Bacterial resistance to antibiotics is an increasing problem in Canada and
worldwide. Vancomycin-resistant enterococci (VRE) are strains of
Enterococcus faecium or Enterococcus faecalis
that contain genes conferring resistance to vancomycin. Escherichia coli (E.
coli), Klebsiella pneumonia (K. pneumonia), and other
gram-negative bacteria may produce the enzymes known as extended spectrum
beta-lactamases (ESBL). These have the ability to inactivate beta lactam antibiotics
such as penicillin, ampicillin, and the cephalosporins.
The presence and growth (colonization) of VRE and ESBL-producing
micro-organisms in the gastrointestinal tract is usually of no consequence for the
host, but under certain circumstances, such as immunosuppression, gastrointestinal
surgery, or physical debilitation, they may serve as a source of infection for the
carrier. These hosts may also serve as a reservoir for the transmission of VRE and
ESBL-producing organisms to other persons. Results from the Canadian Nosocomial
Infection Surveillance Program showed that from 1999 to 2005, the rate of VRE
colonization and VRE infection increased from 0.37 to 1.32 cases, and from 0.02 to
0.05 cases respectively per 1,000 patients admitted to hospital. The
laboratory-based Canadian Ward Surveillance Study in 2008 found
that ESBL-producing E. coli were identified in all Canadian
geographic regions, and that 4.9% of E. coli isolates were
ESBL producers.
Specific prevention and control measures for antibiotic-resistant organisms
(AROs) include screening (a process to identify persons colonized with AROs) and
isolation of the carriers. Hospital infection prevention and control strategies have
been developed in some Canadian jurisdictions, and these are compatible with other
national and international documents. Non-specific strategies for controlling ARO
transmission and infection include hand hygiene; environmental cleaning;
antimicrobial stewardship; and bundled practices, such as those to prevent central
line-associated blood stream infections.
Antibiotic-resistant organisms, such as VRE and ESBL-producers, lead to the
increased use of hospital resources due to extended hospital stays, laboratory
tests, physician consultations, costly medications if therapy for a VRE or
ESBL-related infection were to arise, and the need to adhere to infection prevention
and control measures to prevent the further spread of these pathogens. Some of the
increased resource usage results from the morbidity caused by VRE or ESBL-producing
organism infections, while some is a consequence of control strategies. For example,
it may be harder to transfer a patient to a rehabilitation facility if they are
currently in isolation, which will in and of itself, prolong the length of stay.
The objective of this systematic review is to evaluate the clinical evidence
for the effectiveness of screening, isolation, and decolonization strategies for
persons colonized or infected with VRE and ESBL-producing organisms in acute and
long-term care facilities. The health services impact of these strategies will be
discussed.
CADTH is funded by Canadian federal,
provincial, and territorial governments.
Suggested citation:
Ho C, Lau A, Cimon K, Farrah
K, Gardam M. Screening, Isolation, and Decolonization Strategies for
Vancomycin-Resistant Enterococci or Extended Spectrum Beta-Lactamase
Producing Organisms: A Systematic Review of the Clinical Evidence and Health
Services Impact [Internet]. Ottawa: Canadian Agency for Drugs and
Technologies in Health; 2012 (Rapid Response Report: Systematic Review). [cited
2012-09-21]. Available from: http://www.cadth.ca/media/pdf/htis/sept-2012/RE0028_VREReport_e.pdf
Production of this report is made possible by financial contributions from
Health Canada and the governments of Alberta, British Columbia, Manitoba, New
Brunswick, Newfoundland and Labrador, Northwest Territories, Nova Scotia, Nunavut,
Prince Edward Island, Saskatchewan, and Yukon. The Canadian Agency for Drugs and
Technologies in Health takes sole responsibility for the final form and content of
this report. The views expressed herein do not necessarily represent the views of
Health Canada, or any provincial or territorial government.
Disclaimer: This report was prepared by the Canadian Agency for Drugs and
Technologies in Health (CADTH). CADTH is an independent, not-for-profit organization
funded by the federal, provincial, and territorial governments of Canada. CADTH is
one of Canada’s leading sources of information and advice about the
effectiveness and efficiency of drugs, medical devices, and other health
technologies. The report contains a comprehensive review of the existing public
literature, studies, materials, and other information and documentation
(collectively the ―source documentation) available to CADTH at the time of
report preparation, and was guided by expert input and advice throughout its
preparation. The information in this report is intended to help health care
decision-makers, health care professionals, health systems leaders, and
policy-makers make well-informed decisions and thereby improve the quality of health
care services within the Canadian health care systems. The information in this
report should not be used as a substitute for the application of clinical judgment
in respect to the care of a particular patient or other professional judgment in any
decision making process, nor is it intended to replace professional medical advice.
While CADTH has taken care in the preparation of this document to ensure that its
contents are accurate, complete, and up to date, as of the date of publication,
CADTH does not make any guarantee to that effect. CADTH is not responsible for the
quality, currency, propriety, accuracy, or reasonableness of any statements,
information, or conclusions contained in the source documentation. CADTH is not
responsible for any errors or omissions or injury, loss or damage arising from or
relating to the use (or misuse) of any information, statements, or conclusions
contained in or implied by the information in this document or in any of the source
documentation. CADTH takes sole responsibility for the final form and content of
this report subject to the limitations noted above. The statements, conclusions, and
views expressed herein do not necessarily represent the view of Health Canada or any
Canadian provincial or territorial government. Production of this report is made
possible by financial contributions from Health Canada and the governments of
Alberta, British Columbia, Manitoba, Newfoundland and Labrador, Northwest
Territories, Nova Scotia, Nunavut, Prince Edward Island, Saskatchewan and Yukon.
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