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VRE in ICU: What works?

VRE in ICU: What works?. Craig Boutlis Infection Management and Control Service Wollongong Hospital. The difficult: 2 nd talk after lunch. Craig Boutlis Infection Management and Control Service Wollongong Hospital. 4. 1. 16. 14. 9. 41. 4. 25. 4. We asked 150 old dogs. 117. 20.

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VRE in ICU: What works?

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  1. VRE in ICU: What works? Craig Boutlis Infection Management and Control Service Wollongong Hospital

  2. The difficult: 2nd talk after lunch Craig Boutlis Infection Management and Control Service Wollongong Hospital

  3. 4 1 16 14 9 41 4 25 4 We asked 150 old dogs 117 20 11

  4. 4 1 16 14 9 41 4 25 4 For their new tricks 117 20 11

  5. Confessed VRE endemicity

  6. VRE bacteremias numbers

  7. What works: The old dogs said…

  8. Arch Int Med 2005;165(3):302

  9. Alcohol-chlorhexidine works

  10. Gordin FM, Infect Control Hosp Epidemiol 2005;26(7):650

  11. Lai KK, Infect Control Hosp Epidemiol 2006;27(10):1018

  12. Handrub use at record levels

  13. Technical recession in MRSA

  14. Nosocomial ICU MRSA

  15. HCA-VRE acquisition in ICU

  16. The old dogs said…

  17. Arch Intern Med 2006;166(18):1945

  18. Drees M, Clin Infect Dis 2008;46(5):678

  19. Baseline Cleaning education Washout Hand hygiene intervention Hayden MK, Clin Infect Dis 2006;42(11):1552

  20. 6%  in prevalence for 10%  cleaning Hota B, J Hosp Infect 2009;71(2):123

  21. Nobody cleaning our beds

  22. Once we started cleaning the beds “Advice from the Wards is indicating that the new cleaners are being well received and that the documentation is being completed.” “Beds are being cleaned thoroughly and my observation and that of the cleaning staff has revealed that many of the beds are caked with large build up of organic matter, blood and faecesparticularly under the beds. I think this provides confirmation that specialised cleaning of the beds is needed.” Anon: But someone who can be trusted to know

  23. 1 Litre of cold water + 1 tablet Chlor-Clean Combined detergent / bleach Manufacturer’s website: http://www.qedocctech.com/chlor-clean/

  24. Can we control it at the source? Achromobacter spp Acidaminococcus fermentans Acinetobacter cacoaceticus Aeromonas spp Alcaligenes faecalis Anaerobiospirillum spp Bacillus spp Bacteroides fragilis Bacteroides melaninogenicus Bifidobacterium spp Butyriviberio fibrosolvens Campylobacter coli Campylobacter spp Clostridium difficile Clostridium sordellii Clostridium spp Eikenella corrodens Enterobacter cloacae Enterococcus faecalis Enterococcus faecium Escherichia coli Flavobacterium spp Morganella morganii Mycobacteria spp Mycoplasma spp Peptococcus spp Plesiomonas shigelloides Propionibacterium acnes Propionibacterium spp Providencia spp Pseudomonas aeruginosa Ruminococcus bromii Ruminococcus spp Sarcina spp Staphylococcus aureus Streptococcus anginosus Streptococcus viridans Veillonella spp Vibrio spp Yersinia enterocolitica

  25. Peterson LA, Arch Intern Med 2006;166(3):274 & Vernon MO, pp. 306

  26. Parienti J, Crit Care Med 2009;37(6):2097 & Climo MW, pp. 1858

  27. Do throw the bathwater out before washing the baby! 13% contaminated with VRE Johnson D, Am J Crit Care 2009;18(2):100

  28. The old dogs said…

  29. Pre intervention 61% inappropriate Post-intervention 30% inappropriate Significant reduction in VRE acquisition Restricting vancomycin use Anglim AM, Arch Intern Med 1997;157:1132

  30. Restricting 3 gen Cephs

  31. ABx switch on hematology unit Late switch Early switch B’line Post Tazocin Teico Cipro Ceftaz Bradley SJ, J Antimicrob Chemo 1999;43:261

  32. Winston LG, Am J Infect Control 2004;32(8):462

  34. Factors that increased contamination • Diarrhea • Higher colonization pressure in the ICU • Receipt of antibiotics (in general)

  35. The old dogs said…

  36. Hayden MK, Infect Control Hosp Epidemiol 2008;29(2):149

  37. Snyder GM, Infect Control Hosp Epidemiol 2008 Jul;29(7):583-9

  38. Bearman GM, Am J Infect Control 2007;35(10):650

  39. Adding gowns to gloves no better Slaughter S, Annals Int Med 1996;125(6):448

  40. Adding gowns to gloves is better Srinivason A, Infect Control Hosp Epidemiol 2002;23(8):424

  41. 2:1 Gowns are good! Puzniak LA, Clin Infect Dis 2002;35(1):18

  42. You know it makes sense! Zachary KC, Infect Control Hosp Epidemiol 2001;22(9):560

  43. Gardine: brilliant green + chlorhexidine • Good for MRSA, VRE, MRAB • At 30 second and 10 minutes Reitzel RA, Am J Infect Control 2009;37(4):294

  44. The old dogs said… Don’t get me started!

  45. Possible benefits of screening • Ultimately  reduce colonization pressure • Rather admission to ward with 2 or 20 VRE patients? • Reduce the undetected ratio • Only detect 30% prevalence, 18% of incidence • Perhaps it would change your empiric Rx • Can’t decolonise…but can chlorhexidine wash •  contamination of patient, environment; acquisitions • $pin-off benefit of reducing BSIs in ICUs • An audit tool of other interventions Huang SS, J Infect Dis 2007;195:339-346. Talbot TR, J Infect Dis 2007;195:314-317 Vernon MO, Arch Intern Med 2006;166:306-312. Bleasdale SC, Arch Intern Med 2007;167(19):2073-2079

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