Management of VRE Faecium Detected on Rectal Swab
VRE faecium detected on a rectal swab represents colonization, not infection, and requires strict contact isolation precautions but no antimicrobial treatment. 1
Key Distinction: Colonization vs. Infection
The critical first step is recognizing that a positive rectal swab indicates colonization only. Most patients colonized with VRE have intestinal colonization without clinical infection 1. It is essential to differentiate colonization from true infection prior to prescribing anti-VRE antimicrobial agents 2. Do not treat colonization with antibiotics.
Immediate Infection Control Measures
Once VRE is detected on rectal swab, implement the following isolation precautions immediately 1:
Room Assignment
- Place patient in a private room or cohort with other VRE-positive patients
- Single rooms are preferred to prevent transmission
Contact Precautions (Required for ALL staff entering room)
Glove Use:
- Wear clean, non-sterile gloves when entering the room
- VRE extensively contaminates the patient environment 1
- Change gloves after contact with high-concentration materials (stool)
Gown Use:
- Wear clean, non-sterile gown when entering if:
- Substantial contact with patient or environmental surfaces is anticipated
- Patient is incontinent
- Patient has ileostomy, colostomy, or diarrhea 1
Hand Hygiene:
- Remove gloves and gown before leaving the room
- Immediately wash hands with antiseptic soap or waterless antiseptic agent
- Bland soap does not completely remove VRE 1
- Avoid touching environmental surfaces (door knobs, curtains) after hand hygiene 1
Equipment Management
- Dedicate non-critical items (stethoscope, blood pressure cuff, thermometer) to single patient
- If shared equipment is necessary, adequately clean and disinfect before use on other patients 1
Surveillance and Screening
Screen roommates and contacts:
- Obtain rectal swab or stool culture from roommates of newly identified VRE patients 1
- Apply isolation precautions based on results
- Consider additional ward screening at infection control discretion 1
For high-risk units (ICU, oncology, transplant):
- Implement periodic culture surveys of rectal swabs or stools 1
- Screen patients hospitalized ≥5-7 days or transferred from facilities with known VRE 1
Duration of Isolation
VRE colonization can persist indefinitely 1. Consider removing isolation precautions only after:
- ≥3 consecutive negative cultures (≥1 week apart) from:
- Stool or rectal swab
- Perineal area
- Axilla or umbilicus
- Wound, catheter, or ostomy sites (if present) 1
Documentation and Follow-up
- Flag patient records (ideally computerized) to ensure prompt isolation upon readmission 1
- VRE carriers can remain colonized long after hospital discharge
- Coordinate with local/state health departments regarding discharge to nursing homes or other facilities 1
When to Consider Treatment
Treatment is indicated only for documented VRE infection, not colonization. Clinical infections requiring treatment include:
- Bacteremia with positive blood cultures
- Endocarditis (associated with higher mortality for E. faecium vs. E. faecalis) 2
- Complicated urinary tract infections with systemic symptoms
- Wound infections with clinical signs
For actual VRE infections, treatment options include daptomycin (8-12 mg/kg), linezolid, or in select cases high-dose ampicillin for urinary tract infections 2.
Common Pitfalls to Avoid
- Do not treat asymptomatic colonization - this increases resistance and provides no benefit
- Do not delay isolation precautions - implement immediately upon detection 1
- Do not rely on bland soap alone - use antiseptic agents for hand hygiene 1
- Do not assume clearance without documentation - colonization persists indefinitely in many patients 1
- Be aware that some VRE may appear vancomycin-susceptible phenotypically but carry silent vanA genes (VVE), though clinical significance remains unclear 3, 4