Episode Transcript
Infection Control Explained (ICE) Podcast 6 VRE
This Podcast is brought to you by the GOSH Learning Academy.
[00:00:05] Kate H: Welcome back to the ICE Podcast. ICE stands for Infection Control Explained, and today we will be talking a little bit about a resistant bug called VRE, which stands for Vancomycin Resistant Enterococci. It's a bit of a mouthful. So my name is Kate Harkus. I'm the lead practice educator for infection prevention and control.
And welcome back to Elaine. She previously came to talk to us about viruses and she is first and foremost a scientist. She is our infection control doctor and the deputy Director of Infection Prevention and Control. Welcome back.
[00:00:44] Elaine: Hey, thank you for having me again.
[00:00:47] Kate H: You are very welcome. So let's dive in and talk a little bit about what VRE is, if you're happy to explain.
[00:00:55] Elaine: Yeah. VRE is one of those kind of forgotten resistant bugs. It's not one of those ones that tends to get big headlines, so it's not your MRSAs that you'll hear about on the news and in the papers. It's not even your CPEs, which are currently on the rise and therefore getting quite a lot of coverage.
People are talking about them a lot more. It's almost our forgotten resistant bug.
[00:01:21] Kate H: Okay.
[00:01:23] Elaine: But it has a lot of implications for how we manage patients. So there were a couple of things really to know about it. What is a vancomycin resistant enterococci? It's not like an organism that people think about.
So your enterococci are related actually to your streptococci. So you know, the streps that people talk about in terms of you have them in your mouths and we get strep pneumo. You can get a pneumococcal vaccine if you are of a proper/ right age in order to help stop pneumonia, that kind of thing.
The Enterococci are effectively from that family.
So they used to actually almost be called streptococci, but because they live in your gut, whereas all of the other ones live in kind of your respiratory tract, it was decided to give them a different name. And so that's why they are called Enterococci and not Streptococci.
Okay. But they have very similar features. Because they are Gram-positive bacteria. I'm talking about Gram-positive and Gram-negative as if it's meaningful, but I'll explain what that means. There was a guy called Gram, his surname was Gram. He came up with a way to stain bacteria so we could see them under a microscope.
[00:02:36] Kate H: Okay,
[00:02:36] Elaine: so bacteria have. For the main part, there are exceptions, but we won't go into it. Two different types of cell walls, so containers that keep the inside of the bacteria in. And they function in slightly different ways. So Gram-positive bacteria have a very hardy kind of outside cell wall, and that's because they tend to live on our skin.
They tend to live in our respiratory tract. They're living in places where they could get exposed to like skin creams or all kinds of things, right?
And so they have stuff that really is quite protective. And then you've got your Gram negatives. Now the Gram negatives, 'cause they tend to live in our guts where they'll be exposed to a different type of chemical or, but they also often live in the environment, out in the real world.
They have. A double cell wall and that enables them to chuck out stuff that gets into the cell, like toxins, chemicals that they don't like. And this guy called Gram, designed a stain that means that your Gram positive are purple. One of my favourite colours. And your Gram negatives are pink.
Another one of my favourite colours. So I'm very pro Mr. Gram. He made good things. But the reason, understanding that is important in the context of VRE is Vancomycin is a drug that we use to treat Gram-positive bacteria. Okay. Not Gram-negative bacteria. And that's because Vancomycin, if you look at its chemical composition, it's a really big drug, its actual molecules are huge. They are too big to get through that double layer that I talked about in terms of your gram-negatives. Okay, yeah, that makes sense. So the work on your Gram-positives, so therefore having something that is vancomycin resistant is much more important. In your Gram positives 'cause you're removing one of the big drug classes that you are going to use.
It's a really reliable drug that we give and escalate. So having something that's vancomycin resistant is really important. So that's why Vancomycin Resistant Enterococci. Are important 'cause you're removing one of the big drugs that you would use if you got a VRE infection. Does that make sense?
