VRE   05-­‐11-­‐14  

ICAN  2014   1  

Andreas  Voss,  MD,  PhD  

¤   Controlling  the  spread  of  VRE  and  especially      other  MDRO  may  cause  serious  harm  to  my      job  security  

¤  Advisory  board,  speaker  fees  &  grants  from    3M,  bioMerieux,  JD,  Deb,  AspeMx,  Astra  Zeneca,  Milenium  bioscience,  …  

¤ Everyone  harbours  enterococci  in  his/her  GI-­‐tract  

¤ Resistant  to  cephalosporines  ¤ Most  prevalent  species:  E.  faecalis  ¤ Low  virulence  

– UTI  – Abdominal  infecMons  – CLA-­‐BSI  and  endocardiMs  

 

•  “Big/resistant  brother”  of  E.  faecalis  – Amoxicillin/ampicillin-­‐resistant  

– Recent  shiY:  E.  faecalis  à  E.  faecium  

•  LocaMon  (GI)  unchanged  

•  Virulence  unchanged  

•  SuscepMble  to  vancomycin  

•  E.  faecium  and  (less  frequent)  E.  faecalis  –  other  species  less  important  

•  It’s  all  about  vanA  en  vanB,  the  other  van-­‐gens  are  generally  less  important  

•  Certain  clonal  complex’s  (CCs)  trend  to  be  more  epidemic  e.g.  CC17  

•  VRE  does  not  equal  VRE  

VRE   05-­‐11-­‐14  

ICAN  2014   2  

Ears  june  2011  

Meningitis

Neonatal infection

sepsis

pneumonia

UTI

Surgical infection

Meningitis Meningitis Meningitis Meningitis Meningitis sepsis

Patient: underlying diseases, antibiotics, veel co-morbidity

meningitis

endocarditis

UTI

Wound infections

Intra-abd. infections

¤   Contact  isolaMon  ²   (preferably)  single  room  

²   own  toilet/bed-­‐pan,  …  

²   gloves  and  gown  ²   hand  hygiëne  

²   disinfec<on  of  environment  

¤   Not  one  reason,  but  the  consequence  of      mulMple,  small  factors  

     à  Swiss-­‐Cheese-­‐Accident  Model  

VRE   05-­‐11-­‐14  

ICAN  2014   3  

(hand)hygiene

antibiotics cleaning

Werk pressure

Maintenance

Bad luck (Hand) hygiene

antibiotics

cleaning

Work pressure

Maintenance

Bad luck

(Hand) hygiene

antibiotics

cleaning

Work pressure

Maintenance

Bad luck

VRE outbreak

¤   Bad  luck  ²   virulent  clone      

¤     High  Work  pressure  ²   mixing  personnel  from  different  wards,  trainees  

¤   Cleaning/disinfecMon  ²   vacant  responsibiliMes  

¤   Maintenance/technique  ²   bed-­‐pan  washers  not  sufficient  

¤   Discipline  en  behaviour  ²   basic  infecMon  control  (contact  isolaMon/flagging)  ²   hand  hygiene  

¤   Microbiology  

¤   Epidemiology  

¤   InfecMon  control  

¤   PoliMcs  &  communicaMon  

¤   AnMbioMc  stewardship  

¤   DecolonizaMon  

¤   Chrome-­‐agar  versus  standard  media  

¤   “Added  value”  Ampicillin-­‐MH-­‐boullion    

¤   MulMplex  PCR  on  clinical  materials  

¤   Determine  A0  value  of  the  outbreak  strain  

¤   Compare/evaluate  typingmethods    ²   MLST,  AFLP  

VRE   05-­‐11-­‐14  

ICAN  2014   4  

¤ Up  to  50%  of  ward  HCWs  =  trainees  

¤ Faulty  contact  isolaMon  

¤ Bad  hand  hygiene  &  lacking  adherence  to  basic  infecMon  control  measures  

¤ Flagged  paMents  not  isolated/cohorted    

¤ Bed-­‐pans  and  commodes  frequently  VRE+  

¤ High-­‐touch  surfaces  VRE+  

¤   Bedpan  VRE+  despite    washers  were  tested    and  validqted  !  

