Infectious Diseases in Critical Care Medicine

all concluded that effective VRE control with a reduction in infections caused by VRE is cost-
effective (187–190). In three of the studies, control of VRE was cost-effective with savings to the
hospitals of between $100,000 and $500,000 per year (187,188,190). The other study estimated
the costs of VRE infections in a hospital using a retrospective matched cohort study (189). The
authors estimated that the effects of VRE infections on patients would include 15 cases of in-
hospital deaths, 22 major operations, 26 ICU admissions, and 1445 additional hospitalization
days with excess costs of $2,974,478 during the study period. It is reasonable to conclude from
the available data that control of VRE is cost-effective.

REFERENCES

1. Jevons MP. “Celbenin”-resistant staphylococci. Br Med J 1961;1:124–125.


2. Barrett FF, McGehee RF, Finland M. Methicillin-resistantStaphylococcus aureusat Boston City
   Hospital. N Engl J Med 1968;279:441–448.

Table 6 Control Measures for VRE in ICUs

Measure Comments

When there is one or more patients in the ICU with
infection or colonization due to VRE, culture each of
the other patients in the ICU weekly until discharge
to identify all patients colonized with VRE

Use selective culture media
Take specimens for culture from perirectal area and
wounds
Flag patients’ charts or flag patients in the hospital
computer system who are VRE positive
Place patients with VRE infection and colonization on
contact precautions

Place patients flagged for VRE on contact precautions on
admission
Health care workers should wear both gown and gloves
to enter the room of a patient on contact precautions
Masks are not needed
Remove gown and gloves prior to leaving the room
Practice hand hygiene after leaving the room Wash hands with a soap containing an antiseptic or apply
an alcohol hand rub
If hands are visibly soiled, wash with a soap containing an
antiseptic or wash with plain soap followed by
application of an alcohol hand rub
Culture environmental surfaces to assess extent of
contamination with VRE

Obtain specimens with sterile swabs moistened with
sterile saline without bacteriostatic agents
Use selective culture media to maximize efficiency of
laboratory identification of VRE
Use bucket method to clean and disinfect environmental
surfaces
Identify and clean all surfaces that may become
contaminated
Culture environmental surfaces to determine the
effectiveness of the cleaning and disinfection methods
Do not use phenolic disinfectants in NICUs for
environmental decontamination
When possible, limit use of those antimicrobial agents
that have been identified as risk factors for VRE
acquisition or that increase the concentration of
VRE in stool

Antimicrobial agents that have been identified as risk
factors for the acquisition of VRE include
cephalosporins (particularly third-generation
cephalosporins), vancomycin, metronidazole,
carbapenems, and ticarcillin–clavulanate
Antimicrobial agents that have been shown to increase
the concentration of VRE in stools include clindamycin,
metronidazole, cefoxitin, and ceftriaxone
Piperacillin–tazobactam may protect against acquisition
of VRE
Patients may be taken off of contact precautions when
they have had three consecutive sets of negative
cultures for VRE, each taken1 wk apart

Cultures should be taken from the perirectal area and all

previously positive sites

Abbreviations:VRE, vancomycin-resistant enterococci; ICU, intensive care unit; NICUs, neonatal intensive care
units.

MRSA/VRE Colonization and Infection in the Critical Care Unit 119