Recommendations

In light of the result of this study and the above listed conclusions, the following actions are recommended to slow down VRE phenomenon in particular as well as antimicrobial resistance in general:

1. Strategies to promptly identify colonized patients should be designed and implemented in hospitals. Prompt identification is based on targeted surveillance, considering risk factors for VRE colonization in selected patients, mainly hospitalized ICU patients.

• Regular monitoring for the presence of VRE in both hospitals and the community
• When VRE are detected concerned staff should be promptly notified
• Clinical staff of policies regarding VRE-infected or colonized patients should be informed.

2. Isolation precautions to prevent patient-to-patient transmission should be initiated.

• VRE-infected or colonized patients should be placed in private rooms or in the same room as other patients who have VRE.

• Healthcare workers should wear gloves and gown when entering the room of a VRE-infected or colonized patient.

• Gloves and gown should be removed before leaving the patient's room and immediately wash hands with an antiseptic soap or a waterless antiseptic agent.

• After glove and gown removal and handwashing, clothing and hands should not contact environmental surfaces in the patient's room that are potentially contaminated with VRE.

3. Education and awareness of antibiotic prescribers is important in VRE control. The use of antibiotics, in particular, glycopeptides, should probably be dramatically restricted in order to avoid the selection of VRE, which are already part of the human microflora.

4. Effective strategies for the prevention of antimicrobial resistance in ICUs should be focused on limiting the unnecessary use of antibiotics and increasing compliance with infection control practices.

• A stool culture or rectal swab from roommates of patients newly found to be infected or colonized with VRE should be obtained to determine their colonization status and isolation precautions as necessary should be applied.

·         A system for highlighting the records of infected or colonized patients so they can be promptly identified and placed on isolation precautions upon readmission to the hospital should be established.

·         Clinical microbiology laboratories should be aware of the emergence of resistance and should test appropriate isolates for susceptibility to vancomycin.

·         Further studies to examine the routes of transmission of VRE and the ecologic role e.g., transmission of VRE to other patients, of antibiotics are needed.

·           Further studies are required to clarify the epidemiology of VRE, and they could be usefully complemented by an investigation of the rate of VRE fecal colonization among local animals, one possible source of contamination in the food chain.

·         Further careful epidemiologic studies are needed to determine the impact of restriction of antimicrobial use in limiting the spread of VRE, especially in hospitals where VRE is endemic.

·         People in Gaza city had inadequate or misconception about antibiotic usage. The findings of this study imply the need for programs to promote greater attention about antibiotics usage in the general population of Gaza.

Professional bodies should consider continuous training of practicing physicians to dispel the inappropriate information and initiate necessary steps to deliver the latest advances of the knowledge to every practicing physician through academic activities in order to check over this emerging problem of antibiotic resistance.