VRE - Vancomycin-Resistant Enterococcus


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    General Information

    Special Implications for New Mothers and Babies

    Links to More Information

    General Information

    What is VRE?

    VRE is Vancomycin-Resistant Enterococcus.

    Enterococcus are bacteria that live in the digestive and genital tracts. They are normally benign and don't cause any problems in healthy people.

    Vancomycin is a powerful antibiotic that is often the antibiotic of last resort. It is generally limited to use against bacteria that are already resistant to penicillin and other antibiotics.

    Vancomycin-Resistant Enterococcus is a mutant strain of Enterococcus that originally developed in individuals who were exposed to the antibiotic. It was first identified in Europe in 1986, and in the U.S. in 1988.

    Why is it dangerous?

    It is not dangerous in healthy people with strong immune systems, where the balance of healthy flora in their digestive tract helps keep VRE from getting out of control.

    VRE is dangerous because it cannot be controlled with antibiotics, and it causes life-threatening infections in people with compromised immune systems - the very young, the very old, and the very ill.

    It is especially dangerous because it can easily transmit the resistance genes to other, more dangerous bacteria, such as staph and strep. Two cases of vancomycin-resistant staph have been identified in the U.S. in the last two months. These could cause serious infections even in otherwise healthy people.

    How can it affect me?

    Although VRE generally doesn't affect healthy people, anyone who comes in contact with the bacteria can become a carrier. Once you become a carrier, you can easily spread the bacteria to friends and family. In addition, if you become a chronic carrier of VRE, you could easily become infected when you are older or in declining health.

    The spread of VRE isn't thoroughly documented or understood, but estimates from Europe are that 3.5% to 5% of the population may be carriers of VRE. VRE first appeared in the U.S. on the East Coast and spread to the West Coast. It is likely that carrier rates in those areas will take a couple of years to catch up to the European carrier rates.

    It's particular important to avoid becoming a carrier if you share a home with those at risk - the very young, the very old or the very ill.

    How can I be exposed to it?

    You can be exposed to VRE by coming in contact with a contaminated object or person, or by eating contaminated food.

    In Hospitals - The most likely place to pick up VRE is in hospitals, since this is where VRE tends to originate. In the U.S., all reported cases of VRE were acquired in a hospital. (This is according to the information currently publicly available - this information changes rapidly.)

    VRE has been cultured from hospital equipment, doorknobs, and bedrails. It has also been cultured on the hands of hospital personnel. Anyone who frequents hospitals should be considered at risk for carrying VRE.

    Of course, you can be exposed to VRE by a single visit to the hospital, but people who work in hospitals (even administrative personnel) are at much higher risk for being exposed and becoming a carrier.

    How can I avoid it?

    Fastidious hygiene is the best way to avoid ingesting VRE and becoming a carrier. VRE is a robust bacteria and has been found on hospital personnel's hands after five seconds of hand washing. It is recommended that you wash your hands for twenty seconds with an antibacterial soap every time before you eat. (Note that this means right before you eat. If you are eating in a restaurant and have been handling the menu, you could have picked up VRE. Wash your hands thoroughly before you pick up that piece of bread.)

    Note that the most likely place to pick up VRE is probably the door handle of the rest room. Consider using the towel you dried your hands with as a protective shield when you open the door.

    Avoid hospitals, as this is the only documented source of VRE in the U.S. If you do go to a hospital to visit someone, maintain fastidious hygiene throughout your visit. Avoid eating while at the hospital, and especially avoid eating hospital food.

    In general, avoid taking antibiotics. You don't want to become a breeding ground for an antibiotic-resistant infection.

    What if I need hospital treatment?

    First, consider your options. Is it possible to receive treatment in the caregiver's office or in an outpatient surgery center?

    If a hospital stay is absolutely necessary, it is probably wise to ask thorough questions about the hospital infection situation. Request written information about the hospital's record regarding VRE - how many infections have there been? When was the most recent infection? How many people were infected? How often are hospital personnel tested for VRE carrier status? How many staff are known to be VRE carriers?

    It's best to request that this information be provided in written form, and dated and signed by your caregiver. This way your caregiver will know that you are serious about getting accurate information.

    Consider asking all the hospitals in your area. You may be surprised at the variance of infection rates. In particular, university and teaching hospitals have much higher rates of infection than community hospitals, and it may be possible to arrange to stay at the hospital with the lower infection rate.

    As a patient in a hospital, you have to decide how paranoid you want to be about the possibility of exposure to VRE. It's probably safest to avoid eating any raw vegetables from the hospital kitchen. Wash your hands thoroughly before eating, and avoid eating any foods with your hands.

    It's certainly safest to have anyone who touches you put on sterile gloves first, but this is unlikely to be their standard procedure.

    Request a copy of their guidelines for avoiding hospital-acquired infections, and remind hospital personnel to abide by those guidelines.

    What if I've been in a hospital recently?

    You might want to call the hospital and ask about the infection situation there prior to and during your stay.

