Glycopeptide-Resistant Enterococci (GRE) - Frequently Asked Questions

• What are glycopeptide-resistant enterococci?
• What illnesses do GRE cause?
• Are some people more at risk than others?
• How do people contract it?
• Is it treatable?
• How many of these infections are reported to the HPA?
• Which antibiotics are these infections resistant to?
• How does it compare with other hospital acquired infections such as methicillin-resistant Staphylococcus aureus (MRSA)?
• Have there been any deaths as a result of this infection?
• Is the HPA monitoring GRE?
• What else is the HPA doing about this problem?
• How can the spread be controlled?
• What other hospital acquired infections does the HPA monitor?

 

What are glycopeptide-resistant enterococci?

Enterococci are bacteria that are commonly found in the bowels of most humans. There are many different species of enterococci, but only a few have the potential to cause infections in humans. More than 95% of infections due to enterococci are caused by just two species, Enterococcus faecium and Enterococcus faecalis.

Glycopeptide-Resistant Enterococci (GRE) are enterococci that are resistant to glycopeptide antibiotics (vancomycin and teicoplanin). GRE were first detected in the United Kingdom (UK) in 1986 and have subsequently been found in many other countries. GRE are sometimes also referred to as VRE (Vancomycin-Resistant Enterococci).

The most common type of GRE is Enterococcus faecium, and the second most common type is Enterococcus faecalis. In rare instances, infections may also be caused by other GRE such as Enterococcus casseliflavus or Enterococcus gallinarum.

What illnesses do GRE cause?

GRE commonly cause wound infections, bacteraemia (blood poisoning) and infections of the abdomen and pelvis. GRE may also occasionally cause infections in the bile duct (cholangitis), heart valves (endocarditis) or the urinary tract.

Are some people more at risk than others?

Infections caused by GRE mainly occur in hospital patients, particularly those who are immuno-compromised, those who have had previous treatment with certain other antibiotics (particularly cephalosporins and glycopeptides), those who are on a prolonged hospital stay, or those in specialist units such as intensive care or renal units. However, GRE are sometimes found in the faeces of people who have never been in hospital or have not recently been given antibiotics.

How do people contract it?

There are two routes by which patients tend to contract GRE infections. The first is by cross-infection, which occurs when bacteria causing infection in one patient are passed to another patient, who also becomes infected. The second involves the spread of GRE bacteria that reside harmlessly in a person's gut to other areas of the body where they are not normally found.

Is it treatable?

GRE are not particularly virulent bacteria, but they are difficult to treat because of limitations in the range of antibiotics which are effective against them. Two antibiotics, linezolid and synercid, may be used, while others (daptomycin or tigecycline) have already been launched in the United States and are anticipated in the UK in the near future. Synercid is active against most E. faecium but lacks useful activity against E. faecalis, while linezolid is usually active against both species. GRE resistant to these antibiotics have been isolated from hospital patients, though they are rare.

How many of these infections are reported to the HPA?

In the third year of the mandatory GRE surveillance scheme (October 2005 to September 2006) 903 cases of GRE bacteraemia were reported to the HPA. Data reported by laboratories in England to the voluntary surveillance scheme for 2006 show 594 cases of GRE bacteraemia and reflect the under ascertainment of the voluntary reporting scheme.

Which antibiotics are these infections resistant to?

GRE are resistant to vancomycin and commonly (but not invariably) to teicoplanin. Many GRE, especially if they are E. faecium, are resistant to multiple other antibiotics.

How does it compare with other hospital acquired infections such as methicillin-resistant Staphylococcus aureus (MRSA)?

Data from the mandatory collection scheme show that while there has been 19% increase in the reported cases of bloodstream infections caused by GRE compared with the previous year's reports, there are far fewer cases than bloodstream infections due to methicillin-resistant Staphylococcus aureus (MRSA). Although MRSA occurs widely and causes infections (e.g. wound infections) in otherwise healthy patients, GRE usually cause infections only in patients who are already very unwell.

Have there been any deaths as a result of this infection?

Enterococci usually cause infections in patients who are already seriously ill with underlying problems that predispose them to infection. This means that if a patient with a GRE infection dies, it is often difficult to know if this was due to the pre-existing illness or as a result of the infection.

Is the HPA monitoring GRE?

Surveillance of GRE bacteraemia has been mandatory since September 2003.

What else is the HPA doing about this problem?

There are a number of ongoing research initiatives, from the design of hospital wards, the use of isolation rooms, to the effectiveness of interventions like Clean Your Hands Campaign and investigation of the causes of multi-drug resistance. The Department of Health has also set aside £3 million for research as part of

implementing Winning Ways, the Chief Medical Officer's action plan to reduce healthcare associated infections.

The HPA is working closely with the Department of Health to monitor GRE. GRE is part of our mandatory surveillance scheme, results of which are reported on our website on an annual basis.

How can the spread be controlled?

Prompt recognition of bacteria with unusual resistances and good infection control procedures are needed to prevent spread. Restriction of the use of certain antibiotics, especially vancomycin, teicoplanin and

cephalosporins, to those patients who really need them, will help to limit the occurrence of GRE infections.

GRE is most commonly spread via hands, equipment, and sometimes the environment. It is important that healthcare workers and visitors wash their hands before and after visiting a patient. Provided hands are not soiled (when they should be washed with soap and water), rapid acting alcohol and other hand hygiene solutions are now advocated in healthcare; they are easier and faster to use than hand washing. Equipment should also be cleaned after use.

What other hospital acquired infections does the HPA monitor?

Various infections are reported via the voluntary surveillance scheme. Mandatory surveillance schemes are in place for MRSA bacteraemia, Clostridium difficile infections, and orthopaedic surgical site infections.