Three Years of Healthcare-Associated (HA) Vancomycin Resistant Enterococcus (VRE) in a Tertiary Pediatric Oncology Population; Can You Clear VRE from a Child?

Background: CHOC Children’s Hospital is a 238 bed free standing pediatric hospital with a 12 bed Oncology ICU; 34 bed Oncology unit, 31 bone marrow transplants annually and 1,324 cancer institute patients; 245 on active chemotherapy. The average length of stay is 34 days in OICU and 5.5 days in Oncology with a range of 4-231 days.  Our five year baseline was 4 VRE patients per quarter. We experienced a four-fold increase in VRE among our OICU/Oncology (Onc) patients in 2007.

Objective: Identify a VRE clearance process for Onc children while preventing HA VRE.

Methods: By 3/07, infection prevention (IP) measures in place included; VRE admission screening, strict adherence to contact precautions with gown and gloves, hand hygiene, dedicated equipment, cleaning of equipment/environment, environmental cultures, weekly VRE screening and education. VRE clearance required 3 negative (neg) stool/rectal (s/r) specimens collected at least 1 week apart per CDC guidelines.  In 4/07  after 39 new VRE Onc patients in 9 months (mo) we changed the VRE clearance to 6 neg s/r specimens 1 mo apart. We re-evaluated our data in 4/09. VRE clearance for any non-onc patient remained 3 neg 1 week apart.

Results: From fiscal year 2007 – 2009, there were 129 patients with VRE. Of these 92 were Onc. There were 10 VRE infections; 4 bloodstream, 5 urinary tract and 1 wound.  There were 41 HA colonization and 41 community/other hospital acquired. Of the 129 VRE isolates, 54 were submitted for strain typing analysis (Diversilab v3.3). Of the 41 Onc patients, 29 (71%) were indistinguishable at >97% similarity. Forty-four (48%) patients cleared VRE (6 neg 1 mo apart). Of these, 2 (4.5%) had recurrence of VRE, one expired due to the oncologic disease. Twenty-five VRE patients expired; none due to VRE and 14 patients remained positive. Data review revealed, 50% of 44 patients cleared. If positive was followed by 3 mo neg, subsequent cultures were neg. Two Onc patients did not fit this trend.   In 4/09 we changed VRE clearance for Onc patients;
*VRE clearance, 3 neg 1 mo apart.
*If VRE recurs, then 6 neg 1 mo apart.
*If VRE recurs again, isolation will not be discontinued.
Nine more patients were cleared of VRE (3 neg 1 mo apart); 1 recurred and expired. The remaining 8 are negative. The average number of Onc inpatients in VRE contact precautions for June 2007 was 12 compared to <1 per day for June - Nov 2009.

Conclusions: We had a four-fold increase in VRE in Onc patients in 2007. IP measures were in place.  The majority of our strains were genetically indistinguishable.  Persistence of VRE suggested poor prognosis. We initiated VRE clearance of 6 neg cultures 1 mo apart which was rigorous and burdensome for all. VRE decreased in Onc; balancing family centered care and IP, we modified VRE clearance in Onc patients to 3 neg 1 mo apart. There are 14 Onc patients currently colonized.