Vancomycin-Resistant Enterococcus Infection: Management and Prevention

Enterococcus spp. normally inhabit the gastrointestinal tract of humans, but can cause pathogenic invasions in the case of disrupted gut microbiota. Enterococcal infections can lead to urinary tract infections, which can further “progress to bacteremia or endocarditis” if left untreated (Pontefract et al., 2020, p. 2). This is particularly unfavorable for vulnerable patients. Moreover, these infections have “limited therapeutic options” since they can develop high-level resistance to several antibiotics, including vancomycin (Ayobami et al., 2020, p. 1180). Hence, this health issue not only impairs patients’ quality of life but can also trigger life-threatening conditions. Therefore, it requires careful consideration and targeted intervention.

Vancomycin-resistant enterococcus infections constitute a significant public health concern due to their prevalence and persistence in nosocomial settings. This is because Enterococcus spp. are capable of “easy transmission through multiple routes of cross-contamination, including invasive medical devices” (Ayobami et al., 2020, p. 1180). Over the past few years, researchers have been registering an increasing mean proportion of vancomycin-resistant E. faecium in the U.S. and worldwide (Ayobami et al., 2020).

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As a result, the Centers for Disease Control and Prevention in the United States and the World Health Organization “listed vancomycin-resistant E. faecium as a high priority pathogen in urgent need of drug research and development” (Ayobami et al., 2020, p. 1180). As one can observe, vancomycin-resistant enterococcus infections pose a serious challenge and need joint efforts from clinicians and public health professionals on a global basis.

Contributing factors of vancomycin-resistant enterococcus infection include adult and elderly age, the extensive use of broad-spectrum antibiotics, inpatient treatment, and application of invasive medical equipment during hospitalization (Ayobami et al., 2020). Furthermore, enterococcal bacteriuria often causes urinary tract infections in patients with concomitant immunocompromising conditions, such as malignancies (Pontefract et al., 2020). Other immunocompromising states, contributing to vancomycin-resistant enterococcus infections, include “transplant and rheumatologic disease, or treatment with immune-modulating agents or corticosteroids” (Kram et al., 2018, p. 317).

Ayobami et al. (2020) found higher proportions of vancomycin resistance in the adult population and elderly patients than in younger subjects. The scholars explain this age trend by “more frequent exposure to antibiotics and hospital admission in older patients throughout their lives” (Ayobami et al., 2020, p. 1187). Besides, the researchers reported a significantly increased proportion of vancomycin-resistant enterococcus infections in inpatient settings due to the use of indwelling urinary catheters (Ayobami et al., 2020). In other words, there is a high chance of cross-contamination between the hospital staff and invasive medical devices. Thus, it is essential to consider the abovementioned risk factors for the elaboration of an appropriate prevention algorithm.

Consequently, basic strategies to prevent vancomycin-resistant enterococcus infections logically rely on the identified contributing factors. First of all, it is necessary to restrict the use of broad-spectrum antibiotics, including vancomycin, among patients throughout their lives. Moreover, substantial training of hospital personnel in terms of adequate handwashing and antiseptic treatment is of paramount importance. Routine screening for vancomycin resistance should also be implemented for timely identification and isolation of affected subjects. Furthermore, patients with immunocompromised states should undergo regular screenings to predict vancomycin-resistant enterococcus and address it appropriately and promptly.

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Signs and symptoms of vancomycin-resistant enterococcus invasion include common manifestations associated with urinary tract infections. These symptoms are “increased urinary frequency, urinary urgency, dysuria, fever, and flank pain” (Pontefract et al., 2020, p. 2).

Furthermore, costovertebral angle tenderness is also a sign of urinary tract infections (Pontefract et al., 2020). Moreover, researchers documented such symptoms of catheter-associated urinary tract infections as “rigors, acute hematuria, and pelvic discomfort” (Pontefract et al., 2020, p. 2). However, it is necessary to consider that vancomycin-resistant enterococcus colonization can often produce no symptoms at all. For instance, in the study by Pontefract et al. (2020), “most patients with vancomycin-resistant enterococcus identified on urine culture were asymptomatic” (p. 1). Therefore, clinicians should take into account this peculiarity and re-enforce routine screening of vulnerable populations.

