2004 Lowbury Lecture: the Western Australian experience with vancomycin-resistant enterococci - from disaster to...

Area of Science:

• Infectious Diseases
• Hospital Epidemiology
• Microbiology

Background:

• The first hospital outbreak of vancomycin-resistant enterococcus (VRE) in Western Australia (WA) occurred in 2001, caused by vancomycin-resistant Enterococcus faecium (VREF) of the vanB genotype.
• The outbreak rapidly spread across multiple hospital units, leading to significant patient colonization and infection.
• Conventional laboratory methods for VRE detection were slow, hindering timely control measures and allowing for environmental contamination and nosocomial transmission.

Discussion:

• A Hospital VRE Executive Group was established, supported by substantial funding from the WA Department of Health, to implement enhanced infection control practices.
• A rapid laboratory identification procedure using multiplex polymerase chain reaction (PCR) for vanA and vanB genes was developed, reducing detection time to 30-48 hours.
• Extensive screening of ward contacts, including post-discharge follow-up, identified a significant number of VREF carriers, mitigating the risk of re-admission and further transmission.

Key Insights:

• The outbreak was terminated after five months, with enhanced infection control practices costing AUD 2,700,000.
• Rapid laboratory identification via PCR significantly improved the ability to detect VRE carriers promptly.
• Electronic labeling and active follow-up of ward contacts were effective in identifying carriers who posed a risk for future outbreaks.

Outlook:

• Ongoing control is maintained through targeted active surveillance cultures for high-risk units and opportunistic screening.
• Vigilance is necessary as the epidemic VREF strain remains present in the Perth community, with sporadic cases and small outbreaks continuing.
• The implemented VRE control program has successfully prevented VRE from becoming established in any WA hospital to date.