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[What is to be done with vancomycin-resistant enterococcal infections?]
M J Bonten1, E M Mascini, R Willems
1Universitair Medisch Centrum Utrecht, Heidelberglaan 100, 3584 CX Utrecht. m.bonten@wxs.nl
Abstract:
Recently, three epidemics in Dutch hospitals were caused by vancomycin-resistant enterococci (VRE). Although the number of infections was small, spread of colonization was extensive and many infection control measures were necessary to prevent further spread. VRE are relatively avirulent bacteria. However, few, if any, antibiotics are available for treatment of infections caused by VRE and the genetic code for resistance may be transferable to other, more virulent, bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA). Although colonization and infection with MRSA have become endemic in many surrounding countries, such a situation has been prevented in the Netherlands by employing an aggressive 'search and destroy' policy. Although many questions regarding the optimal approach of VRE remain unanswered, a similar policy as employed for MRSA will not be possible. In contrast to MRSA, colonization with VRE occurs in the open population, no populations with increased risk for colonization appear to be definable and colonization cannot be eradicated. Based on common sense, a differentiated approach seems indicated in which extensive infection control measures should only be implemented when spread of a single genotype has been demonstrated. A reference laboratory should be created for uniform genotyping.
Insights
Vancomycin-resistant enterococci (VRE) caused three Dutch hospital epidemics. Due to VRE
Area of Science:
- Infectious Diseases
- Microbiology
- Hospital Epidemiology
Context:
- Three recent vancomycin-resistant enterococci (VRE) epidemics in Dutch hospitals highlight challenges in infection control.
- VRE, though relatively avirulent, pose treatment difficulties due to limited antibiotic options and potential for resistance gene transfer.
- Methicillin-resistant Staphylococcus aureus (MRSA) control in the Netherlands contrasts with VRE, as MRSA colonization is preventable, unlike VRE.
Purpose:
- To discuss the challenges and propose a differentiated approach for managing vancomycin-resistant enterococci (VRE) in healthcare settings.
- To address the limitations of traditional 'search and destroy' policies for VRE compared to MRSA control strategies.
- To advocate for a new strategy for VRE, emphasizing targeted infection control based on genotypic evidence and centralized laboratory support.
Summary:
- VRE colonization occurs broadly in the open population, making risk stratification and eradication difficult, unlike MRSA.
- Extensive infection control measures for VRE should be reserved for confirmed spread of a single genotype.
- A centralized reference laboratory for uniform VRE genotyping is recommended to guide control efforts.
Impact:
- The proposed differentiated approach aims to optimize resource allocation for VRE control, focusing on evidence-based interventions.
- Implementing uniform genotyping will improve surveillance and understanding of VRE transmission dynamics.
- This strategy may prevent widespread VRE colonization and infection, safeguarding public health in the Netherlands and beyond.