Vancomycin Resistant Enterococcus

Aka: Vancomycin Resistant Enterococcus, VRE

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II. Epidemiology

  1. First described in the 1980s
  2. Multi-drug resistance
  3. Marked resistance in some settings (e.g. ICU)

III. Pathophysiology

  1. Enterococcus is fecal flora in 56-100% adults
  2. Organisms showing resistance
    1. Enterococcus faecium (>60% Vancomycin resistance)
    2. Enterococcus faecalis (<10% Vancomycin resistance)
  3. Transmission
    1. Healthcare workers hands or gloves
    2. Surfaces
      1. Countertops (VRE survives up to 1 week)
      2. Stethoscope (VRE survives 30 minutes)
      3. Tympanic Thermometer
      4. Bedrail
      5. Bedside table
      6. EKG leads
  4. VRE Colonization to VRE Infection
    1. Risk of colonization increases with each day of exposure (e.g. hospitalization on ward or ICU)
    2. VRE colonized patients have an 8% chance of developing VRE Infection
      1. Henning (1996) Pediatr Infect Dis J 15(10): 848-54 [PubMed]
    3. VRE colonization may confer Vancomycin resistance to co-colonized Staphylococcus aureus
      1. Hayakawa (2013) Antimicrob Agents Chemother 57(1): 49-55 [PubMed]

IV. Associated Conditions: Sites of VRE

  1. Endocarditis
  2. Urinary Tract Infections
  3. Meningitis
  4. Wound Infections
  5. Intravenous catheter infections

V. Risk Factors: VRE Colonization

  1. Prior Antibiotic use (especially Cephalosporin, antianaerobe, Vancomycin)
  2. COPD
  3. Longterm Care facility resident
  4. Decubitus Ulcer
  5. End-stage renal disease
  6. Dialysis
  7. Cancer
  8. ICU care
  9. Organ transplant

VI. Labs

  1. Culture MIC
    1. Vancomycin Susceptible Enterococcus: MIC <4 mcg/ml
    2. Vancomycin Resistant Enterococcus: MIC >32 mcg/ml

VII. Management: Vancomycin Resistant Enterococcus

  1. No single Antibiotic is bactericidal
    1. Combination therapy is mandatory
  2. Susceptible to Ampicillin
    1. Antibiotic 1
      1. Ampicillin or
      2. Ampicillin/Sulbactam (Unasyn)
    2. Antibiotic 2
      1. Gentamicin (increasing resistance) or
      2. Streptomycin
  3. High resistance to Ampicillin (MIC >64 mg/ml)
    1. Quinupristin/dalfopristin (Synercid)
    2. Linezolid (Zyvox)
    3. Combination 1 (three drugs)
      1. Ciprofloxacin and
      2. Rifampin and
      3. Gentamicin
    4. Combination 2 (two drugs)
      1. Cefotaxime or Ceftriaxone and
      2. Fosfomycin
    5. Combination 3 (four drugs)
      1. Chloramphenicol and
      2. Doxycycline and
      3. Rifampin and
      4. Quinupristin/dalfopristin (Synercid)
  4. Antibiotics effective against some strains of VRE (consult infectious disease)
    1. Linezolid
    2. Daptomycin
    3. Tigecycline
    4. Gentamicin (increasing resistance)
    5. Imipenem (against E. faecalis only)
    6. Rifampin
    7. Streptomycin
    8. Telavansin (Skin Infections)
    9. Lefamulin
    10. Quinupristin/dalfopristin or Synercid (against E faecium only)
  5. Antibiotics effective against UTI with VRE
    1. Remove indwelling Urinary Catheter if possible (may alone, clear VRE)
    2. Ampicillin or Amoxicillin (UTI)
    3. Fosfomycin (UTI)
    4. Nitrofurantoin (UTI)
  6. Antibiotics for VRE Endocarditis
    1. Valve Replacement may be needed
    2. Daptomycin AND
    3. Gentamicin AND
    4. Ampicillin

VIII. Prevention: Healthcare Transmission of Vancomycin Resistant Enterococcus (VRE)

  1. Hand Hygiene with Chlorhexidine or waterless Alcohol-based hand rub before and after each patient
  2. Contact precautions with gowns and gloves when exposed to colonized or infected sites
  3. Decontaminate healthcare equipment (consider steam vapor)
  4. Practice antimicrobial stewardship and limit Antibiotic use and duration to appropriate indications
  5. Identify VRE positive patients and isolate them from other patients
    1. VRE can be rapidly assayed (same day) from stool samples or perianal or perirectal swabs
    2. Cohort VRE patients in shared rooms, or better yet, isolate in single rooms
    3. Known VRE colonized patients are considered positive for at least one year
      1. Obtain 3 negative Stool Cultures each one week apart to confirm clearance of VRE
      2. Lactobacillus may eliminate the VRE carrier state in some patients
        1. Szachta (2011) J Clin Gastroenterol 45(10): 872-77 [PubMed]

IX. References

  1. Glauser (2014) Crit Dec Emerg Med 28(11): 2-10
  2. Michel (1997) Lancet 349:1901-6 [PubMed]
  3. Murray (2000) N Engl J Med 342:710-21 [PubMed]

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