Monday, April 11, 2011

VRE ...when to treat!!

Vancomycin resistant enterococci are emerging as another leading nosocomial bacteria in hospitals.Enterococci are gram-positive and facultatively anaerobic microorganisms commonly found as part of the normal flora in the gastrointestinal tract.Several factors contribute to this increased risk among hospitalized patients, such as the disruption of the normal gastrointestinal flora by administration of broad-spectrum antibiotics, colonization with hospital-associated strains, poor infection control practices, presence of indwelling devices including urinary catheters, and an immunosuppressed state.Enterococcus faecalis andEnterococcus faecium are the two most common species isolated in this setting. The most common types of infection caused by enterococci are urinary tract infections (UTIs)


Given this intro...there may be 3 clinical scenarios we come across in hospital practice...
1. VRE UTI                 2. aymptomatic VRE bactereuria         3.VRE colonization
Well ..these have to be differentiated in clinical practice, as the last 2 dont need treatment , except in some special circumstances.


 A good detailed history about UTI symptoms in very much the deciding step for who to treat. Any lower or upper UTI system is needed to suspect UTI from VRE( except in elderly pts ). Once this is present, then proceed according to the flow sheet above.Evidence of VRE in the urine in the absence of symptoms or pyuria may have limited clinical importance in most patients, representing asymptomatic VRE bacteriuria or colonization, and generally does not require treatment; however, treatment may be considered in very high-risk patients (e.g., patients with catheter-acquired bacteriuria that persists 48 hrs after indwelling catheter removal, patients with planned genitourinary procedures, solid organ transplant recipients, neutropenic patients, and pregnant women).Always change Foley catheters once VRE is found in the urine.


 Aminopenicillins, both with (e.g., ampicillin-sulbactam, amoxicillin-clavulanate) or without β-lactamase inhibitors and penicillin are generally considered to be the drugs of choice for the empiric treatment of VRE infections.In case of ampicillin resistance , then nitrofurantoin or Linezolid can be used for VRE cystitis...........and Daptomycin or Linezolid can be used for upper tract UTIs and VRE bactermia. Duration of treatment doesnt need to be extended beyond 14 days.

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