Practice forumHorizontal infection prevention measures and a risk-managed approach to vancomycin-resistant enterococci: An evaluation

- A risk-managed approach to vancomycin-resistant enterococci management was implemented only after introduction of 2 horizontal infection prevention measures, namely a comprehensive environmental cleaning program and an antimicrobial stewardship program.
- As part of the risk-managed approach, clinical units deemed at higher risk of vancomycin-resistant enterococci (VRE) infection (bone marrow and solid organ transplant units, burns-trauma unit, intensive care unit) continued to perform admission and weekly point prevalence screening for VRE, whereas all other areas discontinued admission screening for VRE and VRE isolation precautions.
- Surveillance for methicillin-resistant Staphylococcus aureus and Clostridium difficile remained unchanged for all clinical units, including the higher-risk units.
- Almost 2 years after the vancomycin-resistant enterococci (VRE) risk management approach was introduced, VRE bacteremias remain unchanged throughout the facility; the number of patients requiring VRE isolation in all areas of the hospital decreased from 32 (new and readmitted patients) to 6 beds per day.
- The aggressive equipment and surface cleaning program and antimicrobial stewardship efforts have resulted in statistically significant decreases in rates of Clostridium difficile and methicillin-resistant Staphylococcus aureus.

BackgroundThe use of infection control measures in the management of vancomycin-resistant enterococci (VRE) is hotly debated. A risk-managed approach to VRE control after the introduction of 2 horizontal infection prevention measures-an environmental cleaning (EC) and an antimicrobial stewardship (AMS) program-was assessed.MethodsRoutine screening for VRE was discontinued 6 and 4 months after introduction of the EC and AMS programs, respectively. Only 4 units (intensive care, burns-trauma, solid organ transplant, and bone marrow transplant units) where patients were deemed to be at increased risk for VRE infection continued screening and contact precautions. Cost avoidance and value-added benefits were monitored by the hospital finance department. VRE monitoring on these high-risk units and facility-wide comprehensive bacteremia surveillance continued as per established protocols. Surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI) remained unchanged.ResultsVRE bacteremia rates did not increase with the change to the VRE risk-managed approach. The number of patients requiring VRE isolation in all areas of the hospital decreased from an average of 32 to 6 beds per day. Statistically significant reductions in CDI and MRSA rates were observed possibly related to the aggressive decluttering, equipment cleaning, and AMS program elements.ConclusionA risk-managed approach to VRE can be implemented without adverse consequences and potentially with significant benefits to a facility.