Korean J healthc assoc Infect Control Prev.  2021 Jun;26(1):16-23. 10.14192/kjicp.2021.26.1.16.

It Is Time to Address the Isolation Policy for Patients Colonized with Vancomycin-resistant Enterococci

• Chang E
• Kim HB

• KMID: 2516940
• DOI: http://doi.org/10.14192/kjicp.2021.26.1.16

Abstract

Vancomycin-resistant enterococci (VRE) are one of the most important pathogens causing healthcare-associated infections. If VRE is detected in the culture tests of a patient’s clinical specimen, the patient should be isolated in a single room (preferred to a cohort room), and contact precautions should be initiated based on the infection control guidelines for multidrugresistant organisms by the Korea Disease Control and Prevention Agency. VRE is known to transmit vancomycin resistance genes to other bacteria; hence, isolation of VRE-colonized patients is recommended. However, many studies have shown that the probability of the spread of vancomycin resistance genes from VRE to other bacteria is rare and that the discontinuation of isolation and contact precaution does not significantly increase the rate of VRE colonization or infection. Notably, the healthcare qualities for diagnosis and treatment were more improved in the group without isolation than in the group with isolation. Further investigations on the effects of discontinuing the isolation of VRE-colonized patients are warranted, because the characteristics of the Korean healthcare system are distinct from those of other countries. The study designs of quasi-experimental studies, which do not require randomization for analysis, would be useful in conducting studies on the effects of discontinuing the isolation of VRE-colonized patients. Considering the results of the previous and future studies and the unique features of the Korean healthcare system, the isolation protocols could be relaxed gradually and applied only to specific cases, such as residents of nursing hospitals and immunosuppressed patients.

Keyword

Vancomycin-resistant enterococci; Isolation; Infection control

Reference

1. Bennett JE, Dolin R, Blaser MJ. 2020. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 9th ed. Elsevier;Philadelphia: p. 2495–6.

2. Vergis EN, Hayden MK, Chow JW, Snydman DR, Zervos MJ, Linden PK, et al. 2001; Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia: a prospective multicenter study. Ann Intern Med. 135:484–92. DOI: 10.7326/0003-4819-135-7-200110020-00007. PMID: 11578151.

3. Furtado GH, Mendes RE, Pignatari AC, Wey SB, Medeiros EA. 2006; Risk factors for vancomycin-resistant Enterococcus faecalis bacteremia in hospitalized patients: an analysis of two case-control studies. Am J Infect Control. 34:447–51. DOI: 10.1016/j.ajic.2005.08.015. PMID: 16945692.

4. Korea Disease Control and Prevention Agency. Infection control of healthcare-associated infections. Infection control of healthcare-associated infections. https://kdca.go.kr/contents.es?.mid=a20301080100 . Updated on 6 February 2021.

5. Lee S, Lee E, Bahk H, Lee S, Kim S, Lee H. 2019; Results of healthcare-associated infection surveillance in South Korea, 2013-2017. Public Health Wkly Rep. 12:485–90.

6. Korea Centers for Disease Control and Prevention. 2020. Infection control guidelines for healthcare-associated infections in 2020. Korea Centers for Disease Control and Prevention;Cheongju: p. 118.

7. Korea Centers for Disease Control and Prevention. 2012. Infection control guidelines for multidrug resistant microorganisms in healthcare facilities. Korea Centers for Disease Control and Prevention;Cheongju: p. 3–6.

8. Noble WC, Virani Z, Cree RG. 1992; Co-transfer of vancomycin and other resistance genes from Enterococcus faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol Lett. 93:195–8. DOI: 10.1111/j.1574-6968.1992.tb05089.x.

9. Schwalbe RS, Stapleton JT, Gilligan PH. 1987; Emergence of vancomycin resistance in coagulase-negative staphylococci. N Engl J Med. 316:927–31. DOI: 10.1056/NEJM198704093161507. PMID: 3821839.

10. Wagenvoort JH, De Brauwer EI, Penders RJ, Willems RJ, Top J, Bonten MJ. 2011; Environmental survival of vancomycin-resistant Enterococcus faecium. J Hosp Infect. 77:282–3. DOI: 10.1016/j.jhin.2010.11.008. PMID: 21288596.

11. 1995; Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). Am J Infect Control. 23:87–94. DOI: 10.1016/0196-6553(95)90104-3.

