VRE in ICU: What works

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VRE in ICU What works?

• Craig Boutlis
• Infection Management and Control Service
• Wollongong Hospital

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The difficult 2nd talk after lunch

• Craig Boutlis
• Infection Management and Control Service
• Wollongong Hospital

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We asked 150 old dogs
117
20
11
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For their new tricks
117
20
11
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Confessed VRE endemicity
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VRE bacteremias numbers
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What works The old dogs said
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Arch Int Med 2005165(3)302
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Alcohol-chlorhexidine works
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Gordin FM, Infect Control Hosp Epidemiol
200526(7)650
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Lai KK, Infect Control Hosp Epidemiol
200627(10)1018
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Handrub use at record levels
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Technical recession in MRSA
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Nosocomial ICU MRSA
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HCA-VRE acquisition in ICU
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The old dogs said
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Arch Intern Med 2006166(18)1945
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Drees M, Clin Infect Dis 200846(5)678
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Baseline
Cleaning education
Washout
Hand hygiene intervention
Hayden MK, Clin Infect Dis 200642(11)1552
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• 6 ? in prevalence for 10 ? cleaning

Hota B, J Hosp Infect 200971(2)123
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Nobody cleaning our beds
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Once we started cleaning the beds

• Advice from the Wards is indicating that the new
  cleaners are being well received and that the
  documentation is being completed.
• Beds are being cleaned thoroughly and my
  observation and that of the cleaning staff has
  revealed that many of the beds are caked with
  large build up of organic matter, blood and
  faeces particularly under the beds. I think this
  provides confirmation that specialised cleaning
  of the beds is needed.

Anon But someone who can be trusted to know
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Combined detergent / bleach

• 1 Litre of cold water
• 1 tablet Chlor-Clean

Manufacturers website http//www.qedocctech.com/
chlor-clean/
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Can we control it at the source?

• Achromobacter spp
• Acidaminococcus fermentans
• Acinetobacter cacoaceticus
• Aeromonas spp
• Alcaligenes faecalis
• Anaerobiospirillum spp
• Bacillus spp
• Bacteroides fragilis
• Bacteroides melaninogenicus
• Bifidobacterium spp
• Butyriviberio fibrosolvens
• Campylobacter coli
• Campylobacter spp
• Clostridium difficile
• Clostridium sordellii
• Clostridium spp
• Eikenella corrodens
• Enterobacter cloacae
• Enterococcus faecalis

Escherichia coli Flavobacterium spp Morganella
morganii Mycobacteria spp Mycoplasma
spp Peptococcus spp Plesiomonas
shigelloides Propionibacterium acnes Propionibacte
rium spp Providencia spp Pseudomonas
aeruginosa Ruminococcus bromii Ruminococcus
spp Sarcina spp Staphylococcus aureus Streptococcu
s anginosus Streptococcus viridans Veillonella
spp Vibrio spp Yersinia enterocolitica
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Peterson LA, Arch Intern Med 2006166(3)274
Vernon MO, pp. 306
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Parienti J, Crit Care Med 200937(6)2097 Climo
MW, pp. 1858
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Do throw the bathwater out before washing the
baby!

• 13 contaminated with VRE

Johnson D, Am J Crit Care 200918(2)100
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The old dogs said
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Restricting vancomycin use

• Pre intervention
• 61 inappropriate
• Post-intervention
• 30 inappropriate
• Significant reduction in VRE acquisition

Anglim AM, Arch Intern Med 19971571132
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Restricting 3 gen Cephs
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ABx switch on hematology unit
Tazocin
Teico
Cipro
Ceftaz
Bradley SJ, J Antimicrob Chemo 199943261
37
?
Winston LG, Am J Infect Control 200432(8)462
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?
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• Factors that increased contamination
• Diarrhea
• Higher colonization pressure in the ICU
• Receipt of antibiotics (in general)

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Colonization pressure

• Rather admission to ward with
• 2 VRE patients or 20 VRE patients?

