Clinicians targets VRE with infection control, antibiotic efforts
Vancomycin controls, education emerge as prime prevention strategy
A two-pronged approach of antibiotic controls and infection control measures is proving an effective combination against vancomycin-resistant enterococci (VRE), a nosocomial pathogen that has increased dramatically in recent years.
In particular, antibiotic control efforts that enjoy bu- in from attending physicians are curtailing improper vancomycin use, reducing antimicrobial pressures that can give rise to VRE, infection control practitioners report.
Studies reported recently in Atlanta at the annual conference of the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC) provide some of the first evidence that such efforts may eventually stem the tide of VRE in the nation's health care facilities. A multidisciplinary approach to VRE was recommended last year in guidelines by the Centers for Disease Control and Prevention in Atlanta, which has reported an explosive increase in VRE infections in intensive care units and troubling trends toward a similar increase in non-ICU patients.1
The CDC Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines call for broad collaboration among hospital departments -- including infection control, pharmacy, and quality improvement -- to prevent and control infection and colonization with VRE.
Such efforts have been successful says Sally Fontecchio, RN, BSN, CIC, infection control professional at the University of Massachusetts Medical Center in Worcester. The number of cases of VRE at the hospital declined dramatically in the last six months of 1995, dropping to 36 cases for the period after 90 had been identified in the first half of the year.
"We are now seeing more community cases then we did early on," she tells Hospital Infection Control. "We are having an acceptable level at this point. On any one day we only have three [VRE] patients in the hospital."
Through staff education and compliance monitoring, the program has concentrated on improving contact isolation, hand washing and glove use with VRE patients. Likewise, environmental cleaning protocols were reviewed and reinforced through random culturing of surfaces for VRE. Stringent infection control measures and cohorting of infected and colonized patients interrupted cross transmission in the hospital, keeping the VRE reservoir in check while vancomycin controls began lowering the selective pressure that contributes to resistance.
After an initial education effort and voluntary program resulted in appropriate vancomycin use in only about two-thirds of orders, a mandatory policy was adopted in February 1995 requiring all orders to meet HICPAC criteria for use. (See recommendations, p. 99.)
"If it didn't meet criteria then [pharmacy staff] will call the physician who ordered the vancomycin and discuss it," she says. "If it is acceptable then they will release the dose."
If the matter cannot be resolved at that level, the attending physician discusses the case with an infectious disease physician, who might suggest alternative drug therapy or agree that the vancomycin should be administered. Under such control measures, overall vancomycin use began dropping, and the doses that are being administered are more often in sync with the HICPAC guidelines.
"What has been accomplished is that, first fewer orders are being written, and second, the orders are appropriate." Fontecchio says.
Reducing the pressure
While infection control measures for identified cases are critical, prudent use of vancomycin is particularly important because the drug may predispose patients to colonization and infection with VRE by inhibiting the growth of normal gram-positive gut flora, providing a selective advantage for VRE that is colonizing a patient's gut or skin.2
"We're putting less pressure on the microbiological flora in the institution," Fontecchio says. "If we are exposing fewer patients to vancomycin, then the nosocomial flora in the patients is less pressured into developing resistance. It is going to take a while to reduce the pool of patients that already have VRE out there and act as reservoirs for cross transmission. But I think if we are not inducing more resistance on top of the pool we already have for potential cross infections, that in the long run we will see far fewer cases."
Indeed, a similar general trend was seen in collaborative data compiled from 10 hospitals in New Jersey, notes Pat Bain, RN, BSN, CIC, infection control coordinator at Englewood (NJ) Medical Center. Most facilities implemented VRE infection control measures first, then followed with antibiotic controls, says Bain, who presented the findings at APIC.
"We noticed an increase in VRE in our hospitals that was not in the intensive care units," she tells Hospital Infection Control. "But over a six month period of time we noticed that it was going down. When we looked back to see what had happened, the hospitals had imposed restrictions in the use of vancomycin. We had [implemented] contact isolation before that, but it took the hospitals a while to get the restrictions on the use of vancomycin in place. We could attribute the [VRE] decrease more to the decrease in vancomycin [use] than anything else."
In that regard, some ICPs in hospitals that have not had a documented case of VRE are focusing on prudent vancomycin use and other antibiotic control measures as a prime prevention strategy.
"We have not had any VRE in our medical center, and we wanted to keep it that way," says Linda Becker, RN, BSN, MPH, department administrator of infection control at Kaiser Permanente Medical Center in Fontana CA.
