Frequent Acquisition of Vancomycin-Resistant Enterococcus Colonization in a Veterans Affairs Long-term Care Facility

Background: Vancomycin-resistant Enterococcus (VRE) intestinal colonization is common among long-term care facility residents in many U.S. medical centers. However, previous studies have suggested that most person-to-person transmission of VRE occurs in hospitals rather than in long-term care facilities.

 

Objective: To test the hypothesis that person-to-person transmission within long-term care facilities accounts for a significant proportion of cases of VRE colonization in this setting.  

 

Methods: We performed a prospective cohort study of 120 patients being transferred from a Veterans Affairs hospital to an affiliated long-term care facility. The hospital has a high endemic rate of VRE colonization and does not isolate VRE colonized or infected patients. Rectal swabs for VRE culture were collected at the time of transfer and then weekly for up to 6 weeks. Environmental cultures were also collected from common patient areas including recreational and therapy rooms as well as patient rooms after completion of terminal cleaning by housekeeping staff and prior to admission of new patients. Handprints of healthcare workers (HCWs) were also done.

    

Results: Of 120 patients studied, 69 (58%) were already colonized with VRE prior to transfer to the long-term care facility, and a majority maintained colonization throughout the 4-6 week follow-up period. Of 51 patients with negative rectal swabs prior to transfer, 25 (49%) developed new detection of colonization while in the long-term care facility with 17 (68%) of them occuring within the first two weeks of stay. Environmental contamination with VRE of frequently-touched environmental surfaces occurred in 3 out of 18 (17%)  rooms that had been cleaned by housekeeping, 2 out of 15 (13%) cultures from therapy areas and 1 out of 14 (7%) recreational and activity areas. One out of 12 (8%) HCWs handprint cultures were positive for VRE.

 

Conclusions: In contrast to previous studies, new acquisition of VRE colonization was common in a Veterans Affairs long-term care facility with a high endemic rate of colonization. Interventions to improve environmental cleaning and hand hygiene may address critical potential sources for transmission in this unique setting.