Precautions to Prevent MRSA and VRE Transmission in Healthcare Setting

Michael Calderwood, MD, MPH, previously assistant hospital epidemiologist and associate director of antimicrobial stewardship at Brigham and Women’s Hospital, outlines ways in which infection prevention strategies can be modified to fit the needs of immunocompromised individuals.

Interview Transcript (slightly modified for readability).

“In these populations we want to be thoughtful in how we are preventing infections. We talked earlier on about [methicillin-resistant Staphylococcus aureas (MRSA)] and [vancomycin-resistant enterococci (VRE)]. These are two bacteria, MRSA predominantly in the nares and VRE predominantly in the [gastrointestinal (GI)] tract, that can colonize patients. [Infected] patients then can colonize the environment around them and be a source of infection for others.

In these special populations, one thing that has been done is to do regular surveillance. Oftentimes, patients coming into the hospital, and then on somewhat of a regular basis, weekly is one practice, are swabbed in both the nares and the rectum looking for MRSA and VRE. If someone is colonized, or positive, they are then put into a private room. We, [as healthcare providers], wear gowns and gloves [before] going into the room to try and prevent transmission to other patients in the hospital.

We do similar things for patients that are found to be colonized or infected with certain resistant gram-negatives. For instance, if we have found that we have an uptick in our [Carbapenem-resistant Enterobacteriaceae (CRE)] rates, then we will do rectal swabs for Carbapenem-resistant Enterobacteriaceae. We don’t necessarily do that for [patients infected with] other gram-negatives, but if we’ve found that they have high levels of drug resistance, we will put them on contact precautions as well.

Other things that we do in these patient populations is decolonization of the skin, and so, there has been a big push for daily chlorhexidine bathing. At our hospital we’ve been doing that both in our [Intensive Care Unit (ICU)] populations as well as in our oncology and bone marrow transplant populations. The idea here is that as you’re hospitalized, you are colonized with bacteria and this goes beyond the common things we know about, but if you are bathing [daily] with chlorhexidine, you’re removing the skin colonizers of all types. It has been linked to lower risk of bacteremia, particularly MRSA bacteremia, [and] there have also been some studies showing lower rates of [urinary tract infection (UTI)], probably because of reductions in gram-negative colonization.

Now the other thing we do in these populations is focusing on prevention bundles. I had mentioned that patients who are getting chemotherapy will have long-term lines in place, central lines, and so things that we do around insertion of those lines, trying to put those in in a sterile manner. [We are also] focused on maintenance, and so we may have things like a chlorhexidine patch at the point of entry and we may have alcohol line locks to prevent the seeding of bacteria into the distal end port. Then, the nurses have a lot of work on what we call “scrub the hub” and trying to prevent colonization of these longer term catheters. We have similar bundles in place for urinary catheters [and] similar bundles in place for ventilated patients in trying to prevent catheter-associated urinary tract infections and ventilator-associated pneumonia respectively."