[00:04:56] Kate H: That makes total sense. So in terms of then the level of concern that we would have for our patients about VRE, what would you think about with that?
[00:05:07] Elaine: It's an interesting one in that it's really important to know that you have VRE on board so that if we then find a Gram positive in a blood culture, if we've taken a sample because someone's not well, it means we will change up what we might give that patient in order to be able to give them the most appropriate antibiotic quickly. But one of the big things is because VRE is carried in the gut and you, most of the time you won't. No one will know they've got it, it's a really silent organism. But it survives really well if it gets into the environment.
So one of the other reasons that we wanna know about it is because actually you clean and do things quite differently after a patient has been in a space. Okay. Has VRE, just because, I talked about the fact that it's quite a hardy organism in terms of where it lives and it's being able to deal with it has all the hard features of a Gram positive plus a Gram negative 'cause of where it lives. It's a really adapted kind of organism.
[00:06:15] Kate H: So there's
[00:06:17] Elaine: lots of data out there that basically could go, shows that if you go into a room and this is based on US data, so slightly different to how we work things here, but if you went into a room in the US in some of the studies they've done and the person in that room, before you had VRE, you were over twice as likely to get VRE. Okay. And acquire it as a hospital acquired organism during the course of your stay. Now that obviously has a load of provisos because we clean differently. In the uk we screen differently, like our risks are different.
But based on that work, we also make sure that we do all of our cleans differently if we have a patient that's coming in with that spa organism, just because we know it's a bit trickier in order to make sure that we get rid of it. So it does, it's meaningful that for the individual patient because we want to be able to treat them properly, but it's also meaningful more widely for across the hospital to make sure that we are keeping our environment safe and clean so that we don't put anybody else at risk.
[00:07:28] Kate H: Got you. So what are those like different things that we do at GOSH, as opposed to another like resistant bug.
[00:07:35] Elaine: So we will do a special level of clean. So we use something called hydrogen peroxide vapor.
As an additional cleaning agent within, gosh, for things like VRE. So what we'll do is we'll do a deep clean, we're using chlorine in order to drop things down, but because we know that this organism can stay, it produces something called dry biofilm, which is really interesting and slightly complicated, but most people think, when you look in a plug hole and there's loads of goop there,
that's your normal biofilm. And that can make stuff quite hard to get rid of, which is why your drains can sometimes clog and all of that stuff at home.
VRE can call something called dry biofilm where it can stick really tightly to a surface.
And you have to effectively get it wet enough to then get it off. Okay. And so we use both a chlorine based cleaning agent in order to try to plump it up and rehydrate it and get rid of it. And then we use something called hydrogen peroxide vapor, where we put a machine in the middle of a room and it creates a vapor of hydrogen peroxide.
And then when that lands on, touches on the surface, it splits into oxygen and water, and that process actually impacts and kills organisms that are on the surface. So it gives you an extra level of redundancy, an extra level of kill in order to make sure that you are really getting rid of anything that's there.
So we do this extra two level combined approach in order to try to make sure that stuff is definitely gone before the next person enters the space.
[00:09:21] Kate H: Got you. It's all making sense. So we've talked about cleaning and the environment and stuff like that, and other measures that we can do in the hospital to try to, prevent the spread of VRE.
What would you say are like the important things.
[00:09:38] Elaine: So getting stool samples. Obviously a must because if you don't know it's there, you can't really do the rest of the stuff that follows on. So even though it can be quite hard to get a stool sample, especially from somebody that is older, I know that I wouldn't love it.
Myself, this is a regular admission stool screen, right? Yeah. We're talking about a regular admission, as close as possible as you can do, but within those first 72 hours so that we can know that it's there.
Really paying attention to the alerts that are on. So our infection alerts that say, this patient has VRE, can you make sure that you send a repeat sample if they're in, can you make sure that you monitor them in order to, and put them in isolation and the things that need to have happened and that we get those cleans booked that are so important.
