Hospital and Health Services

Clusters of vancomycin resistant enterococcus (VRE) carriage identified through a surveillance program in a tertiary teaching hospital Nelly Engelhardt 1, Julie Pearson 2, Geo rey Coombs2,3,4, David McGechie1,3 1 Department of Microbiology, PathWest Laboratory Medicine-WA, Fremantle Hospital, Fremantle, WA, 2 Department of Microbiology and Infectious Diseases, Royal Hospital, Perth WA, Australia 3 School of Pathology & Laboratory Medicine, The University of , Nedlands, WA, Australia 4 Australian Collaborating Centre for Enterococcus and Staphylococcus Species (ACCESS) Typing and Research, School of Biomedical Sciences, Curtin University, Perth, WA, Australia

ABSTRACT

Background: VRE infections in Australian hospitals have been increasing and hospital-acquired bacteraemia is becoming more common. Following emerging resistance in Perth hospitals in 2001 a state screening policy was developed. Aim: To describe recent experience from screening of high risk units (HRU) in a 350 bed tertiary teaching hospital with isolation of carriers and screening of patient contacts. Methods: Haematology, Renal and intensive care unit (ICU) patients were screened on admission and regularly thereafter using VRE chromogenic agar. Presence of vanB or vanA gene was confirmed by polymerase chain reaction (PCR) and typing was performed by pulsed field gel electrophoresis. Results: Between October 2011 and June 2014 VRE was isolated from 204 patients: 10 clinical isolates, 117 screening isolates and 77 isolates from room contacts. No bloodstream infections were recorded in this time. Seventeen pulsotypes were identified throughout the hospital but three types accounted for 74% of cases in three consecutive clusters on the Haematology, Renal and Surgery wards. All three types were found in ten wards across the hospital including ICU. Environmental swabbing on the surgical ward revealed VRE contamination throughout the ward including o ices and equipment outside of isolation rooms. Enhanced cleaning of toilets and bathrooms including use of vaporised hydrogen peroxide (Deprox) was associated with reduction in the number of cases. Conclusion: Focused screening for VRE carriage and isolation of positive patients has resulted in low levels of carriage in HRU. The number of infections remains low.

BACKGROUND RESULTS

In recent years, VRE have emerged as important nosocomial pathogens, causing significant morbidity and mortality(1). DeproxTM decontamination Carriers of Enterococcus faecium with vanB vancomycin resistance have become common in Perth tertiary teaching In recent years hydrogen peroxide vapour (HPV) has been shown to be e icient in ridding the hospital environment of VRE hospitals in the last decade. where routine cleaning has failed(3). We used the Deprox™ decontamination system in toilet areas on ward B7N where Currently clinical infections are unusual although there has been a dramatic increase in VRE hospital acquired bacteraemia there had been increased spread and widespread environmental contamination. In conjunction with enhanced cleaning this in other parts of Australia(2). A surveillance, screening and isolation program appears to have maintained control in Perth. terminated spread in the ward and there have been no new cases of the VRE since the decontamination process. These Repeated introductions of VRE to our hospital have resulted in spread on the wards due to contamination of shared toilet results are in concordance with the findings of Passaretti et al. where patients admitted to rooms decontaminated with HPV facilities and other equipment via the hands of patients and sta . were 80% less likely to acquire VRE(4). Molecular epidemiology AIMS The multilocus sequence types of the three predominant VRE PFGE were ST203 (PFGE 34/36); ST78 (PFGE 94) and ST555 To describe: (PFGE 90). All three sequence types belong to the hospital associated clonal complex 17 (Figure 2). 1. Recent experience of VRE screening and isolation of patients of high risk units (HRU) in a 350 bed tertiary teaching hospital. CONCLUSION 2. The e icacy of the Deprox™ decontamination system in preventing the environmental transmission of VRE in HRU. Surveillance of carriage in high risk units with isolation of carriers and room contacts together with enhanced cleaning have METHOD maintained clinical infections at a low level.

Newly acquired VRE PFGE Pulsotypes Predominant VRE PFGE Pulsotypes Haematology, Renal and Intensive Care Unit (ICU) patients were screened on admission and regularly thereafter using VRE October 2011 - June 2014 October 2011 - June 2014 35 chromogenic agar. Presence of vanB or vanA gene was confirmed by polymerase chain reaction (PCR) and typing was 18 20 22 29 31 39 42 53 performed by pulsed-field gel electrophoresis and multilocus sequence typing. 54 62 90 94 122 129 145 146 30 30 34/36 Unique Non typeable Not sent 34/36 (ST203) 94 (ST78) 90 (ST555) Screening Policies: 25 25

RDF* patients and HCF* patients ICU* Renal Haematology/Oncology 20 20 transferred from outside Western Haemodialysis patients Room contact inpatients Australia

15 15

Medical records electronically Screening on admission Screening on admission Screening on admission tagged 10 10

5 5 Three negative swabs on three Weekly screening if long stay Routine three monthly screening consecutive days