    If the hospital has a history of VRE, consider the possibility that you might have been exposed during your stay, and you might now be a carrier.

    Those who are VRE carriers are unlikely to know it. It is possible to be cultured to find out if you are a VRE carrier, but this is unlikely to be covered by a health plan.

    If you think there's a possibility that you were exposed to VRE and might be a carrier, you should maintain fastidious hygiene in order to avoid spreading the bacteria. It is important to wash your hands for twenty seconds with an antibacterial soap every time after using the toilet. This will reduce the chance that you will spread VRE to others with whom you come in contact. Be especially fastidious if you are regularly in contact with those at risk - the very young, the very old, or the very ill.

    If you are certain that you were exposed to VRE or suspect that you may have become a carrier, it is essential to maintain your own good health in order to avoid developing a serious infection.

    Special Implications for New Mothers and Babies

    N.B.About 4% of Group B streptococcus (GBS) isolates demonstrate penicillin tolerance (from Merck Manual).  Consider alternative treatment aimed at reducing colonization without relying on antibiotics.

    VRE is not generally dangerous to healthy individuals with fully functioning immune systems. However, it is very dangerous to newborn babies because they have an immature immune system that cannot cope with many different types of germs.

    In the U.S., most women give birth in hospitals. Unfortunately, the emergence of VRE as an increasingly common pathogen can make the hospital a very dangerous place for your baby. Hospitals have always recommended that newborns be kept away from hospitals because of the increased danger to their immature immune systems. This danger becomes even more serious when the hospital germs cannot be treated with antibiotics.

    The Center for Disease Control warns that the primary concern about VRE is that it could easily share its resistance with staph bacteria, which can easily infect a baby's skin. Two strains of staph resistant to vancomycin were reported in the U.S. in the summer of 1997, and it is expected that this number will increase rapidly.

    What are the dangers to my baby?

    There are two primary dangers.

    The first is that your baby may be exposed to VRE or resistant staph through contact with hospital equipment or personnel.

    The second is that you may become a VRE carrier and take the bacteria to your home, where you may spread it to other family members, including your new baby. Your own body might become an incubator for resistant strep or staph, which could cause serious infection in your baby.

    What are the dangers to me?

    In addition to the risks of becoming a carrier, you are at increased risk for exposure every time the integrity of your skin is broken by an IV or injection. An unnecessary episiotomy or Cesarean wound puts you at particular risk.

    Germs introduced vaginally are particularly dangerous because if they migrate to the placenta site, they can move directly into the larger vessels in the mother's bloodstream and cause systemic infection quite rapidly.

    How can I minimize the dangers?

    The best way to avoid hospital-acquired infections is to avoid hospitals. Consider the possibility of an out-of-hospital birth:

    Birth Centers - Birth Centers are different from hospitals in that they are much less likely to harbor antibiotic-resistant germs. This is because Birth Center clients aren't typically taking antibiotics. However, as a public place, birth centers do have a lot of people passing through, which increases the risk of introduction of antibiotic-resistant germs in the environment. In particular, if the birth center personnel also work in hospitals, there is an increased risk that they may be carriers of antibiotic-resistant germs.

    At home - The best way to protect your baby from dangerous germs is to give birth at home. It's very unlikely that VRE is present in your home, unless you or someone else in your family became a carrier through previous exposure to VRE. In addition, a baby born at home is always kept very close to the mother, thereby ensuring that the mother is exposed to the same germs the baby is exposed to. This allows the mother's body to customize the antibodies in her breastmilk to be exactly the ones her baby needs.

    If your pregnancy is complicated by high-risk factors that limit your out-of-hospital options, you can still make choices that minimize your exposure to hospital germs:

    When you go to the hospital, follow these safety guidelines: Many families find it much easier to achieve these goals with the help of a private labor assistant dedicated to meeting their needs.

    You can find professional labor assistants by looking in the Yellow Pages or calling your local midwives or childbirth educators. There are some national organizations that maintain a referral service: ALACE (Association of Labor Assistants & Childbirth Educators), and DONA (Doulas of North America).

    Trained labor assistants offer advocacy for your birth plan and provide the hands-on help that will help you fulfill your plans. Benefits include:

    50% reduction in the cesarean rate
    25% shorter labor
    60% reduction in epidural requests
    40% reduction in oxytocin use
    30% reduction in analgesia use
    40% reduction in forceps delivery

    For more information about:

    Recent News Reports about VRE, Hospital-Acquired Infections and Antibiotic-Resistant Infections

    References for VRE, Antibiotic Resistance and Hospital-Acquired Infections

    (VRE)Questions and Answers for Home Care

    The Newborn Immune System and Immunological Benefits of Breastmilk - extracts from textbooks

    The wonders of human breastmilk - written for parents

    Breastfeeding's Immunological Benefits - breastfeeding kept an immuno-compromised baby alive for 18 months.

    Homebirth - Safety and Benefits


These web pages were originally composed by Ronnie Falcao, LM MS, in Sept., 1997.
They have been updated as new information has become available.

Permission to link to these pages is hereby granted.

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