That's quite important with things like VRE, because sometimes people look at these alerts and they're like, oh my God, they're like five years old, or they're eight years old. It's like this stuff sticks around. Because it's not really disrupting the patient's gut. It's quite happily living there’ cause that's where enterococci live, right? It's not changing, it's just, it happens to be an antibiotic resistant version of what they might have in their stool anyway. So you're not. Gonna get rid of it. It's not like it's an invader. It's part of that patient's gut flora. So even if it is quite old, that doesn't mean that it's no longer present.
And so we need to be sending those regular stool samples and not ignoring it just because it's a few years old and therefore we think it might have just disappeared. It can disappear, but also because it's not causing them any harm, it won't necessarily. Do and so we do need to make sure that if we see those alerts that they're there, but also if they are old, make sure we get a new stool so they can be updated.
Yeah. So that we can show that they're still relevant. And then the other thing that's really important on a patient level is making sure that we are keeping an eye out for those patients that could be stepped down from having those alerts. Have they been out of hospital for six months? Are they no longer in immunosuppressed?
Have they been off antibiotics? Can we get those three negative stools a month apart if they have managed to lose it, so that we can get them de alerted and therefore enable them to have kind of more regular access. And also remove the requirement for that higher level cleaning, which means that we might not get another patient into that room so quickly because it takes quite a lot of time to do those two clean, so it's beneficial for other patients if that patient doesn't need to have that alert to have it stepped down both for them and for the way your service works.
[00:12:27] Kate H: Yeah, and that was one of my questions actually. You mentioned a few key points there in order to get a patient de-alerted from VRE and that is, is that the actual criteria that a patient needs to hit then in order to be de-alerted?
[00:12:41] Elaine: Yeah, so we need them to not be immunosuppressed. And the reason for that is because if a patient is immunosuppressed, then actually your body isn't reacting the same way that it would do when you are immunocompetent and it means that you can almost, there's lots of reasons for why you might not find the VRE there when it is actually there.
But some of that is if you are immunosuppressed, your gut might look a bit different. You might have more of an upset stomach and it could mask it 'cause VREs often there in very low levels. So we might be detecting other things instead of the VRE. And so the negative doesn't necessarily hold, they need to be out of hospital for six months because that shows that you've had a good window to get back to your normal gut flora. So you are back home. You're doing the things you normally would if you're going to like, change what's going on in terms of what you've got in your gut. That six months allows you to have the time to do that.
And to get back. 'cause we know that people's gut flora basically comes from their household and their environment.
So if they've been back home living normally. It gives them the best chance to get that other organisms back in that they would normally have if they've acquired or were detecting the VRE because of the fact that they've been on antibiotics or other things. And that's the reason also that we need six months clear of antibiotics because if we're treating you for something, then we might also be killing off the VRE. Yeah, sure. And so it doesn't necessarily mean that you are free of it. We have to have you off antibiotics. And so that's why we need those three samples a month apart after all those things have happened. So that we can get a really good idea of what's going on.
'cause if you think about the length of a human intestine, I know this sounds like a weird thing, but actually there's a lot of intestine in all of us. Yeah. And if we're looking at a tiny piece size piece of poo out of all of that. We need three lots of it to really feel more assured that if it's there, we are gonna have found it.
So
that's why we can't just do a one and done.
[00:14:48] Kate H: That's fair enough and does make total sense. I mean there is a definitely a recurring theme in all of these podcasts that we really do need poo samples.
[00:14:58] Elaine: Yeah. As a microbiologist, I always want more poo.
[00:15:02] Kate H: Yes. More poo, please. That's a big
[00:15:04] Elaine: more poo, please.
[00:15:05] Kate H: That's a big message. Thinking about our messages then to take home more poo, please. So what do you think after having talked about all of that stuff are the three sort of key take home messages? For staff or parents or carers and to be aware of about VRE.
[00:15:22] Elaine: I think, us having really good conversations with parents about why it is that we need samples in the way that we need them.