0 0 3 2 1 4 3 2 1 3 2 3 2 1 3 2 3 2 4 3 2 4 3 2 4 3 2 2 4 3 4 3 2 3 2 1 1 1 1 1 1 3 2 1 1 4 3 2 3 2 1 1 3 2 1 3 2 1 1 1 1 1 1 1 3 2 1 1 1 4 3 2 4 3 2 4 3 2 1 1 1 1 1 1 1 1 1 1 1 4 3 2 4 3 2 1 3 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 - - - - 1 - - - - 1 1 1 - - 1 1 1 1 1 1 1 - - - - - 1 ------1 1 - 1 ------r r r y y y - v v v c c c - p p r r r y y y v v v c c - c ar ar ar p a p a p a p p o o o e e e ul - ul ug ug - e e eb - eb - eb - an an an - ar ar ar un un un p a p a p a J J o o o e e e ul - ul ug ug - e e Oc t Oc t Oc t eb - eb - eb - A A A J J J an an - an F J F J F J un un un S S D D D N N N J J A A M M M M M M Oc t Oc t Oc t A A A J J J F J F J F J S S D D D N N N A A M M M M M * M * RCF: Residence care facility * HCF: Health care facility Cleared ICU: Intensive care unit VRE PFGE Pulsotypes per source wards VRE PFGE Pulsotypes per acquisition mode October 2011 - June 2014 October 2011 - June 2014 40 80 18 20 22 29 Room contact On admission Clinical specimen

31 39 42 53

54 62 90 94

122 129 145 146 35 70 Laboratory testing: 34/36 Unique Non typeable Not sent

30 60 Rectal swab/Faeces

25 50

Culture on VRE chromogenic agar 20 40

Culture positive Culture negative

15 30

PCR Test for vanA/vanB gene Testing discontinued (Xpert® vanA/vanB cepheid) 10 20

PCR positive PCR negative

5 10

VRE typing (pulsed-field gel Testing discontinued 0 0 E 5 6 4 S U S R U S H N N M N e 1 8 2 3 4 0 4 2 0 2 9 V V 8 7 8 9 D E S C 8 9 7 E 1 2 2 2 3 3 4 5 5 6 9 9 IC U B B B en t KA L S PR E 12 2 12 9 14 5 14 6 B B B

electrophoresis) C qu e NS U G RE M M MA U HI T s S GA G E 34/3 6 Un i No t Un ty pe ab l

VRE PFGE Pulsotypes per acquisition mode per source ward VRE PFGE Pulsotypes for Ward B7N References: October 2011 - June 2014 June 2013 - June 2014

35 1. Oprea SF, Zaidi N, Donabedian SM, Balasubramaniam M, Hershberger E, Zervos MJ. Molecular and clinical epidemiology of Room contact On admission Clinical specimen vancomycin-resistant Enterococcus faecalis. Journal of Antimicrobial Chemotherapy. 2004;53(4):626-30. 2. Coombs GW, Pearson JC, Daley DA, Le T, Robinson OJ, Gottlieb T, et al. Molecular epidemiology of enterococcal bacteremia in 30 16 Australia. Journal of Clinical Microbiology. 2014;52(3):897-905. 90 Unique Not sent

3. Chan HT, White P, Sheorey H, Cocks J, Waters MJ. Evaluation of the biological e icacy of hydrogen peroxide vapour decontamination in 25 Environmental screening during outbreak period 14 29th - 30th October 2013 DeproxTM wards of an Australian hospital. Journal of Hospital Infection. 2011;79(2):125-8. System Ward Site Culture cleaning 12 Jug in flusher before washing Heavy 4. Passaretti CL, Otter JA, Reich NG, Myers J, Shepard J, Ross T, et al. An evaluation of environmental decontamination with 20 Leather armchair by window Light Nurse station phone Light ENT cabinet Light hydrogen peroxide vapor for reducing the risk of patient acquisition of multidrug-resistant organisms. Clinical Infectious Diseases. 10 Macerator top Moderate 2013;56(1):27-35. Rm 6 handrail Light 15 Rm 6 floor Light B7N Rm 6 F+Call button Light 8 Rm 11 handrail Light Acknowledgement: Rm 14 handrail Light Rm 14 floor (moderate growth) Moderate Rm 12 handrail (moderate growth) Moderate 6 We gratefully acknowledge Hui-leen Tan, Yung Ching Lee, Denise Daley and Lynne Wilson from the Department of Microbiology and 10 Rm 16 handrail Light Rm 17 toilet seat Light Infectious Diseases, PathWest Laboratory Medicine-WA, , Perth, Western Australia, Australia. RM 17 toilet bowl (moderate growth) Moderate 4 BBN Macerator command panel Light

5 Envionmental screening post outbreak period: 2 Mid April - Mid May 2014

101 samples taken on wards B7N, B9N and V6, VRE was not isolated 0 0 E 5 6 4 U U V V G D C 3 4 3 3 3 IC U 3 4 4 4 A B7 S B8 S B9 S KA L 4 4 3 PR E B8 N B9 N B7 N C 3 1 NS U GE M RE M MA U 1 HIT H 1 1 1 1 SS S G EME R - - - - 1 - - - - 1 - 1 - 1 - 1 - 1 y v l c g - 1 b ct n ar a pr o e u u e u J O A Ja n F Ju n J Se p D N A M M