Not  our  model    

¤   Combined  value  of  temperature  and  Mme  

 Z      =    10C  (thermal  destrucMon  factor)  T      =    measured  temperature            =    Mme  for  disinfecMon  (sec)  

¤   Bed-­‐pan  washers  according  to  EU  norm  A60  ²   A60  =  the  effect  of  1  min  80°C    

¤   The  A0  values  A0  >  60    cleaning,  contact  with  intact  skin  A0  >600    semi  criMcal,  in  contact  with  non-­‐intact  skin  or  mucous            membranes  A0  >  A0  >3000    criMcal,  in  contact  with  sterile  Mssue,  high-­‐level  disinfecMon    

 

¤   Range  of  values!  ²   CWZ  A0  80  to  5000  (too  much  variaMon)  

¤ TesMng  did  not  follow  the  norms  ²   No  cold  start  tesMng  

¤   ValidaMon  of  measurements?    ²   detailed  knowledge  no  longer  present  in      service  company  

VRE   05-­‐11-­‐14  

ICAN  2014   5  

 ¤   A0  value  of  outbreak  strain:  =    160  (2  min,  80C)    

¤   Bed-­‐pans  visible  dirty:      A0  is  not  a  statement  about  being  clean  

¤   Roomservice  ¤   Roomservice-­‐plus  ¤   Registered  nurse  ¤   Nurse  asistant  ¤   Cleaning  

Even  if  you  think  you  know  it,  are  they  actually  doing  it?  

VRE   05-­‐11-­‐14  

ICAN  2014   6  

¤   Do  certain  anMbioMcs  select  for  VRE?  

¤   Which  anMbioMcs  are  used  in  your  paMent      populaMon?  

Antibiotics (AB):

•  chephalosporines, vancomycin, cipro

Selective Digestive tract Decontamination (SDD)

•  no proof that SDD increases prevalence of VRE ↑  

•   NL: 10 of 14 (71%) of VRE+ hospitals use SDD

CWZ:

•  93% ≥ 1 AB in the 3 months before first VRE+ culture

•  54% was on AB at the time of their first VRE+ culture

•  On average VRE+ patient received 2.85 (range 0-10) different ABs before their first VRE+ culture

0.9%  =  close  to  nothing  

¤   Does  your  hospital  has  an  A-­‐team?   ¤   Nothing  in  the  literature  

¤   Possible  intervenMons?  ²   probioMcs  ²   feces-­‐transplantaMon  ²   ban  of  certain  food    (eg.  no  chicken)  

 

VRE   05-­‐11-­‐14  

ICAN  2014   7  

•  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  &  isola<on  

Flagging/sor<ng  

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  &  isola<on  

Flagging/sor<ng  

Trained  HCWs  

1  

2  

3  

4  

5  

6  

7  

….  

A  long  <me  

Twee  week  meeMng  with  CEO,  IC,  medical  head  and  unit  manager  !  

¤ VRE tiredness after a few months

¤ BC to get the disposable system (VernaCare)

¤ Continuing merging of units

¤ Financial pressure – no closure of wards

¤ Too much work – to little trained HCWs

VRE   05-­‐11-­‐14  

ICAN  2014   8  

AYer  14  months,  450+  cases,  20.000  PCRs,  extra  cleaners,  new  products,  and  endless  audits  

International Society of Chemotherapy for Infection and Cancer

www.ischemo.org

…..…..to  advance  the  educa.on  and  the  science  of  therapy  of  infec.on    

•  AnM-­‐infecMve  pharmacology  

•  AnMmicrobials  of  the  Future  

•  AnMmicrobial  Stewardship    

•  AnMsepMcs    

•  Bone,  Skin  and  SoY  Tissue  InfecMons  

•  Clostridium  difficile  InfecMon  

•  Collateral  Effects  of  AnM-­‐infecMves  

•  Controlling  AnMmicrobial  Resistance  

•  Device  Related  InfecMons  and  Biofilm  

•  EndocardiMs  &  Blood  Stream  InfecMons  

•  Fungal  InfecMons  

•  HepaMMs  

•  Human-­‐Animal  Interface  in  AnMmicrobial  Resistance  

•  ImmunisaMons  and  Vaccines    

 

•  Infec<on  Control  

•  InfecMons  in  Catastrophic  Areas  

•  InfecMons  in  the  ICU  and  Sepsis  

•  Intra-­‐abdominal  InfecMon  

•  MRSA  

•  OPAT  

•  Streptococcal  InfecMons  

•  Tuberculosis    

•  Urinary  Tract  InfecMons    

•  Zoonoses  

•  AnMmicrobial  Stewardship  &  InfecMon  Control  African  Network  

 

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