Massachusetts Department of Developmental Services Risk Management Protocols 
Subject:
VRE - VANCOMYCIN RESISTANT ENTEROCOCCI 
What is it? 
Vancomycin resistant enterococci is a  bacteria that can colonize or infect people and is resistant to one of the strongest available antibiotics, vancomycin.  Acute and long term care facilities have seen a dramatic increase of VRE infections among their general population. Occasionally within DDS we see medically fragile individuals who have VRE. It is the goal of this protocol to ensure proper management for infected individuals and prevention of the spread of infection to other individuals and personnel.
While most cases of VRE come from the individual’s own bowel flora, VRE can spread by direct individual-to-individual contact or on the hands of caregivers. VRE infection can be transmitted from contaminated articles by direct contact with such articles by an at-risk individual or indirectly by a staff person who does not comply with thorough hand washing, hygiene, housekeeping and other infection control measures. VRE have been recovered from bedrails, sheets, call buttons, telephones, horizontal surfaces, doorknobs, and equipment such as stethoscopes and thermometers.
Individuals with VRE in the stool may continue to shed the bacteria for weeks to months and treatment may not completely eliminate the organism.  VRE is distinguished from most other bacteria because it is particularly resistant to antibiotics.  .
Common Definitions: 
Colonized individual (carrier): Any person who is found to be culture-positive for VRE , but has no signs or symptoms of infection caused by the organism (asymptomatic).
Community Acquired Infection: An infection acquired from a non-hospital source.
Decolonize: To administer topical and/or systemic antimicrobial agents for the purpose of eradicating VRE carriage by an individual.
Health Care provider : HCP
Infected person: Any individual who has laboratory and clinical evidence of disease caused by VRE
.	Nosocomial Infection: An infection acquired in a hospital.
Outbreak: An increase in the incidence of VRE above its expected normal level. An outbreak is suggested if there are three or more cases that are linked by person (e.g., same health care provider), place (e.g. same wing, room) or time (onsets within 10 days of one another) of occurrence in a given facility.
Standard Precautions: A system of protective actions that assumes that all body substances may contain potentially infectious material. It requires good hand washing technique and use of barriers such as gloves, gowns, masks and eye protection to prevent transmission based on source of infection. 
Universal Precautions: A system of protective actions similar to Standard Precautions but which apply only to blood spills or body fluids 

What risk does this present? 

How is this managed? 
•	Management of the Infected Individual
When an individual living in or receiving services from a DDS operated or funded facility or program is diagnosed with VRE, the following shall occur:
A.	 The individual’s physician shall determine whether the VRE represents colonization or an active infection, and shall order treatment as necessary. Consultation with an infectious disease specialist may occur as indicated. 
1.	Treatment with antibiotics may be ordered as indicated for infected or colonized persons by their HCP. 
2.	Management of severe infection usually requires hospitalization for treatment with antibiotics. 
3.	Cultures of infected/colonized sites may be recommended by the person's HCP or an infectious disease specialist. It is customary that two negative cultures indicates the individual is free of infection or colonization. DDS will follow that standard.
B.	The DDS area nurse shall be notified as soon as possible and consulted if necessary. 
C.	The service provider in consultation with the person’s HCP shall review the health issues specific to the individual and make recommendations and/or decisions regarding home, work, and other activities as appropriate. Participation in normal living activities shall be encouraged as appropriate for the individual. In making such decisions, the team shall consider: 
1.	the body sites from which VRE has been cultured and whether drainage from such sites can be contained; 
2.	the person's competence regarding personal hygiene and whether these factors relate to the potential spread of VRE;  
3.	the type of direct care the person requires; and 
4.	the ability of staff to comply with strict hand washing and infection control procedures and environmental hygiene.
D.	The team recommendations/decisions regarding the person's living, day and social situations shall be based upon the following considerations: 
1.	Individuals infected with VRE may share a bedroom with a low-risk roommate (i.e., one who does not have tubes, catheters, wounds or decubiti, intravascular lines, and/or is not immuno-compromised) or with another VRE positive individual. 
2.	 VRE positive individuals can be considered for a private room and should not socialize without one-to-one supervision if the person 
i.	has VRE isolated in stool and has uncontrolled diarrhea; 
ii.	has VRE isolated from stool and does not understand or cannot/will not cooperate with basic hygiene; 
iii.	has VRE isolated from a wound that cannot be covered or has drainage that cannot be contained.
3.	Decisions regarding placement and treatment shall be documented in the individual’s record and progress notes. 
4.	Individuals with VRE infection or colonization shall not be refused placement/services solely on the basis of his or her VRE status.
E.	The service provider shall ensure that staff receives training regarding VRE infection including issues and concerns specific to the individual with VRE.
•	Standard Precautions
A.	Hand washing and adherence to standard precautions remain the most important measures in controlling the spread of infection, including the spread of VRE.  Practice of standard precautions includes: 
1.	Thorough hand washing before donning gloves and immediately after gloves are removed. 
2.	Thorough hand washing between caring for individuals. 
3.	Use of gloves when caring for individuals whenever contact with wounds, sores, stool, mucous membranes, or other body substances 
4.	Use of gowns for activities that generate splashes an sprays of fluids
5.	Masks and eye protections during any activities that may generate splashes or sprays.
•	Equipment 
A.	Equipment should be dedicated for the person infected with VRE whenever possible (. e.g., thermometers, commodes, toilets etc.), especially when use of disposable equipment is not feasible. 
B.	Non-dedicated or non-disposable equipment shall be disinfected after every use by or exposure to the individual and prior to use by another individual using an EPA registered disinfectant or bleach solution 1:100 dilution. 
•	Communication, Documentation and Confidentiality
A.	Information regarding the individual's infection or colonization with VRE shall be handled in the same manner as any other medical information. 
1.	As with all medical information, diagnosis and treatment of VRE shall be released to the individual's health providers. Standard medical consent to release information shall be maintained in the individual's record (health or master file). 
2.	Information regarding VRE infection shall be released to others on a need to know basis and only after obtaining the consent of the individual or his or her guardian. 
3.	If information cannot be shared due to lack of consent and concerns include potential risk to other individuals, legal advice should be sought.
4.	When the person is being transferred to another setting, advance notification shall be given to ensure appropriate planning if consent has been obtained.
5.	
Where and to whom do these recommendations and protocols apply?
These guidelines apply to the care of any individual supported by DDS who has VRE.
Where can I find additional help?
Check the Department of Public Health Website at: www.Mass.gov/dph and search “VRE”.