Vancomycin intermediate-resistant Staphylococcus aureus

Overview-Incidence

A colonized patient is more than 10 times more likely to become infected with the organism than an uncolonized patient, such as through a breach in the immune system. All confirmed cases have been associated with end-stage renal disease and concurrent dialysis, central venous catheter, or prosthetic graft material. This disorder has been noted in patients receiving multiple courses of vancomycin for MRSA infections.

Nursing Considerations-Nursing Diagnoses

Acute pain Decreased cardiac output Deficient fluid volume Hyperthermia Impaired tissue integrity Risk for decreased cardiac perfusion Risk for infection

Treatment-Medications

Antimicrobials such as mupirocin topically to eradicate the organism from the nose of the patient and health care workers during localized outbreaks Possibly daptomycin, linezolid, and quinupristin-dalfopristin

Nursing Considerations-Associated Nursing Procedures

Blood culture sample collection Contact precautions Hand hygiene Intake and output assessment IV bag preparation IV bolus injection IV catheter insertion IV pump use Pain management Pulse assessment Respiration assessment Temperature assessment Venipuncture

Diagnostic Test Results-Laboratory

Culture may show staphylococci with decreased susceptibility to vancomycin after 24-hour incubation.

Overview-Causes

Direct contact with an infected or colonized patient or colonized health care worker or contact with a contaminated surface such as an overbed table

Overview

First discovered in 1996 Staphylococcal infection that has a decreased susceptibility to vancomycin Common in chronically ill patients, most commonly developing in health care settings Also called VISA and glycopeptide intermediate-resistant Staphylococcus aureus

Overview-Pathophysiology

Genes encode resistance and are carried on plasmids that transfer themselves from cell to cell. Resistance is mediated by enzymes that substitute a different molecule for the terminal amino acid so that vancomycin can't bind. The cell wall becomes unusually thick, interfering with the availability of the drug to the target molecules. Patients with methicillin-resistant Staphylococcus aureus (MRSA) are normally most reliably and effectively treated with vancomycin; MRSA that has a decreased susceptibility to vancomycin may be a sign that vancomycin-resistant strains are emerging.

Treatment-Diet

No restrictions

Nursing Considerations-Nursing Interventions

Place the patient in a private room, and minimize the number of staff caring for the patient. Use standard and contact precautions during patient care; perform meticulous hand washing. Perform meticulous hand hygiene. Use disposable equipment when possible; when not possible, use nondisposable items only on the infected patient. Ensure judicious and careful use of antibiotics. Encourage physicians to limit the use of antibiotics. Provide supportive care for the patient's underlying infection. Ensure that invasive devices are used for the shortest time possible. Enlist the aid of an infection control specialist, as indicated. Double-bag all specimens for transport. Administer fluids as ordered. Encourage frequent turning and position changes. Obtain specimens for laboratory testing as appropriate.

Assessment-History

Possible breach in the immune system, surgery, or a condition that predisposes the patient to infection, such as invasive lines or devices Multiple antibiotic use

Treatment-Activity

Rest periods when fatigued

Overview-Complications

Sepsis Multisystem organ involvement Death in the immunocompromised patient

Assessment-Physical Findings

The carrier patient is commonly asymptomatic but may exhibit signs and symptoms related to the primary diagnosis. The patient may exhibit cardiac, respiratory, or other major symptoms.

Nursing Considerations-Monitoring

Vital signs, especially temperature Cardiac status Fluid balance Tissue integrity Response to treatment Complications

Treatment-General

With an infection, possibly no treatment Standard and contact precautions

Patient Teaching-General

disorder, diagnosis, and treatment, including possible methods of disease transmission importance of adhering to infection control precautions, including the need for family and friends to wear personal protective equipment when they visit the patient proper disposal of disposable and nondisposable supplies and equipment importance of adhering to strict hand-washing and hand hygiene measures application of a topical antimicrobial if ordered. measures to prevent transmission, such as cleaning frequently touched areas and surfaces with a disinfectant or a mixture of ¼ cup bleach to 1 qt water and wearing gloves if in contact with body fluids.

Nursing Considerations-Expected Outcomes

report decreased pain levels maintain adequate cardiac output have an adequate fluid volume remain afebrile maintain adequate circulation to impaired tissues attain and maintain hemodynamic stability demonstrate a resolution of the infection.