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Andreas  Voss,  MD,  PhD  Senior  Consultant  Clinical  Microbiology  

Canisius-­‐Wilhelmina  Hospital  Professor  of  Infec@on  Control  

Radboud  University  Medical  Centre  Nijmegen,  The  Netherlands  

¤   First  report  in  Europe  (1988)  

¤   Endogenous  flora  was      considered  only  source      for  a  long  @me  

¤   Role  of  environment  

UQley  et  al.  Lancet    1988;57-­‐58  

Pavia  et  al.  J  Food  Protect    2000;63:912  

•  Enterococci  in  45%  of  the  samples.    

•  Mostly  chicken  meat  (65.4%)  

•  VRE  in  29%  of  the  samples  

•  Highest  prevalence  of  VRE  in  chicken  meat  (76.5%)  

Schouten  et  al.      Lancet  1997:349:1258  

VRE  coloniza6on  of  Vegans  versus  meat  eaters:  0  versus  6%  

¤   Range  2-­‐4%  

Endtz  et  al.  J  Clin  Microbiol  1997;35:3026  

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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

…  frequently  one  of  a  bunch!  

UQley  et  al.  Lancet    1988;57-­‐58  

Care  or  Not?  

I  wish  VRE  control  would  be  possible  

•  Between  August  2004  and  December  2010,  45  VRE  outbreaks  occurred  in  21  of  the  38  AP-­‐HP  hospitals    

•  An  ins@tu@onal  control  programme  was  implemented    

•  The  number  of  cases  per  outbreak  was  significantly  lower  ager  implementa@on  of  the  programme.    

Less  pa@ents  –  s6ll  outbreaks!  

…  if  VRE  has  established  itself  outside  of  the  hospital  and  in  the  community,  we’re            going  to  see  a  lot  more  VMRSA.  And  an  epidemic  strain  only  has  to  get  lucky  once…  

…  thus  maybe  Mike  isn’t  that  

mad  ...  

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Did  anyone  check  Guinness  for  VRE?  

NL:    only  interested  in  VR-­‐E.  faecium  (possibly  certain  CC’s)  

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NL:    es6mated  number  of  infec6ons:  500,  number  of  death:  33  when  prevalence  is  40%                                                  at  1%  =  12.5  cases  and  1.2  death  

¤   Not  one  reason,  but  the  consequence  of      mul@ple,  small  factors  

     à  Swiss-­‐Cheese-­‐Accident  Model  

(hand)hygiene

antibiotics cleaning

Werk pressure

Maintenance

Bad luck (Hand) hygiene

antibiotics

cleaning

Work pressure

Maintenance

Bad luck CC17,  bed-­‐pan  washers  

Low  compliance  

Too  much  Cipro  

Too  high,  trainees  

Not  good  enough  

Not  good  enough  

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(Hand) hygiene

antibiotics

cleaning

Work pressure

Maintenance

Bad luck

VRE outbreak

CC17,  bed-­‐pan  washers  

Low  compliance  

Too  much  Cipro  

Too  high,  trainees  

Not  good  enough  

Not  good  enough  

¤   Roomservice  

¤   Roomservice-­‐plus  

¤   Registered  nurse  

¤   Nurse  asistant  

¤   Cleaning  

¤   Bedpan  VRE+  despite    washers  were  tested    and  validated  !  

Not  our  model    

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

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

…  no  one  told  us  that  we  have  to  

die  at  A60  

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•  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  &  isola6on  

Flagging/sor6ng  

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  &  isola6on  

Flagging/sor6ng  

Trained  HCWs  

1  

2  

3  

4  

5  

6  

7  

….  

A  long  6me  

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¤   14  month  outbreak  à  VRE tiredness  

¤   450+  cases  (coloniza@on)  ¤  Financial pressure – insurance contracts  ¤   28.000  PCRs,  7.000  extra  cultures  ¤   Extra  cleaners  &  new  detergent  &  wipes  ¤   New  products  &  business  cases  ¤   Endless  audits  &  training  sessions  ¤   Change  of  an@bio@c  formulary    

VRE  HERE  

¤   S@gma@za@on  &  uncertainty  ¤   Problems  in  returning  to  nursing      homes/home  hospital  

¤   VRE-­‐posi@ve  for  >  1  year  ¤   Cases  with  BSI:  5      (4  cured,  1  died  with  VRE)  

IS VRE A REAL PROBLEM

Mammatus  Clouds  

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Is  that  possible  once  we  eat  it?  

Yes,  but  ac6ve  surveillance?  

Always  good?  But  need  to  reduce  MRSA  first!  

No  need  in  vanB!  

¤   LiQle  clinical  impact  (at  least  in  most  units)  ¤   High  cost  of  control    ¤   S@gma@za@on  of  pa@ents  ¤   Lack  of  decoloniza@on  possibili@es  ¤   Community  spread  including  our  food  ¤   Need  to  waist  energy  to  clean  bedpans  at  2  min/80C    (or  invest  in  disposable  system)  

¤   AMS  changes  (stop  SDD?)  may  protect  us  from  VRE      but  select  for  something  else,  far  worse  

Not  really  6me  to  give  up,  but  certainly  6me  to  stop  making  

such  a  fuzz  about  it  !  

VRE  should  not  be  seen  as  an  An6bio6c  Resistance  Threat  

but  as  an  indicator  of  a  failing  preven6ve  

system