VRE, MRSA: Hospitals starting to send nasty new bugs to home care
Some infections incurable, so prepare staff for increased occurrence
Home care professionals at a St. Louis agency received a call from the local hospital that a patient being referred for wound care had a disease they had never encountered: vancomycin-resistant Enterococcus (VRE).
Ana Casey, RN, BSN, clinical educator at Visiting Nurse Association of St. Louis, tried to find out what VRE is and what precautions the staff needed to take. The research wasn’t easy.
"When I called the local health department, they didn’t know what it was," Casey recalls. "The state wouldn’t take a stand, and we needed some [safety] guidelines."
VRE infection has increased dramatically in hospitals in recent years, and experts say home care providers should be prepared to deal with VRE because these patients soon will be coming their way. The Centers for Disease Control and Prevention (CDC) in Atlanta reported that the disease also has spread rapidly in long-term care facilities since VRE was first isolated in 1988.1
The proportion of enterococcal isolates resistant to vancomycin increased from 0.3% to 7.9% between 1989 and 1993, according to a recent CDC report.1
The CDC acknowledges that infections of VRE are virtually untreatable, which makes it imperative that education managers teach staff how to prevent transmission.
It’s almost impossible to eradicate’
"Once it gets into a hospital, it’s almost impossible to eradicate it," says Stephen Green, MD, FACP, FIDSA, an associate professor of medicine at Eastern Virginia Medical School in Norfolk, VA.
"A nurse could become a carrier, so it’s particularly important to emphasize good hand washing technique and wearing gloves whenever handling secretions," adds Green, who also is a hospital epidemiologist for Sentara Hampton General Hospital in Hampton, VA.
Casey is convinced that increasing numbers of home care agencies are going to see VRE patients as people leave hospitals more quickly.
"In order for a person to be clear of the disease, they have to have three clean cultures," she says. "But they can be released from the hospital before they have those three clean cultures."
So Casey and other professionals at the nonprofit full-service Visiting Nurse Association that covers St. Louis and three counties in Illinois went to work to develop their own protocol. (See VRE protocol, inserted in this issue.)
VRE is similar to methicillin-resistant Staphylococcus aureus (MRSA) in that both diseases involve bacteria that typically cause illnesses in people who are elderly or have weakened immune systems. Healthy people can be carriers of the bugs, but they won’t come down with the diseases. (For a quick look at MRSA, see story, at right.)
Green explains that the bug has developed a resistance to the drug vancomycin because that antibiotic has been given to many patients to treat a certain type of diarrhea and for other reasons.
There are two enterococci species: One is faecalis, which rarely becomes resistant to vancomycin, and the other is facium, which typically becomes a problem.
"In the hospital, one person is exposed to it and then develops a resistance to the drug," Green says, adding that the bacteria is spread through the patient’s stool.
It might contaminate the patient’s bedding and then is spread, primarily by hand-to-hand contact, to a nurse or health care professional, who unknowingly carries it to another patient who might have an open wound, he says.
"Then [the bacteria] hops around, and it makes it very difficult to treat. In the United States, we have no licensed drugs available to treat this thing," Green says.
The medical community is hopeful, Green says, that new drugs under development will be able to kill the bacteria.
Patients who contract the VRE disease might not die, but it can be dangerous and cause septicemia, a condition in which disease-causing micro-organisms are present in the bloodstream. It also can cause a urinary infection or wound infection.
When the VNA of St. Louis received word that they would be treating a VRE patient, the staff quickly researched the disease and then decided that normal infection-control precautions would not be adequate to prevent infection.
"We inserviced the staff, showed them a video, and gave them a supply of gowns," Casey says. "They each wore gowns and gloves when entering the home, and they took the gowns off and threw them away when leaving the house.
"It was an extra expense, but you can’t put your staff at risk. And for the safety of all of our patients, we can’t go home to home and transmit it."
[A 19-minute video on VRE, produced with the Association for Professionals in Infection Control and Epidemiology, costs $250 for APIC members and $275 for others. It can be ordered from Envision in Nashville, TN, by calling Jamie Lee at (615) 321-5066. Also, reprints of a brochure on how to prevent the spread of VRE, published in Infection Control and Hospital Epidemiology 1995; 16:105-113, are available from the National Technical Information Service at (703) 487-7650.]
Reference
1. MMWR (April 12, 1996) Vol. 45: 289-291.
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