Kentucky addresses VRE transfer issue

Noninfected patients can move to nursing homes

Infection control practitioners in hospitals and nursing homes should not require three negative cultures for vancomycin-resistant enterococci (VRE) before transferring patients, who may be only VRE colonized and pose no infection risk to others, according to Kentucky state health guidelines.

Adopted by a VRE working group formed by the Department of Health Services in Frankfurt, the Kentucky guidelines are among the first that address the controversial issue of VRE patient transfers between hospitals and nursing homes.1 Fearful that the pathogen will establish an endemic foothold, institutions have balked at accepting VRE transfers -- but guidelines by the Centers for Disease Control and Prevention left it to individual states to devise policy on the issue.2 (See Hospital Infection Control, June 1995, pp. 70-74.)

"Do not allow the practice of requiring three negative cultures prior to nursing home placement," the Kentucky guidelines state. "This only encourages more antibiotic use and does not differentiate between colonized and infected patients, and keeps patients who are ready for long-term care settings in the acute care setting unnecessarily."

Though the state policy still left it to individual institutions to determine their exact discharge and transfer policies, the three-negative culture provision was an attempt to head off similar transfer woes that arose with methicillin-resistant Staphylococcus aureus.

"By implication, we said you should go to a nursing home unless you have a clinically active infection -- colonization shouldn't keep you out," says Reginald Finger, MD, state epidemiologist. "We are trying to learn from the MRSA experience."

The state has had problems with nursing homes requiring three negative cultures before accepting MRSA patients, adds Karen Adams, RN, BSN, surveillance nurse consultant at the health department.

"We just didn't want that to happen again with any other organism," she says. "If [patients] don't have clinical symptoms, then the nursing home -- we would hope -- would go ahead and accept them back if they had been transferred out, or accept them as a new patient."

In addition, the state guidelines recommend that patients with VRE -- an pathogen commonly found in the gastrointestinal tract -- should not be discharged to nursing homes if they have diarrhea. Additional recommendations by the state for management of VRE patients in acute care settings include:

* Inpatients with infection or rectal colonization with uncontrolled diarrhea require a private room if hygiene is poor. Infection control measures should include strict hand washing, gloves for patient contact, gowns if soiling is likely, and masks and eyeware if splashing is likely.

* Emphasize the importance of cleaning the environment around the patient, especially areas where the patient can reach or where contaminated items are placed. Clean equipment used in a patient's room before use on other patients

* Adhere to standard infection control principles, especially aseptic technique, decontamination, and disinfection.

* Surveillance cultures are not indicated in the absence of an outbreak.

* Keep a VRE log for epidemiologic tracking of cases, their location, antibiotic history, risk factors, and disposition.

* If an outbreak occurs or there are more than three endemic cases recognized, notify the state health department for instructions regarding cohorting and a discussion of overall outbreak management.

References

1. Kentucky Department for Health Services. Guidelines for the Prevention and Management of Vancomycin-Resistant Enterococci. Frankfort; 1995.

2. Centers for Disease Control and Prevention. Hospital Infection Control Practices Advisory Committee. Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol 1995; 16:105-113. *