Background
Case presentation
Decolonization of gastrointestinal carriage of VRE
1. | Patient was managed in isolation room A and subjected to bowel preparation according to the protocol commonly used prior to colonoscopy examination: (i) ingestion of 2 liters of polyethylene glycol (Klean prep) over 6 hours to wash out the bowel content; (ii) taking fluid diet including rice water, clear soup, and fruit juice on the first day of decolonization. |
2. | When the defecated bowel content became clear fluid, patient was transferred from isolation room A to B, which had been terminally disinfected with sodium hypochlorite 1,000 ppm. |
3. | After transferal to isolation room B, a five-day course of medication with activity against VRE was given, including oral linezolid 600 mg every 12 hourly, orally-taken intravenous preparation of daptomycin 8 mg per kg daily. |
4. | At the same time, the patient was cleansed with 4% chlorhexidine bath and shampoo, and oral chlorhexidine gargle for 5 days. Where possible, avoid use of other antibiotics treatment during the decolonization period. |
5. | At the time of bathing, the patient’s clothes, underwear, and bed linens were replaced and sent for hot laundry daily. All personal belongings were disinfected to prevent re-colonization. The isolation room was thoroughly cleaned and disinfected by sodium hypochlorite 1,000 ppm twice daily. |
6. | After completion of 5-day decolonization regimen, Lactobacillus rhamnosus GG 80 mg was given daily to replace the gut flora. |
7. | All foods and drinks throughout the decolonization procedure must be boiled. All visitors and healthcare workers must comply with hand hygiene with alcohol based hand rub. |
Microbiological analysis
Discussion
Ref | Country/year of publication/study setting | Decolonization regimens/study end point(if mentioned) | Results at study end point | Microbiology culture methods/presence of broth enrichment or not |
---|---|---|---|---|
[7] | US/1994/observational study | Oral vancomycin 125 mg q6h for 10 daysa/follow up for 15 days post treatment | VRE negative in 8 (42%) of 19 patients | Campylobacter agar containing 10 μg/ml of vancomycin (B-D Microbiology Systems, Cockeysville, MD, USA)/no broth enrichment |
[7] | US/1994/observational study | Oral bacitracin 25,000 U (500 mg) q6h for 10 days/follow up for 15 days post treatment | VRE negative in 8 (100%) of 8 patients | Campylobacter agar containing 10 μg/ml of vancomycin (B-D Microbiology Systems, Cockeysville, MD, USA)/no broth enrichment |
[15] | US/1995/observational study | Oral novobiocin (500 mg q6h plus oral tetracycline 500 mg q6h (five patients) or intravenous doxycycline 100 mg q12h (one patient) for a median of 3.5 days (range, 1 to 6 days) | VRE negative in only one patient while receiving decolonization therapy | Not mentioned |
[8] | US/1995/observational study | Bacitracin 25,000 U (diluted in 5 mL of 0.9% normal saline) given orally or by gastrostomy tube twice a day for 10 days/follow up for 3 weeks post treatment | VRE negative in 5 (63%) of 8 patients | Not mentioned |
[9] | Canada/1999/prospective observational cohort study in a tertiary care institution | Oral doses of bacitracin solution (75,000 U/15 mL) four times daily and doxycycline 100 mg once daily for 14 days/follow up for 4 months | VRE negative in 15 (100%) of the antibiotic treated vs 8 (33.3%) of the untreated patients (P <0 .001) at the end of treatment; but VRE positive in 9 (60%) of 15 and 15 (62.5%) of 24 in the treated and untreated cohort (p = 0.86) following up for a mean of 127 and 130 days respectively b
| M-enterococcal agar with vancomycin (6 mg/mL)/no broth enrichment |
[10] | US/2001/randomized, controlled study | Oral zinc bacitracin (50,000 U) q6h for 10 days vs placebo/follow up for 3 weeks post treatment | VRE negative in 2 (33%) of 6 patients in each group after 3 weeks post treatment | Bile esculin agar plates supplemented with 6 mg/mL of vancomycin/no broth enrichment |
[14] | US/2001/phase II, double-blinded, randomized, multicenter, placebo-controlled study | Oral ramoplanin: 2 daily doses of 100 mg or 400 mg or placebo for 7 days/follow up on day 0, 7, and 14 post treatment | Day 0: VRE negative in 17 (81%) of 21 and 18 (90%) of 20 patients in the 100-mg and 400-mg ramoplanin groups; Day 7: VRE negative in 6 (29%) of 21 and 7 (41%) of 17 in the 100-mg and 400-mg ramoplanin groups; Day 14: VRE negative in 4 (21%) of 19 and 5 (29%) of 17 patients in the 100-mg and 400-mg ramoplanin groupsc
| Bile-esculin azide broth that contained 6 mg/mL of vancomycin (Hardy Diagnostics)/broth enrichment |
[12] | US/2002/observational study | Oral bacitracin (25,000 U three times daily) and oral gentamicin (80 mg three times daily) for a mean duration of 16 days (median, 14 days; range, 7 to 29 days)/follow up for 3 months post treatment | VRE negative in 5 (17.8%) of 28 patients | Not mentioned |
[11] | France/2010/observational study in a geriatric rehabilitation care facility | Oral bacitracin 30,000 U three times daily for 15 days/follow up for 6 months | VRE negative in 3 (43%) of 7 patients at the end of therapy and at 6 months | Not mentioned |
[11] | France/2010/observational study in a geriatric rehabilitation care facility | Bacitracin 30,000 U three times daily plus streptomycin 1 g once daily orally for 15 days/follow up for 6 months | VRE negative in 3 (75%) of 4 patients at the end of therapy and at 6 months | Not mentioned |
Ref | Country/year of publication/study setting | Decolonization regimens/study end point(if mentioned) | Results at study end point | Microbiology culture methods/presence of broth enrichment or not |
---|---|---|---|---|
[20] | Australia/2007/double-blind, randomized, placebo-controlled trial in nephrology patients |
Lactobacillus rhamnosus GG in the form of commercially available yoghurt: 100 g daily of yoghurt containing Lactobacillus rhamnosus GG for 4 weeks/follow up for 4 weeks post treatment | VRE negative in all 11 patients in treatment group at the end of therapy; 8 (73%) remained VRE negative 4 weeks post treatment; VRE negative in 1 (8%) of 12 control patient at the end of treatment | Enterococcosel agar (BD, Sparks, Md, USA) containing 6 μg vancomycin/no broth enrichment |
[21] | France/2010/double-blind randomized pilot study in adult |
Lactobacillus rhamnosus Lcr35: 5-week course of Lcr35 (109 active cells daily) or a placebo/follow up till the end of therapy | VRE negative in 3 (50%) of 6 patients in treatment group vs 2 (100%) of 2 patients in control group at the end of therapy | Not mentioned |
[18] | Poland/2011/randomized, single-blind, placebo-controlled study in children |
Lactobacillus rhamnosus GG 3 billion colony forming unit per day vs placebo for 21 days/follow up till the end of therapy | VRE negative in 20 (63%) of 32 patients in treatment group vs 7 (24%) of 29 in control group (p = 0.002) | Selective medium (D-Coccosel agar, BioMe’rieux) and a chromogenic medium (ChromID, BioMe’rieux)/no broth enrichment |