12. Banach DB, Bearman G, Barnden M, Hanrahan JA, Leekha S, Morgan DJ, et al. 2018; Duration of contact precautions for acute-care settings. Infect Control Hosp Epidemiol. 39:127–44. DOI: 10.1017/ice.2017.245. PMID: 29321078.

13. Gysin DV, Cookson B, Saenz H, Dettenkofer M, Widmer AF. 2018; Variability in contact precautions to control the nosocomial spread of multi-drug resistant organisms in the endemic setting: a multinational cross-sectional survey. Antimicrob Resist Infect Control. 7:81. DOI: 10.1186/s13756-018-0366-5. PMID: 30002821. PMCID: PMC6038251.

14. Jeong SY, Kim OS, Lee JY. 2014; The status of healthcare-associated infection control among healthcare facilities in Korea. J Digit Converg. 12:353–66. DOI: 10.14400/JDC.2014.12.5.353.

15. Walters MS, Eggers P, Albrecht V, Travis T, Lonsway D, Hovan G, et al. 2015; Vancomycin-resistant Staphylococcus aureus - Delaware, 2015. MMWR Morb Mortal Wkly Rep. 64:1056. DOI: 10.15585/mmwr.mm6437a6. PMID: 26402026.

16. Werner G, Freitas AR, Coque TM, Sollid JE, Lester C, Hammerum AM, et al. 2011; Host range of enterococcal vanA plasmids among Gram-positive intestinal bacteria. J Antimicrob Chemother. 66:273–82. DOI: 10.1093/jac/dkq455. PMID: 21131318.

17. Vehreschild MJGT, Haverkamp M, Biehl LM, Lemmen S, Fätkenheuer G. 2019; Vancomycin-resistant enterococci (VRE): a reason to isolate? Infection. 47:7–11. DOI: 10.1007/s15010-018-1202-9. PMID: 30178076.

18. Kang J, Cho J, Kim Y, Kim DH, Lee J, Park HK, et al. 2009; Hospital nurses' knowledge and compliance on multidrug-resistant organism infection control guideline. J Korean Acad Nurs. 39:186–97. DOI: 10.4040/jkan.2009.39.2.186. PMID: 19411790.

19. Cui L, Iwamoto A, Lian JQ, Neoh HM, Maruyama T, Horikawa Y, et al. 2006; Novel mechanism of antibiotic resistance originating in vancomycin-intermediate Staphylococcus aureus. Antimicrob Agents Chemother. 50:428–38. DOI: 10.1128/AAC.50.2.428-438.2006. PMID: 16436693. PMCID: PMC1366884.

20. Walsh CT, Fisher SL, Park IS, Prahalad M, Wu Z. 1996; Bacterial resistance to vancomycin: five genes and one missing hydrogen bond tell the story. Chem Biol. 3:21–8. DOI: 10.1016/S1074-5521(96)90079-4.

21. Faron ML, Ledeboer NA, Buchan BW. 2016; Resistance mechanisms, epidemiology, and approaches to screening for vancomycin-resistant Enterococcus in the health care setting. J Clin Microbiol. 54:2436–47. DOI: 10.1128/JCM.00211-16. PMID: 27147728. PMCID: PMC5035425.

22. O'Driscoll T, Crank CW. 2015; Vancomycin-resistant enterococcal infections: epidemiology, clinical manifestations, and optimal management. Infect Drug Resist. 8:217–30. DOI: 10.2147/IDR.S54125. PMID: 26244026. PMCID: PMC4521680.

23. Leavis HL, Willems RJ, van Wamel WJ, Schuren FH, Caspers MP, Bonten MJ. 2007; Insertion sequence-driven diversification creates a globally dispersed emerging multiresistant subspecies of E. faecium. PLoS Pathog. 3:e7. DOI: 10.1371/journal.ppat.0030007. PMID: 17257059. PMCID: PMC1781477.

24. de Niederhäusern S, Bondi M, Messi P, Iseppi R, Sabia C, Manicardi G, et al. 2011; Vancomycin-resistance transferability from VanA enterococci to Staphylococcus aureus. Curr Microbiol. 62:1363–7. DOI: 10.1007/s00284-011-9868-6. PMID: 21234755.

25. Zhu W, Murray PR, Huskins WC, Jernigan JA, McDonald LC, Clark NC, et al. 2010; Dissemination of an Enterococcus Inc18-Like vanA plasmid associated with vancomycin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 54:4314–20. DOI: 10.1128/AAC.00185-10. PMID: 20660665. PMCID: PMC2944587.

