National update on Vancomycin Resistant Enterococci (VRE) in New Zealand

While VRE is not currently endemic in New Zealand unlike many other countries, there has been an increase in hospital patients colonised with VRE in some regions of New Zealand.

Measures to respond to this increase have been implemented, including monitoring where our current cases are, and enhancing interventions to limit further transmission. The below surveillance information is an indication of the current number of positive screens or new infections and does not represent outbreaks.

For current VRE case numbers in NZ, please refer to the ESR report on VRE. The ESR case report is replacing the fortnightly case update provided by Te Whatu Ora.  

Please note that there are several different VRE species and van gene types circulating in NZ. The Waikato Hospital cluster (vanB type) continues to cause concern in the Waikato, Bay of Plenty, Tairawhiti and Lakes regions, with ongoing transmissions occurring. 

Screening is a valuable tool to identify new or increases in cases within New Zealand and it enables appropriate mitigations and actions to be undertaken.

• All hospitals should assess patients on admission for VRE.
• All patients who have had an overnight stay at Waikato, Thames, Tauranga or Lakes hospital, or as a day patient in their renal or oncology units should be screened for VRE and isolated with Contact Precautions while awaiting results.
• All patients who have had an admission overnight to another New Zealand hospital should be screened for VRE and isolated as per local policy.
• All patients who have been admitted to an overseas hospital in the last year should be screened for VRE and other multi drug resistant organisms and isolated with Contact Precautions while awaiting results.
• On admission patients should be checked for MDRO alerts/ National Warnings and treated accordingly.

Hand hygiene remains a key component to prevent transmission of VRE given that this is a faecal to oral pathogen. Improving hand hygiene opportunities for patients is an important aspect to reduce transmission and should be part of basic good hygiene measures, including enabling patients to clean their hands after they have used the toilet or commode and before they eat their meals.

Implementation examples include providing:

• Personal hand sanitiser within patient reach (as appropriate based on safety for patient).
• Pre-packed cleansing hand towelettes on patient food tray with every meal.
• A way for patients to clean their hands after using a commode for toileting.

For further information for healthcare staff regarding hand hygiene reports see Compliance reports and quality safety marker.

Cleaning is another key element required to reduce transmission of VRE due to the pathogens’ ability to survive for prolonged periods of time on surfaces objects and gloves. It is essential for hospitals to ensure that they have appropriate resources and capacity for increased cleaning to be undertaken in the event of an outbreak.

To reduce cross transmission, hospitals must undertake the following processes and checks and ensure these critical responsibilities are well understood by all healthcare staff through regular communication from IPC teams:

• Patient space cleaning must occur as per hospital policy on terminal cleans before a new patient is admitted into that space or room. This is to make sure that the appropriate cleaning and disinfection has occurred to avoid transmission of VRE and other multi-drug resistant organisms to patients admitted into the ward.  
• Frequent and thorough cleaning schedules are actioned, including for priority areas and wards units. 
• Make sure the correct type and use of cleaning and disinfection products including dwell time of products is understood and adhered to. 
• Undertake regular cleaning audits to ensure the interventions put in place are working. This is particularly important with toilets, commodes and sluice rooms. 
• Cleaning and disinfection of multi-use patient use equipment occurs when single-use or dedicated non-critical equipment is not available, and on discharge. 

As VRE is not endemic in New Zealand, contact precautions are required for all patients with VRE colonisation or infection. Ideally patients with VRE should be placed in single rooms with their own toilet facilities. In practice, it is acknowledged that due to capacity, availability and demand for single rooms, this can be difficult for some hospitals to achieve. Use of a risk assessment to identify patients at higher risk of environmental shedding can help prioritise use of single rooms. Where single rooms are not available, local IPC teams can help advise on best patient placement and can ensure all staff and visitors clearly understand what precautions are needed to reduce risk of transmission to others.

Hand hygiene, donning of gown/apron and gloves before entry to ward bay (or room) are to be worn for all interactions with the patient and their environment. PPE should be removed and discarded safely and appropriately before leaving the ward bay or room to contain pathogens and hand hygiene performed by staff.

For further information and guidance refer to here.