Clinical Considerations in the Approach to Vancomycin-Resistant Enterococci : A Narrative

. Vancomycin-Resistant Enterococci (VRE) increasingly colonize and infect assorted patient populations 2 throughout the world, maintaining a continual reservoir of opportunistic pathogens with varying antibiotic 3 resistance. Here we present the current general epidemiology and classification of these pathogens within the 4 scope of healthcare-associated infections (HAIs). Risk factors for colonization and conditions for subsequent 5 infection are reviewed, along with infection characteristics. Current infection control protocols and their 6 effectiveness, selected evidence-based medical therapies, and ongoing research into alternative therapies are 7 summarized. retrospective analysis et al . of probiotic therapy conducted in suggests that boulardii and Escherichia Nissle to traditional antibiotic regimens reduces VRE transmission in stroke and trauma patients without any adverse side effects. 62 Following implementation of probiotic regimens, VRE colonization rates dropped from 78 patients per year to 51 per year, an overall 35% reduction. 62 These studies highlight the potential impact of primary rebiosis as an emerging VRE therapy that may improve the efficacy of existing antimicrobial regimens.

commonly identified. [8][9][10]18 Increasing VRE prevalence intensifies the need to quickly identify patients at risk 32 for colonization and infection in order to treat colonized and infected patients with the potential for lowering 33 overall rates of colonization. The aim of this review is to present the general epidemiology and medical 34 management of healthcare-associated VRE infections. In order to clarify the variable at risk patient 35 populations, we reviewed important factors for colonization and recently reported conditions for subsequent 36 infection, followed by a review of infection control protocols, which are of heightened importance in health care settings. Further, recent updates to the pharmacological interventions and alternative therapies, including 38 rebiosis, are discussed and compared. IJMS

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A narrative review of English language literature from 1994 to August 2019 was utilized to assess the historic 3 development of vancomycin-resistance within the Enterococcus family. This timeline was revisited prior to 4 publication and updated to include the time frame to March 2022. Scale for Assessment of Narrative Review 5 Articles (SANRA) was used to guide appropriate research methods. 19 The primary research method was an 6 online search, conducted in September of 2019, of Google scholar and PubMed. Search terms included: 7 vancomycin resistance OR vre OR "vancomycin-resistant" OR multidrug resistant OR mdro OR infec* AND 8 enterococc* OR "E. faecalis" OR "E. faecium" OR "enterococcus faecalis" OR "enterococcus faecium" OR 9 microbiome OR microbiota. Meta-analyses and systematic reviews were given a narrower time frame, namely 10 the past 10 years, when compared to case reports or series and other literature reviews or position papers.

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This allowed for more recent data on current treatment practices and protocols while allowing a broader scope 12 for assessing the historic development and response to vancomycin-resistant Enterococci. The competencies 13 of evidence-based medicine were utilized when developing inclusion/exclusion criteria. 20 These competencies 14 include recognition of a problem, retrieving and critically appraising the literature, and integration of 15 information found. Papers dealing specifically with human models were preferred; however, some animal 16 model studies were included due to lack of data with human models.

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Inclusion required: 1. Title or abstract inclusion of at least 2 of the search term(s) OR 20 2. Significant (2+ pages) discussion of at least 2 of the search terms within the body of the paper OR 21 3. Position papers whose content would apply to at least 2 of the search terms, even if not specifically stated

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Exclusion required: 24 1. Any paper published more than 25 years ago at time of search (1994 or earlier) 25 2. Any meta-analysis or systematic review published more than 10 years ago at time of search (2009 or 26 earlier) 27 3. Any paper that contained only 1 search term and failed to meet the inclusion criteria outlined above 28 4. Any paper that included 1 or more search terms but whose primary focus was either another form of drug 29 resistance or another species of bacteria (e.g. methicillin-resistant Staphylococcus aureus) IJMS RESULTS AND DISCUSSION.

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reporting a 50% decrease in the incidence of VRE colonization following CP implementation. 27 47 The charts of isolated patients contained fewer vital sign records, fewer physician progress 3 notes, and elevated complaint and dissatisfaction levels at discharge. 47 While evidence supports isolation as a 4 component of VRE infection control protocols, concerted efforts must ensure these patients receive the same 5 standard of care during treatment as compared to their non-isolated counterparts.

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The CDC continually updates practice guidelines for VRE and other MDROs, advocating for effective 7 use of infection control measures in a multi-disciplinary approach that emphasizes prevention as well as 8 treatment. 48 Prevention methods include sterilization of medical equipment, using anti-bacterial washes on 9 patients, and hand hygiene. 48   While only bacteriostatic to VRE, linezolid has been successfully used as a monotherapy in several VRE 23 infective endocarditis cases. 13,31 VRE-mediated UTIs and central nervous system (CNS) infections also 24 respond well to linezolid monotherapy. 13,36 Daptomycin, a cyclic lipopeptide, has bactericidal action against 25 VRE in certain disease states and may be used for both VRE-mediated UTIs and infective endocarditis. 8,13,32 26 A recent comparison study revealed that linezolid was associated with significantly lower rate of clinical failure 27 as compared to the standard dose of daptomycin. 49 The same study found that higher doses of daptomycin 28 may overcome some of the clinical failures. A recent study by Kelly et

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In the years since physicians identified vancomycin-resistant Enterococci, our understanding of this 3 family of multidrug-resistant, opportunistic pathogens has grown exponentially. While this body of evidence 4 has grown, we are still looking for the most appropriate measures to limit the spread of antibiotic resistant