Bonten MJ, Arch Intern Med 19981581127-1132
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The old dogs said
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Hayden MK, Infect Control Hosp Epidemiol
200829(2)149
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Snyder GM, Infect Control Hosp Epidemiol 2008
Jul29(7)583-9
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Bearman GM, Am J Infect Control 200735(10)650
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Adding gowns to gloves no better
Slaughter S, Annals Int Med 1996125(6)448
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Adding gowns to gloves is better
Srinivason A, Infect Control Hosp Epidemiol
200223(8)424
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21 Gowns are good!
Puzniak LA, Clin Infect Dis 200235(1)18
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You know it makes sense!
Zachary KC, Infect Control Hosp Epidemiol
200122(9)560
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• Gardine brilliant green chlorhexidine
• Good for MRSA, VRE, MRAB
• At 30 second and 10 minutes

Reitzel RA, Am J Infect Control 200937(4)294
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The old dogs said
Dont get me started!
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Possible benefits of screening

• Ultimately ? reduce colonization pressure
• Rather admission to ward with 2 or 20 VRE
  patients?
• Reduce the undetected ratio
• Only detect 30 prevalence, 18 of incidence
• Perhaps it would change your empiric Rx
• Cant decolonisebut can chlorhexidine wash
• ? contamination of patient, environment
  acquisitions
• pin-off benefit of reducing BSIs in ICUs
• An audit tool of other interventions

Huang SS, J Infect Dis 2007195339-346. Talbot
TR, J Infect Dis 2007195314-317
Vernon MO, Arch Intern Med 2006166306-312.
Bleasdale SC, Arch Intern Med 2007167(19)2073-20
79
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A tale of 2 hospitals
NO
YES
Price CS, Clin Infect Dis 200337921-8
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Who do we screen?
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Who should we screen?
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Happy with screening policy?
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The first time we screened 20 acquisition rate
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What you lose on the swings
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ICU admissions and VRE
23/429 (5.4) positive for VRE on arrival
MRSA 10
15/229 (6.6) staying gt 2 days acquired VRE
MRSA 6
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Prioritisation of MROs Who should get the
single room?

• Dangerousness e.g., MRSA gt VRE
• Route of infection (airborne gt droplet)
• Published evidence of transmission
• Antibiotic resistance amount present
• Susceptibility of surrounding patients
• Prevalence of infection in hospital
• Dispersal characteristics
• Of patient (High, Medium, Low)

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Prioritisation of MROsWho should get the single
room?
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Prioritisation lists

• GENERAL WARDS
• Tuberculosis (respiratory or laryngeal)
• Measles
• Chicken pox
• Norovirus or astrovirus
• Influenza
• MRAB - high dispersal risk
• Clostridium difficile
• Suspected infectious gastroenteritis
• MRSA - high dispersal risk
• MR-GNB - high dispersal risk
• MRAB - medium dispersal risk
• MRSA - medium dispersal risk
• MR-GNB - medium dispersal risk
• MRAB - low dispersal risk
• VRE - high dispersal risk
• MRSA - low dispersal risk
• MR-GNB - low dispersal risk
• VRE - medium dispersal risk

• HIGH RISK WARDS (HEMATOL / ICU)
• Tuberculosis (respiratory or laryngeal)
• Measles
• Chicken pox
• Norovirus or astrovirus
• Influenza MRAB - high dispersal risk
• Clostridium difficile
• Suspected infectious gastroenteritis
• MRSA - high dispersal risk
• VRE - high dispersal risk
• MR-GNB - high dispersal risk
• MRAB - medium dispersal risk
• MRSA - medium dispersal risk
• VRE - medium dispersal risk
• MR-GNB - medium dispersal risk
• MRAB - low dispersal risk
• MRSA - low dispersal risk
• MR-GNB - low dispersal risk
• VRE - low dispersal risk

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Diekema DJ, Clin Infect Dis 2007441101-07
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Sowhat works?
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In the absence of evidence, all opinions are
equal

• Dr Steve Hall

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What works?

• Hand hygiene
• Availability right before patient contact
• Cleaning
• Trained cleaners, combined products, clean
  patients
• Judicious use of antibiotics
• ? Bulk use and preference against anti-anerobics
• Gowns / gloves / isolation
• Aprons for adherence, ?discard gloves, prioritise
• Active screening
• Essential but needs to be comprehensive to get it
  right

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• Package of basics
• Hand hygiene
• Screening
• Isolation and contact precautions
• Antibiotic restriction with education

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The WA approach to an outbreak

• Formation of VRE executive control group
• Rapid laboratory identification
• Mass screening of all patients for carriage
• Isolation or cohorting of positive patients
• Envtl. screening and dedicated cleaning
• Flagging positive patients
• Post-discharge screening and precautions
• Antibiotic restrictions

