soiled or
– Move from dirty to clean task
– Gowns and gloves removed before exiting room
• Handwashing:
– With antimicrobial soap after removal of gloves,
gowns and other protective equipment

15. Risk factors for transmission
• Patients with diarrhoea or faecal incontinence
• Patient with enterostomies
• Patient with discharging wounds
• Catheterised patients with VRE colonisation of
urinary tract
• Patients incapable of maintaining own
personal hygiene

16. Prevention: Routine environmental
and equipment cleaning
• Documented cleaning schedules for all areas
of Health Care Facility (HCF)
• Routine cleaning is performed in all areas on
daily basis
• High risk areas identified eg. Shared toilets
• Documented procedures available to render
shared equipment safe for reuse on other
patients

17. Surveillance and Notification
• Microbiological surveillance
– Inpatients faecal, perianal or rectal swabs
• All laboratories isolating VRE shall ensure
prompt notification is made to Doctor
• Notify Infection Control Committee and nurse
in charge of unit

18. Outbreak management
• HCF should have documented Outbreak
Management plan
• Stop further spread
• Communicate to all concerned parties

19. Thank you
!!!