Fortress hospital: Aussies win battle royal with VRE

Canadian ICPs also proving cause is not lost

Fairly or not, American hospitals are often chastised for letting multidrug-resistant bugs establish an endemic footing that can be virtually impossible to eradicate. Given that perception — and the ensuing troubles with infections and outbreaks — it is little wonder that some hospitals in other countries go to extraordinary lengths when the first case of drug-resistance pathogens appear.

But few infection control professionals in any country can top the tale of a hospital in Western Australia that set up a "war cabinet" and took drastic measures after vancomycin-resistant enterococci (VRE) breeched the hospital walls. VRE first appeared at Royal Perth Hospital in Perth, Australia, in July 2001, reports K. Christiansen, MD, hospital epidemiologist at the 855-bed facility. Though infection control measures were quickly enacted, a situation all too familiar to American ICPs began to unfold.

"We contact traced and isolated any positive patients, reinforced hand washing in the hospital, and [emphasized] education programs," she said recently at the Interscience Conference on Anti-microbial Agents and Chemotherapy (ICAAC) in San Diego. "But it ran out of control, and by the end of September, we had 68 patients colonized with VRE. At this stage, we were very concerned, and we decided to add extra measures to get on top of this."

The hospital formed a VRE executive group that consisted of the hospital administrator, a clinical microbiologist, an infection control practitioner, and the epidemiologist. "This was a very powerful group [within] the hospital," Christiansen said. "We called it the war cabinet, and we met every night from 6 to 9 over about a three-month period."

A single epidemic strain

Determined to stamp out VRE before it became endemic, the team implemented sweeping measures on all fronts. To rapidly detect the bug, the hospital laboratory started using direct cultures on selective media followed by PCR testing for vancomycin-resistance genes vanA and vanB. Discovering that a single strain was spreading throughout the hospital, the VRE team took the extraordinary measure of shutting down select units. "We closed wards when necessary," she said. "Our intensive care unit was completely closed."

Other measures included switching to antiseptic (chlorhexidine 2% or alcohol) hand washes; isolation of positive patients and cohorting of contact patients; widespread patient and environmental screening; formation of a VRE cleaning team; and restriction of third generation cephalosporins and vancomycin use in the hospital. A staggering total of 19,600 patient swabs and 31,000 environmental cultures were processed. The effort uncovered a total of 169 VRE colonized patients. Three months later — as all control measures continued in place — there were none. The hospital remains VRE free, though the vigilant ICPs recently doused a "spot fire" cluster of five cases, Christiansen said.

"It is possible to terminate a VRE outbreak despite widespread dissemination in a hospital." She conceded, however, that the eradication effort involved "enormous management problems" and high costs ($1.5 million, U.S.). Eradicating VRE reduces morbidity, mortality and carries the overriding ethic of protecting future patients from acquiring infection. Still, the inevitable bottom line question came from the ICAAC audience: Was such a massive, costly effort worth it? "This is a question we get asked repeatedly," she said. "It is very hard to gauge how much it would have cost us if we had allowed it to become endemic in our hospital. We hope so."

In an era of patient safety, ICPs in U.S. hospitals are less and less likely to tolerate VRE if they think they have a chance to put the pathogen to flight. But unless resources are provided to wage such a fight, many U.S. hospitals will continue to fall to endemic VRE infestation. But such success stories offer hope. Another example comes from Canadian ICPs in Ontario, where an epic struggle with both VRE and methicillin-resistant Staphylococcus aureus (MRSA) has been under way since the mid-1990s.

Success in the North

Speaking at the same ICAAC session was Karen Green, RN, CIC, infection control coordinator at Mount Sinai Hospital in Toronto. Most hospitals in the province have adopted admission-screening policies to identify and isolate incoming cases of VRE and MRSA, she said. VRE were first identified in Ontario in 1993, but now is clearly in decline, she reported. "The screening guidelines — circulated to all of the acute-care facilities in 1997 — recommend screening any direct transfers from other institutions; anyone who had a previous admission to any type of health care facility in the prior six months; or anyone previously known to be positive for MRSA or VRE," Green said.

As a result, the number of identified VRE patients in Ontario has decreased for three consecutive years (685 in 1999; 445 in 2000; and 237 in 2001), she reported. MRSA has proven more difficult, but last year the number of patients colonized or infected with the pathogen decreased for the first time in the seven-year provincewide surveillance program. The 7,684 MRSA isolates detected in 2001 represent an 18% decline form the 9,345 cultured the previous year.

"Adherence to provincewide control programs have led to decreased rates of nosocomial MRSA in Ontario for the first time since 1992 and appear to have been successful in reducing the rate of VRE colonization and infection," she said. "The more rapid decrease of VRE may be due to the earlier response that we saw to this epidemic in Ontario. Most hospitals in Ontario [have] implemented some very aggressive control measures and isolation strategies. Once these patients are identified early, then the control measures are put in place. I think [with MRSA], what we are seeing now is just the benefit of several years of really hard work."

Green was asked at ICAAC whether U.S. hospitals could enjoy similar success, or whether the results were indicative of certain advantages to the national health care system in Canada. "The infection control community started very early with very aggressive measures trying to get this under control. But certainly having [government infection control] guidelines go to CEOs of hospitals added support to those programs. I wouldn’t say it’s too late for a lot of American hospitals. When we started out, our MRSA [rate] was probably 55 cases per 10,000-hospital admission. That’s obviously down [now]. I am not familiar with all the numbers in the U.S., but I would think that there are many hospitals well within that range that could still make an impact."