Because like it's not intuitive, is it? If you are staying at home with your child, you're like, why wouldn't you just take one sample? Why does it have to be three months apart? Why do all of these things have to be in place? And so we need to be having really good conversations with our families about why it is that we have the step down criteria we do. Why it might look different to if you are having this at your local hospital. Because we're at a place where we have high risk and we have long stay and a very different patient population to a local hospital, which might have just much more kind of short stay, less immunosuppressed patients.
What we do at GOSH is often different to what somebody would do elsewhere and that's because we're protecting both our individual patients, but also the whole population as a whole. So we need to have really good conversations about what it is that we need in order to get it stepped down and what will happen to that family, while that patient is still alerted about the fact that they'll go into isolation about the fact that they can't be wandering around, they're not gonna go be able to pop down to the lagoon to grab an ice cream. They're not gonna be able to do those things until we step them down.
And that's because of the fact that this organism does such a good job of surviving in the environment.
And so for me, the next thing is really remembering that your environment. Is a risk, right? We touch it, we interact with it. Especially if we've got, if we're doing clinical care and stuff, you are going to see that environment and if your patient's there for a really long time.
Then actually those loads can get quite high. And so we need to think about the environment as not just somewhere that we think of as being inanimate and not a thing. Actually touching stuff does have a risk. And if we're touching things then we need to be doing hand hygiene, but we also need to be thinking about what cleans are gonna be needed.
And like we had a conversation even this week about the fact that if we've got a long-term patient, we might need to be moving them. Out of their rooms on a monthly basis so that we can get in and do that room a really good clean. 'Cause if that patient's there for months, a year, then that's quite a lot of build up to expect
a single clean to be able to get rid of at the end of that patient's stay. So really what we need to be thinking about is how do we make that better? Can we cycle those rooms every month? Can we talk? Yeah. And we can
[00:18:07] Kate H: accumulate a lot of. Stuff. I used to manage a long term unit and I remember quite it was quite difficult in general 'cause you wanted the room to feel like a home for the patient.
But at the same time we wanted them to take the stuff home to give it a good wash and rotate things and try to keep minimal stuff at the bedside. But that conversation, is really needed for any of these resistant bugs,
[00:18:29] Elaine: yeah, very much and is there something that like on a Friday you can do a joint kind of staff and parent clean time, so that we just get into the habit of it.
You wouldn't not clean at home for a week and your hospital room is no different if you've got things that you've brought in. So actually having a day where you rotate stuff around also, 'cause you know it's probably nicer for your for your patients as well in that they get new things. They get to be re-stimulated within their space.
It doesn't become very samey. So really supporting that kind of activity I think is really key. And then the third one is. Send me more poo please.
[00:19:11] Kate H: Yeah, we like poo
[00:19:13] Elaine: pay attention to the signage and the reminders and if we can work together to get those negative samples when they can happen so that we can take the alerts off people and so that it can then. Because we don't see negatives. I think that's the thing that people don't realise in infection control. I see all of the positives coming through.
I don't see the negatives, so unless someone from a ward gives me a heads up and says, oh, actually we've got three negatives, and they meet your conditions.
There isn't like a thing that occurs where I'm like, oh, this patient is, it has to be driven by ward and clinical teams so that we can get these patients de-alerted when they can be.
[00:19:58] Kate H: Yeah. Yeah. Totally makes sense. Thank you so much, Elaine, for your time and I hope that's been a useful podcast for everyone to learn a little bit more about VRE.
What it is, what we do in hospital to manage it, and what can everybody do to help prevent the spread. So thank you so much.
[00:20:21] Elaine: Thank you for having me again.
[00:20:22] Kate H: That's all right. And we'll see you next time for another ICE podcast.
[00:20:29] SA: Thank you for listening to this episode. If you want to find out more about the work of the GOSH Learning Academy, you can find us on social media on Twitter, Instagram, and LinkedIn.
You can also visit our website at www. gosh. nhs. uk and search Learning Academy. We have lots of exciting new podcasts coming soon, so make sure you're subscribed wherever you get your podcasts. We hope you enjoy this episode and we'll see you next time. Goodbye.
