The document discusses the prevalence and impact of vancomycin-resistant Enterococcus (VRE) in healthcare settings, highlighting its colonization in patients and the challenges of controlling outbreaks despite implemented infection control measures. It mentions that factors influencing VRE outbreaks include hand hygiene compliance and environmental cleanliness, while also reflecting on the financial and operational pressures faced during prolonged outbreaks. Overall, the document underscores the need for a more strategic approach to managing VRE, positioning it not merely as an antibiotic resistance threat but as a symptom of broader preventive system failures.

1. 20-­‐11-­‐14
1
Andreas
Voss,
MD,
PhD
Senior
Consultant
Clinical
Microbiology
Canisius-­‐Wilhelmina
Hospital
Professor
of
Infec@on
Control
Radboud
University
Medical
Centre
Nijmegen,
The
Netherlands
¤
First
report
in
Europe
(1988)
¤
Endogenous
flora
was
considered
only
source
for
a
long
@me
¤
Role
of
environment
UQley
et
al.
Lancet
1988;57-­‐58
• Enterococci
in
45%
of
the
samples.
• Mostly
chicken
meat
(65.4%)
• VRE
in
29%
of
the
samples
• Highest
prevalence
of
VRE
in
chicken
meat
(76.5%)
Pavia
et
al.
J
Food
Protect
2000;63:912
VRE
coloniza6on
of
Vegans
versus
meat
eaters:
0
versus
6%
Schouten
et
al.
Lancet
1997:349:1258
¤
Range
2-­‐4%
Endtz
et
al.
J
Clin
Microbiol
1997;35:3026

2. 20-­‐11-­‐14
2
Meningitis
Neonatal infection
sepsis
pneumonia
UTI
Surgical infection
sepsis
meningitis
endocarditis
UTI
Intra-abd. infections
…
frequently
one
of
a
bunch!
Wound infections
Patient: underlying diseases, antibiotics, veel co-morbidity
UQley
et
al.
Lancet
1988;57-­‐58
Care
or
Not?
I
wish
VRE
control
would
be
possible
• Between
August
2004
and
December
2010,
Less
45
pa@VRE
ents
–
outbreaks
occurred
in
21
of
the
38
AP-­‐HP
s6hospitals
ll
outbreaks!
• An
ins@tu@onal
control
programme
was
implemented
• The
number
of
cases
per
outbreak
was
significantly
lower
ager
implementa@on
of
the
programme.
…
thus
maybe
Mike
isn’t
that
mad
...
…
if
VRE
has
established
itself
outside
of
the
hospital
and
in
the
community,
we’re
going
to
see
a
lot
more
VMRSA.
And
an
epidemic
strain
only
has
to
get
lucky
once…

3. 20-­‐11-­‐14
3
Did
anyone
check
Guinness
for
VRE?
NL:
only
interested
in
VR-­‐E.
faecium
(possibly
certain
CC’s)

4. 20-­‐11-­‐14
4
NL:
es6mated
number
of
infec6ons:
500,
number
of
death:
33
when
prevalence
is
40%
at
1%
=
12.5
cases
and
1.2
death
¤
Not
one
reason,
but
the
consequence
of
mul@ple,
small
factors
à
Swiss-­‐Cheese-­‐Accident
Model
(hand)hygiene
antibiotics
cleaning
Maintenance
Werk pressure
Bad luck
Low
compliance
(Hand) hygiene
antibiotics
cleaning
Not
good
enough
Maintenance
Work pressure
Bad luck
CC17,
bed-­‐pan
washers
Too
much
Cipro
Not
good
enough
Too
high,
trainees

5. 20-­‐11-­‐14
5
Low
compliance
(Hand) hygiene
antibiotics
cleaning
Not
good
enough
Maintenance
Work pressure
Bad luck
VRE
outbreak
CC17,
bed-­‐pan
washers
Too
much
Cipro
Not
good
enough
Too
high,
trainees
¤
Roomservice
¤
Roomservice-­‐plus
¤
Registered
nurse
¤
Nurse
asistant
¤
Cleaning
¤
Bedpan
VRE+
despite
washers
were
tested
and
validated
!
Not
our
model
¤
Bed-­‐pan
washers
according
to
EU
norm
A60
²
A60
=
the
effect
of
1
min
80°C
A0
value
of
outbreak
strain:
=
160
(2
min,
80C)
…
no
one
told
us
that
we
have
to
die
at
A60

6. 20-­‐11-­‐14
6
• Weekly audits including feedback
• Are screening cultures* negative
• Are bed pans visible clean à later dropped when
switch to disposable bed-pans
• Do HCWs regard HH-rules and show no mistakes
during observation of contact isolation
• Are all flagged patients actually in isolation (SR or
cohort)
• Only trained nurses taking care of VRE patients
* Weekly microbiological screening of the environment and all patients in affected units (n=8)
Ward
Cultures
(pats
&
en.)
Cleaning
HH-­‐rules
&
isola6on
Flagging/
sor6ng
Trained
HCWs
A
B
C
D
E
Reported
to
medical
head,
unit
manger,
head
nurse,
CEO
….
cleaning
flagging
cleaning
Week
Cultures
(pats
&
en.)
Cleaning
HH-­‐rules
&
isola6on
Flagging/
sor6ng
Trained
HCWs
1
2
3
4
5
6
7
….
A
long
6me

7. 20-­‐11-­‐14
7
¤
14
month
outbreak
VRE
HERE
à
VRE tiredness
¤
450+
cases
(coloniza@on)
¤ Financial pressure – insurance contracts
¤
28.000
PCRs,
7.000
extra
cultures
¤
Extra
cleaners
&
new
detergent
&
wipes
¤
New
products
&
business
cases
¤
Endless
audits
&
training
sessions
¤
Change
of
an@bio@c
formulary
¤
S@gma@za@on
&
uncertainty
¤
Problems
in
returning
to
nursing
homes/home
hospital
¤
VRE-­‐posi@ve
for
>
1
year
¤
Cases
with
BSI:
5
(4
cured,
1
died
with
VRE)
IS VRE A REAL PROBLEM
Mammatus
Clouds

8. 20-­‐11-­‐14
8
Is
that
possible
once
we
eat
it?
Yes,
but
ac6ve
surveillance?
Always
good?
But
need
to
reduce
MRSA
first!
No
need
in
vanB!
¤
LiQle
clinical
impact
(at
least
in
most
units)
¤
High
cost
of
control
¤
S@gma@za@on
of
pa@ents
¤
Lack
of
decoloniza@on
possibili@es
¤
Community
spread
including
our
food
¤
Need
to
waist
energy
to
clean
bedpans
at
2
min/80C
(or
invest
in
disposable
system)
¤
AMS
changes
(stop
SDD?)
may
protect
us
from
VRE
but
select
for
something
else,
far
worse
Not
really
6me
to
give
up,
but
certainly
6me
to
stop
making
such
a
fuzz
about
it
!
VRE
should
not
be
seen
as
an
An6bio6c
Resistance
Threat
but
as
an
indicator
of
a
failing
preven6ve
system