Diagnostic tests used to identify colonization with vancomycin-resistant enterococcus include the urine culture, the blood culture, and polymerase chain reaction. The urine culture is conducted in patients with a suspected urinary tract infection, whereas polymerase chain reaction helps to detect vancomycin-resistant enterococcus bloodstream infections. This test involves adding to a sample of urine a substance, promoting the growth of bacteria. After the urine culture collection, the test is considered positive if “>103 colony forming units (CFU)/mL of vancomycin-resistant enterococcus” grow in the sample (Pontefract et al., 2020, p. 2). Similarly, the blood culture is applied to detect bacteremia, which is the presence of bacteria in the blood.

Meanwhile, polymerase chain reaction relies on rectal screening. In other words, this test is used for identifying vancomycin-resistant enterococcus in rectal swabs (Kram et al., 2018). However, researchers point out that polymerase chain reaction for rectal screening has a low positive predictive value for the detection of vancomycin-resistant enterococcus bloodstream infections (Kram et al., 2018). At the same time, the negative predictive value is high, and it amounts to 90.3% (Kram et al., 2018, p. 317).

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Moreover, the cerebrospinal fluid culture is also applied when vancomycin-resistant enterococcus infection affects the central nervous system (Ayobami et al., 2020). As one can observe, the array of diagnostic tests corresponds to a multi-channel nature of vancomycin-resistant enterococcus infection, which can colonize the gastrointestinal tract, the urinary tract, and bloodstream.

After the collection of cultures to detect vancomycin-resistant enterococcus, the physicians check the sensitivity of bacteria and select appropriate antibiotics. In particular, patients are given intravenous and/or oral antibiotics with intrinsic activity against vancomycin-resistant enterococcus (Pontefract et al., 2020). The list of antibiotics used to treat vancomycin-resistant enterococcus infection include but is not limited to linezolid, penicillin, nitrofurantoin, daptomycin, tetracyclines, fosfomycin, and quinupristin/dalfopristin (Pontefract et al., 2020). Hence, targeted antibiotic therapy is a cornerstone for the management of vancomycin-resistant enterococcus infection.

Furthermore, nursing care is a key prerequisite for the effective management of individuals with vancomycin-resistant enterococcus and prevention of the spread of the infection. These measures include compliance with the regimen of patients’ isolation, appropriate waste disposal, and disinfection of hands and medical tools. Follow-up care for patients upon discharge from the hospital relies on periodic screenings to detect possible re-infections.

Thus, vancomycin-resistant enterococcus infection is a strong challenge for clinicians and public health professionals from all over the world, and it requires coordinated actions to prevent its spread and complications. The necessary interventions include restriction in the use of broad-spectrum antibiotics among populations throughout their lives, routine screening of vulnerable patients, and education of healthcare personnel in terms of antiseptic measures.

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These strategies can be implemented through relevant outreach and educational programs in communities, starting from schools and extending to healthcare facilities. If implemented appropriately and in tandem, these prevention strategies are able to minimize the spread of vancomycin-resistant enterococcus infections and thus prevent their possible life-threatening complications.

References

Ayobami, O., Willrich, N., Reuss, A., Eckmanns, T., & Markwart, R. (2020). The ongoing challenge of vancomycin-resistant enterococcus faecium and enterococcus faecalis in europe: An epidemiological analysis of bloodstream infections. Emerging Microbes & Infections, 9(1), 1180–1193. Web.

Kram, S., McRae, A., Schultheis, J., & Kram, B. (2018). 661: A vancomycin-resistant enterococcus (VRE) screen to predict VRE bloodstream infection in the ICU. Critical Care Medicine, 46(1), 317. Web.

Pontefract, B. A., Rovelsky, S. A., & Madaras-Kelly, K. J. (2020). Linezolid to treat urinary tract infections caused by vancomycin-resistant enterococcus. Sage Open Medicine, 8, 1–7. Web.

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