Control of an outbreak of Vancomycin Resistant Enterococci(VRE) at an NICU of a tertiary care teaching hospital-Role of a microbiologist in a resource poor setting

Background: Outbreaks of Healthcare associated infections do occur and if are not identified and controlled can become an “insitu-phenomenon”  posing continued risk for the patients and healthcare workers. Simple methods  like awareness, education, cleaning and standard precautions can be used systematically and cost effectively to identify and control spread of nosocomial pathogens in resource poor setting.

Objective: During June 2008 an isolate of VRE  from the blood of a baby(preterm) was identified(index case) similar organisms were isolated  from the central line  and stool of the baby. As Enterococci had never been isolated from blood of babies in the NICU in the past, an outbreak situation was announced.Clinical samples from 3 other babies grew VRE and the other 30 babies exposed to this environment were under surveillance. Measures to control were discussed by the microbiologist and the consulting clinicians and the nursing staff.
Methods: Routine samples received in the laboratory for diagnosis of infective processes were processed and Enterococci isolated were identified by standard microbiological methods.Susceptibility was done by Kirby Bauer disc diffusion and confirmed by MIC and E test for Vancomycin and Teicoplanin. Surveillance samples as part of activity of Infection control: Rectal swabs, environmental swabs.
Infection Control Protocols were instituted eg stool cultures/rectal swabs of all patients , environmental  and fomite sampling,cohorting of all colonised and exposed babies, reduced intake of new babies), identified a temporary area to house the new babies. Post- cleaning surveillance cultures were taken to rule out stubborn colonising bacteria. Strict  hand hygiene with soap and water and alcohol, proper use of gloves and masks. Dedicated nursing staff , sterile gowns, equipment( stethoscope, measuring tape),restricted use of vancomycin, cleaning of the unit and strict supervision of all procedures
Results: Total of 30 babies were exposed of whom 4 babies had  isolates from clinical samples. All infected babies with clinically significant isolates of VRE were treated with Linezolid. Two other babies grew VRE from one or more sites of surveillance. All fomites from colonised babies grew VRE,eg warmer, charts, measuring tape etc. The tapes were identified as the potential culprit harbouring the VRE .There was no mortality and the outbreak was successfully controlled within a span of 4-6 weeks. Molecular studies for Van A and Van B genotype, done on 6 isolates obtained during the outbreak showed the presence of Van A genotype in all but one of the strains.

Conclusions: Outbreaks can be controlled if identified and acted upon fast. Enterococci colonization and contamination of the environment is not easily got rid of. A strong laboratory support and a even stronger clinician, microbiologist and infection control team work  is needed