26. Rossi F, Diaz L, Wollam A, Panesso D, Zhou Y, Rincon S, et al. 2014; Transferable vancomycin resistance in a community-associated MRSA lineage. N Engl J Med. 370:1524–31. DOI: 10.1056/NEJMoa1303359. PMID: 24738669. PMCID: PMC4112484.

27. Melo-Cristino J, Resina C, Manuel V, Lito L, Ramirez M. 2013; First case of infection with vancomycin-resistant Staphylococcus aureus in Europe. Lancet. 382:205. DOI: 10.1016/S0140-6736(13)61219-2.

28. Centers for Disease Control and Prevention (CDC). CDC reminds clinical laboratories and healthcare infection preventionists of their role in the search and containment of vancomycin-resistant Staphylococcus aureus (VRSA). CDC reminds clinical laboratories and healthcare infection preventionists of their role in the search and containment of vancomycin-resistant Staphylococcus aureus (VRSA). https://www.cdc.gov/hai/settings/lab/vrsa_lab_search_containment.html . Updated on 13 May 2014.

29. Shariati A, Dadashi M, Moghadam MT, van Belkum A, Yaslianifard S, Darban-Sarokhalil D. 2020; Global prevalence and distribution of vancomycin resistant, vancomycin intermediate and heterogeneously vancomycin intermediate Staphylococcus aureus clinical isolates: a systematic review and meta-analysis. Sci Rep. 10:12689. DOI: 10.1038/s41598-020-69058-z. PMID: 32728110. PMCID: PMC7391782.

30. Rupp ME, Fitzgerald T, Hayes K, Van Schooneveld T, Hewlett A, Clevenger R, et al. 2017; Effect of cessation of contact isolation for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Infect Control Hosp Epidemiol. 38:1005–7. DOI: 10.1017/ice.2017.122. PMID: 28592333.

31. Bearman G, Abbas S, Masroor N, Sanogo K, Vanhoozer G, Cooper K, et al. 2018; Impact of discontinuing contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus: an interrupted time series analysis. Infect Control Hosp Epidemiol. 39:676–82. DOI: 10.1017/ice.2018.57. PMID: 29580304.

32. Lemieux C, Gardam M, Evans G, John M, Suh KN, vanWalraven C, et al. 2017; Longitudinal multicenter analysis of outcomes after cessation of control measures for vancomycin-resistant enterococci. Infect Control Hosp Epidemiol. 38:24–30. DOI: 10.1017/ice.2016.235. PMID: 27804901.

33. De Angelis G, Cataldo MA, De Waure C, Venturiello S, La Torre G, Cauda R, et al. 2014; Infection control and prevention measures to reduce the spread of vancomycin-resistant enterococci in hospitalized patients: a systematic review and meta-analysis. J Antimicrob Chemother. 69:1185–92. DOI: 10.1093/jac/dkt525. PMID: 24458513.

34. Marra AR, Edmond MB, Schweizer ML, Ryan GW, Diekema DJ. 2018; Discontinuing contact precautions for multidrug-resistant organisms: a systematic literature review and meta-analysis. Am J Infect Control. 46:333–40. DOI: 10.1016/j.ajic.2017.08.031. PMID: 29031432.

35. Kotkowski K, Ellison RT 3rd, Barysauskas C, Barton B, Allison J, Mack D, et al. 2017; Association of hospital contact precaution policies with emergency department admission time. J Hosp Infect. 96:244–9. DOI: 10.1016/j.jhin.2017.03.023. PMID: 28454768.

36. Schrank GM, Snyder GM, Davis RB, Branch-Elliman W, Wright SB. 2020; The discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: impact upon patient adverse events and hospital operations. BMJ Qual Saf. 29:1–2. DOI: 10.1136/bmjqs-2018-008926. PMID: 31320496.

37. Martin EM, Bryant B, Grogan TR, Rubin ZA, Russell DL, Elashoff D, et al. 2018; Noninfectious hospital adverse events decline after elimination of contact precautions for MRSA and VRE. Infect Control Hosp Epidemiol. 39:788–96. DOI: 10.1017/ice.2018.93. PMID: 29745356. PMCID: PMC6677236.

38. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. 2009; Adverse outcomes associated with Contact Precautions: a review of the literature. Am J Infect Control. 37:85–93. DOI: 10.1016/j.ajic.2008.04.257. PMID: 19249637. PMCID: PMC3557494.