A multidisciplinary continuous quality improvement (CQI) team was formed in January 1995 to ensure prudent use of vancomycin. Using the HICPAC criteria, retrospective chart review was conducted on all vancomycin usage from January 1994 through June 1995. The total number of vancomycin usage days was also collected. Areas of compliance and opportunities for improvement were identified and reviewed with three medical staff committees.
Benefits of buy-in
Lack of physician awareness of the consequences of inappropriate vancomycin use was determined to be the root cause of inappropriately ordered vancomycin, Becker says. Having been brought into the improvement effort at the onset, physicians were receptive to both the initial findings and to improving the situation, she says.
"I really feel the keys to the success of this process where the physician buy in on the criteria up-front," Becker says. "It's so critical to get that physician buy in and multidisciplinary support for these kinds of projects. You just can't go off and do them in isolation and expect people to accept the data or take action if they haven't been brought into the process."
A variety of educational approaches were taken to improve appropriate usage, including monitoring of vancomycin use by pharmacists and infectious disease physicians and discussions with attending physicians ordering the drugs. In addition, mandatory physician training on bloodborne pathogens was expanded to include prevention and control of VRE. Under such efforts, the initial appropriate usage improved from 75% in 1994 to 88% in 1995. Likewise, overall days of inappropriate vancomycin use declined from 30% in 1994 to 14% in the first six months of 1995. The next step will be sharing department-specific data with physician quality assessment and improvement representatives and collaborating to improve the prudent use of vancomycin, she says.
"The largest area for improvement was in empiric antimicrobial therapy without strong evidence of beta-lactam resistant, gram positive infection," she says. "This would be an area that might also be important for other medical centers."
A recently published study found that 44 of 66 identified inappropriate uses of vancomycin were due to empiric treatment without obtaining cultures. The threat of methicillin-resistant Staphylococcus aureus was cited for the quick-trigger on vancomycin use, but the authors noted that "a number of antibiotic agents were potentially useful alternatives, but were used rarely."3 The authors also concluded that shortening the course of empiric therapy should decrease the amount of vancomycin used.
'Is it safe?'
To facilitate such decisions, the team at Kaiser Permanente developed a simple clinical decision chart that reminded physicians to reconsider the appropriateness of vancomycin use after three days. (See chart, below.)
"What we thought was really crucial was the reevaluation of vancomycin usage in three days because then you are going to know your lab results and that is going to drive your decision making," she says. "And from there you go to ongoing use of vancomycin -- appropriate or inappropriate -- or discontinuation, which could also be appropriate or inappropriate."
Since empiric administration comprises the vast majority of vancomycin use, reconsidering discontinuation or using alternative drugs after three days can have a great impact, says Charles Salemi MD, MPH, the hospital epidemiologist and chairman of the infection control committee.
"Physicians are now aware of the problem of VRE," he says. "When the physicians are aboard, it's simple. It's not just lip service, saving money, or us trying to make their lives miserable. It is really important for patient care."
While such approaches may not be enough in hospitals that already have rampant VRE, raising physician awareness about vancomycin use is a solid prevention approach for hospitals that have not yet had to deal with the pathogen, he adds.
"If medical centers don't have [VRE], they really better get aboard and start doing something," he says.
Underscoring the importance of the situation may not fall solely to infection control professionals. The VRE reports at APIC come amid increasing public awareness about the pathogen, which is seen as a harbinger of a post-antibiotic era because it carries the threat of transferring resistance capabilities to S. aureus. (See Hospital Infection Control September 1995, pp. 109-113.) That would -- by virtually all assessments -- be a public health disaster, and thus the threat of VRE is drawing coverage from mainstream press. In that regard, a recent article on VRE in the Los Angles Times did not go unnoticed by the patients at Kaiser Permanente, Salemi notes.
"That really got everybody's attention," he says. "Patients actually were asking their doctors, is it safe? They wanted to know if we had antibiotic-resistant organisms in our medical center."
References
1. Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1995; 44:(RR-12)1-13.
2. Boyce J. Vancomycin-resistant enterococci: Pervasive and persistent pathogens. Infect Control Hosp Epidemiol 1995; 16:676-679.
3. Evans ME, Kortas KJ. Vancomycin use in a university medical center: Comparison with hospital infection control practices advisory committee guidelines. Infect Control Hosp Epidemiol 1996; 17:356-359. *
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