Date post: | 04-Jul-2015 |
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Healthcare |
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20-‐11-‐14
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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