VRE in pediatric transplant patients cleared through IC

Cohorting measures include VRE playroom

While a well-known threat to severely ill adult patients, vancomycin-resistant enterococci (VRE) also can pose an infection risk to pediatric populations like abdominal transplant patients. Co-outbreaks of VRE colonization at a pediatric hospital were eradicated through infection control measures that included some creative cohorting in the form of a VRE playroom, a clinician reports.

"Because of the involvement of the abdomen as the surgical site, we know the enterococci are a very frequent organism for this group of children," says Mike Green, MD, an infectious disease clinician at Children’s Hospital in Pittsburgh and professor of pediatrics and surgery at the University of Pittsburgh School of Medicine.

In that regard, the hospital has long conducted passive surveillance for stool colonization with VRE in candidates and recipients of liver and intestinal transplants. But because only one VRE-colonized child was identified in 1997, concerns were raised when five VRE-colonized children were identified on the abdominal transplant service in January 1998. That led to expanded, active weekly surveillance, he said.

"At that point in time, we then did surveillance on the whole floor," he says. "We had this high rate — about 40% of the kids were found to be colonized."

Indeed, 18 of 39 transplant patients had positive stool cultures for VRE at the time of initiation of active surveillance. But after the infection control interventions, none of 32 patients cultured were colonized with VRE.¹

"It was really a very clonal outbreak," he says. "When we shut the floor down in terms of isolation, we cut off transmission. Our transplant patients really did clear in a relatively short period of time. It was really a pleasant surprise. I told the parents I didn’t think it would happen and for the whole time that they would be in the hospital — which for these kids can be a long period of time — that they were going to [be in gown and glove isolation]. At one point we opened up a VRE playroom,’ a special playroom for the kids who were VRE-colonized so they didn’t go crazy in their rooms."

Meanwhile, transfer of a child with known VRE sepsis to the ICU from another hospital prompted surveillance of all ICU patients. The child was placed in the ICU in gown and glove isolation, but the strain — a different clone from the other outbreak — began spreading rapidly until infection control measures were re-emphasized. Initial surveillance cultures from the ICU identified 12 of 21 VRE-colonized children. After infection control breaches were reported, strict infection control was re-emphasized, and subsequently only one of 41 cultured children were colonized with VRE.

"When we really enforced true, strict isolation procedures, the spread stopped again," Green says. "It spread in a clonal fashion for both of these isolates, and when we enforced strict gown and glove isolation, it stopped spreading. We were very fortunate because the only invasive disease associated with either one of those co-outbreaks of colonization was the primary case that came in with bacteremia. Certainly, in a high-risk population like our liver/bowel patients, I was very pleased that there wasn’t clinical disease, because we were wondering what we were going to do in terms of treating it."

The hospital is a national and international referral center, so VRE and other multiresistant bacteria are frequently imported on incoming patients, he adds.

"We are pretty sure that the sources of our outbreaks now are coming from outside — [primarily] from the East Coast," Green says. "So if I know a kid’s coming from the East Coast and they are new to our system, I am interested in getting colonization data on them. When we know kids are colonized, we then follow the full [CDC] HICPAC recommendations of gown and glove isolation until cleared."

While most VRE cases in the hospital are imported from other settings, Green and colleagues also have attempted to limit inappropriate vancomycin use to eliminate selective pressure for VRE. For example, past practices of using vancomycin to sterilize the gut as a prophylaxis at the time of the operation has been dropped, as has the practice of administering oral vancomycin in response to high quantities of enterococci in the stool, he notes.

"We try to be rational in our use of the vancomycin," Green says. "We don’t use it when we don’t need to, but there are lots of cases where we do have to use it."

Reference

1. Green M, Martin JM, Farley A. Simultaneous spread of different clones of vancomycin-resistant Enterococcus faecium in a children’s hospital. Abstract 603 Fr. Presented at the annual meeting of the Infectious Disease Society of America. Denver; Nov. 12-15, 1998.