VRE Infection Control Needs Regional Strategy

Hospitals can't expect to control or prevent outbreaks of infections such as vancomycin-resistant enterococcus without sharing data and coordinating with other regional providers, a Johns Hopkins researcher says.

Hospital competition and the failure of infection control teams to talk with each other can lead to worse regional outbreaks of infections such as vancomycin-resistant enterococcus or VRE, according to a study in this month's American Journal of Infection Control.

"Hospitals can't expect to control or prevent VRE without really cooperating with all the other hospitals in that region," says Bruce Lee, MD, lead author of the paper and Director of Operations Research at Johns Hopkins Bloomberg School of Public Health in Baltimore, who says the only solution is through cooperation and data sharing, whatever form that may take.

"You can claim that your hospital has great infection control, and it's clean, but as long as one or two hospitals in the county, or even one small hospital, is having problems controlling VRE, your hospital is at risk. You can keep pouring money and efforts into control, but you'll have (VRE) in patients moving in and percolating through the system."

Unfortunately, Lee says, hospitals in these interdependent regions "don't talk with each other, and in fact, many compete," which makes the problem worse.

Lee's research modeled actual cases of patients colonized with VRE at 29 hospitals in Orange County, CA. A 10% increase in VRE colonization prevalence in any one hospital resulted in a 2.8% average relative increase in VRE prevalence in all 28 other hospitals.

The modeling program, which Lee likens to a "Sim City" of healthcare infection transmission, found that VRE bacteria persisted in infecting patients for years later, and in some cases took more than 10 years to fully manifest.

Asked if regional government authorities, such as those that exist for emergency room coordination and paramedic response, or trauma care, or more robust state or county health department infection control powers, might help overcome the practice of competitive secrecy over such outbreaks, Lee says they probably could.

"Think of these pathogens as like invaders from space. The response we have today is like having every single state setting up its own defense system and not really talking with each other. So you really need a coordinating authority and incentives to get everyone together to say this is a common enemy, a common threat," adding that hospital teams "need to see the big picture, that this affects everyone."

If a hospital knew, for example, that an outbreak of VRE had occurred at another facility from which they are likely to receive transfers, or transfer patients to, "you can step up screening measures and contact precautions, and you may want to divert resources toward that hospital. If they can't control the outbreak, it will become a problem in other hospitals, just growing, and mushrooming for months or even years."

Lee says that his findings are not really an enormous surprise to the healthcare industry. "Everyone understands this. But the problem is that in the real world, our policies, practices, interventions and infection control measures are structured as if the opposite is true, that individual control is what we need to worry about. The sense that, 'As long as it's not in my back yard, I don't have to worry. I just have to worry about me.' "

For example, penalties and reporting policies and procedures promulgated by the Centers for Medicare & Medicaid Services target rates of hospital-acquired infections at the individual facility level, not rates for the community at large, and Lee thinks that's misguided.

"We really have to essentially force everyone to realize that we all depend on each other, and the only real way to do that is to introduce very short term, obvious benefits for working together, and negative incentives for not working together. Until those are in place, cooperation is not going to occur."

VRE is primarily spread from patient-to-patient in healthcare settings, usually through the hands of healthcare providers who have had contact with other people colonized with VRE or surfaces that are contaminated with the bacteria. Estimates vary on its prevalence, but suggest it can be as high as 12% throughout a hospital system, and 28% of patients treated in intensive care units.

According to the Association for Professionals in Infection Control and Epidemiology (APIC), there are an estimated 20,000 to 85,000 cases of VRE each year in U.S. hospitals.

It's considered a difficult problem in acute care because it is a form of bacteria that's resistant to an antibiotic that Lee described as "one of our final big guns that's reasonably priced." There are alternatives, but they are expensive, and concerns are that if those more costly drugs are used, resistance will develop to them as well.

Lee's project used 2006 and 2007 patient level admission and transfer data collected by California's Office of Statewide Planning and Development for all 29 hospitals in Orange County, which is buttressed by Los Angeles County to the north, the Pacific Ocean to the west, San Diego County to the south and Riverside County and San Bernardino County to the east.

It then calculated the flow of VRE colonized patients to other facilities, based on costs in the state database.

Lee says the next version of the study will include patterns of infection in nursing homes, and how they impact hospital infections, and vice versa.