Christiansen KJ, Infect Control Hosp Epidemiol
2004 25384-90.
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2.7 million dollars later
Pearman JW, Aust Infect Control 200381-8
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Acknowledgements

• John Ferguson (helped with survey)
• Keith Wise and Peter Newton (micro)
• Our IMACS team of ICPs and others
• Joanna Harris, AnnMaree Wilson, Beth Bint,
  Suzanne Alexander, Helen Newman, Robyn Bourke,
  Lisa Burke, Ghosh
• Malcolm Goddard (cleaning)
• Michael Davis and Albert Vasquez (ICU)

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HIDDEN SLIDES FOLLOW
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The evidence is a little shaky

• Of 30 MRO studies examining surveillance cultures
  and/or barrier precautions
• 7 were of high quality
• 1 was randomized
• 6 had a control group
• 90 tested multiple interventions
• Over 20 in total
• Poorly described in a third
• Only 40 monitored

Aboelela SW, Am J Infect Control 200634484-94
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A tale of 2 hospitals

• Hospital A and B, 7 km apart, similar
• One screened all ICU, haem-onc, tplants
• Other units if a case was identified
• Weekly swabs until 3 weeks neg then mthly
• Not clear what happened next re isolation etc.
• Retrospective, 6yr periods (91-96, 92-98)
• 218 vs 72 BSIs (17.1 vs 8.2/100,000 obd)
• Monoclonal vs polyclonal isolates

Price CS, Clin Infect Dis 200337921-8
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A tale of 2 hospitals
Price CS, Clin Infect Dis 200337921-8
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If you dont have to, why bother?

• Ultimately ? reduce colonization pressure
• Rather admission to ward with 2 or 20 VRE
  patients?
• Clinical isolates are all tip, no iceberg
• Retrospective study of 14 high risk units (ICU,
  haem)
• 3 fold increase in monthly prevalence (6.2 to
  19.2)
• 5.7 fold increase in monthly incidence (0.7 to
  4.0)
• The higher the prevalence, the higher the
  incidence
• Use of contact precautions increased 2.3 fold
• Fall in incidence per month of 0.22 (modest)

Huang SS, J Infect Dis 2007195339-346. Talbot
TR, J Infect Dis 2007195314-317
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If you dont have to, why bother?

• Ultimately ? reduce colonization pressure
• Rather admission to ward with 2 or 20 VRE
  patients?
• Reduce the undetected ratio
• Only detect 30 prevalence, 18 of incidence

Huang SS, J Infect Dis 2007195339-346. Talbot
TR, J Infect Dis 2007195314-317
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Proximity appears to matter
Byers KE, Infect Control Hosp Epidemiol
200122140-7
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Risk of bacteremia in a colonised hematology
patient
Matar MJ, Clin Infect Dis 2006421506-7
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ASC reduced BSI in hematology
Hachem R, Infect Control Hosp Epidemiol
200425391-394
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ASC reduced BSI in hematology
Hachem R, Infect Control Hosp Epidemiol
200425391-394
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Risk of bacteremia liver transplant pre-transplant
McNeil SA, Clin Infect Dis 200642195-203
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Risk of bacteremia liver transplant
post-transplant
McNeil SA, Clin Infect Dis 200642195-203
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Frequency of screening
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Advice for lookers

• Can your laboratory manage it?
• Increased resources, changed work flow, focus
• How will you manage the downside?
• 50 ? contacts, including specialist examn
• Anxiety, depression, dissatisfaction, complaints
• ? adverse events (falls, pressure sores, fluids)
• Impact on the infection control program
• Tracking, educating, co-ordinating, measuring

Diekema DJ, Clin Infect Dis 2007441101-07
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Advice for leapers

• Will it work to prioritise one step at a time?
• Maybe, maybe not, do you have a choice?
• Focus on all aspects of the intervention
• Capacity to expand contact precautions in an era
  of increasing community MRSA
• Where to put them? How to teach/look after them?
• Monitor and improve adherence to make it work
• Measure meaningful outcomes
• Infection and non-infection morbidity, mortality

Diekema DJ, Clin Infect Dis 2007441101-07
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Cost effectiveness of screening
Muto CA, Infect Control Hosp Epdemiol,
200223429-35
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Twice weekly vs weekly screening in surgical ICU
Hendrix CW, Annals Surg 2001233259-65
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ICU screening proportions
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ICU screening by hosp size
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ICU believers
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Agree with your ICU policy?
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Agree with your ICU policy?
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