39. Kim YJ, Park JS. 2017; Survey on infection control status and perceived importance of ICP (infection control practitioner) in long term care hospital. J Korea Acad Ind Coop Soc. 18:466–75.

40. Yoonchang SW, Peck KR, Kim OS, Lee JH, Lee NY, Oh WS, et al. 2007; Efficacy of infection control strategies to reduce transmission of vancomycin-resistant enterococci in a tertiary care hospital in Korea: a 4-year follow-up study. Infect Control Hosp Epidemiol. 28:493–5. DOI: 10.1086/513024. PMID: 17385160.

41. Jung J, Park K, Shin SH, Lee JY, Kim MN, Kim SH. 2019; The pitfall of cohort isolation in an outbreak of linezolid-resistant, vancomycin-resistant enterococci. Clin Microbiol Infect. 25:1568–9. DOI: 10.1016/j.cmi.2019.08.014. PMID: 31449869.

42. McDonald EG, Dendukuri N, Frenette C, Lee TC. 2019; Time-series analysis of health care-associated infections in a new hospital with all private rooms. JAMA Intern Med. 179:1501–6. DOI: 10.1001/jamainternmed.2019.2798. PMID: 31424489. PMCID: PMC6705142.

43. Cho SY, Kim HM, Chung DR, Choi JR, Lee MA, Huh HJ, et al. The impact of vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated VRE bacteremia. Infect Control Hosp Epidemiol. in press 2021. DOI: 10.1017/ice.2021.189. PMID: 33993892.

44. Johnstone J, Shing E, Saedi A, Adomako K, Li Y, Brown KA, et al. 2020; Discontinuing contact precautions for vancomycin-resistant Enterococcus (VRE) is associated with rising VRE bloodstream infection rates in Ontario hospitals, 2009-2018: a quasi-experimental study. Clin Infect Dis. 71:1756–9. DOI: 10.1093/cid/ciaa009. PMID: 31922536.

45. Kim B, Lee KS, Park YK, Choi YA, Cho SM, Kim SY, et al. 2017; A study of nurses' perception of the comprehensive nursing service. Korean J Fam Pract. 7:99–104. DOI: 10.21215/kjfp.2017.7.1.99.

46. Shin S, Park JD, Shin JH. 2020; Improvement plan of nurse staffing standards in Korea. Asian Nurs Res (Korean Soc Nurs Sci). 14:57–65. DOI: 10.1016/j.anr.2020.03.004. PMID: 32305508.

47. Hwang JH, Park JS, Lee E, Bae JY, Song KH, Choe PG, et al. 2018; Active surveillance for carbapenem-resistant Enterobacteriaceae, vancomycin-resistant enterococci and toxigenic Clostridium difficile among patients transferred from long-term care facilities in Korea. J Hosp Infect. 99:487–91. DOI: 10.1016/j.jhin.2018.02.017. PMID: 29476883.

48. Yoon YK, Lee MJ, Ju Y, Lee SE, Yang KS, Sohn JW, et al. 2019; Determining the clinical significance of co-colonization of vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus in the intestinal tracts of patients in intensive care units: a case-control study. Ann Clin Microbiol Antimicrob. 18:28. DOI: 10.1186/s12941-019-0327-8. PMID: 31601221. PMCID: PMC6785887.

49. Kim HS, Kim DH, Yoon HJ, Lee WJ, Woo SH, Choi SP. 2018; Factors associated with vancomycin-resistant enterococcus colonization in patients transferred to emergency departments in Korea. J Korean Med Sci. 33:e295. DOI: 10.3346/jkms.2018.33.e295. PMID: 30473648. PMCID: PMC6249167.

50. Kluytmans-van den Bergh MFQ, Bruijning-Verhagen PCJ, Vandenbroucke-Grauls CMJE, de Brauwer EIGB, Buiting AGM, Diederen BM, et al. 2019; Contact precautions in single-bed or multiple-bed rooms for patients with extended-spectrum β-lactamase-producing Enterobacteriaceae in Dutch hospitals: a cluster-randomised, crossover, non-inferiority study. Lancet Infect Dis. 19:1069–79. DOI: 10.1016/S1473-3099(19)30262-2.

51. Hemming K, Taljaard M, Weijer C, Forbes AB. 2020; Use of multiple period, cluster randomised, crossover trial designs for comparative effectiveness research. BMJ. 371:m3800. DOI: 10.1136/bmj.m3800. PMID: 33148538.