U.S. CDC Guidance on CRE Infection Prevention and Control
Arjun Srinivasan, M.D.
Associate Director for Healthcare Associated Infection Prevention Programs
Division of Healthcare Quality Promotion
National Center for Emerging and Zoonotic Infectious Diseases
Want to halt the spread of antibiotic resistance? Think infection prevention. We all know that the best method for preventing antibiotic resistant infections is to limit the overuse and misuse of antibiotics in inpatient and outpatient facilities. Antibiotic stewardship is the cornerstone for CDC’s Get Smart: Know When Antibiotics Work and Get Smart for Healthcare programs. However, what do you do when you find that one of your patients has a drug-resistant infection? How are you going to prevent the infection from spreading to other patients within your ward or healthcare facility? Recent studies have demonstrated that some of these infections can even spread between communities’ acute care and long-term care facilities. How will you stop this from happening in your community? In short – think infection prevention.
Every year, antibiotic resistance adversely impacts the health of millions of hospitalized patients. We’ve seen that antibiotic resistance can travel the globe. For example, Klebsiella pneumoniae carbapenemase (KPC) infections, a type of resistant carbapenem-resistant Enterobacteriaceae (CRE), were once seen in limited locations in the United States but are now found throughout the country.
Those of you who have cared for a patient with a CRE infection know that these organisms are resistant to almost all available antimicrobial agents, and infections from these organisms are associated with high rates of morbidity and mortality. Patients who are critically ill or have been exposed to invasive devices (such as ventilators or central venous catheters) and antibiotics are most likely to be infected with CRE. Fortunately, experience from outbreak investigations and in endemic settings in other countries has suggested that early detection and implementation of strict infection control measures can help control the spread of carbapenem-resistant organisms in healthcare facilities. We often refer to this as a “search and destroy” strategy.
In 2009, CDC and the Healthcare Infection Control Practices Advisory Committee released new guidance in an effort to limit the further emergence of CRE in acute care settings. The guidelines recommend several steps:
Start in the laboratory. First, microbiology laboratories in all acute care facilities should implement established protocols to detect carbapenemase production in Enterobacteriaceae, particularly in Klebsiella species or E coli. If clinical laboratory staff identifies an organism of concern, they should immediately alert hospital infection prevention or epidemiology staff.
Implement contact precautions. When a hospitalized patient with CRE is identified, the most important immediate infection control measure is to implement contact precautions for the patient. Contact precautions require the use of gloves and gowns for patient care.
Search and destroy. If the CRE is thought to have been acquired within the facility – it was not known to be present when the patient was admitted – the guidelines recommend a “search and destroy” strategy through the use of active surveillance among patients who are epidemiologically linked to the case-patient. Active surveillance cultures for CRE can be done through the use of rectal swabs; published protocols are available in the medical literature and in the related links on this page. CRE patients may be in the same unit or may have been cared for by the same healthcare personnel as case-patients. By conducting active surveillance in this manner, you can identify additional patients colonized with these organisms, which can determine whether you have ongoing patient-to-patient transmission of these bacteria in your facility.
If you detect transmission – meaning that you identify cases among patients with epidemiologic links to your case-patient, then infection prevention measures should be vigorously reinforced, and surveillance cultures repeated periodically until no new cases are identified. If no other colonized patients are identified after several instances where surveillance cultures are done on epidemiologically linked patients, it likely means that your facility is effectively controlling transmission. In this circumstance, you may wish to forgo active surveillance in response to new cases of CRE and replace it with periodic point prevalence surveys in units with patients at high risk for CRE infection to ensure that carbapenem-resistant or carbapenemase-producing Klebsiella species and E. coli do not reemerge.
Review regularly. In facilities where CRE infections have not been reported, experience also indicates that in some instances, cases of CRE are reported by the microbiology laboratory, but are not detected and acted upon by infection control staff. Hence, to ensure infection control staff has the most accurate information on CRE within their facilities, the guidelines recommend that staff in acute care facilities review microbiology records for the past 6-12 months to ensure that previously unrecognized CRE cases have not occurred. If you find a previously unrecognized case, it is recommended that you perform some form of active surveillance to determine if there is unrecognized transmission of CRE in your facility. This can be done by conducting a point prevalence survey, which involves performing a single round of active surveillance cultures in units with patients at high risk – such as intensive care units, units where previous cases have been identified, and units where many patients are exposed to broad-spectrum antimicrobial agents. The goal of this survey is to identify any additional patients infected or colonized with carbapenem-resistant or carbapenemase-producing Klebsiella species or E. coli.
Since first being described in North Carolina in 1999, CRE has been found in at least 37 states and are now widespread in some locations. However, we do have an opportunity to act aggressively to halt the spread of CRE. I encourage all of you to review and implement the CDC Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities. Experience with CRE suggests that a comprehensive and consistent infection prevention approach can be extremely effective in limiting the transmission of these pathogens. By working together and taking action, we can prevent CRE from becoming a more significant threat to our patients – ultimately improving medical care and saving lives.
Find more of Dr. Srinivasan’s insights on how to develop a strong antibiotic stewardship program in his article “When It’s Time for an Antibiotic Time Out” (APUA Clinical Newsletter Vol.29 No.1), or take a look at the fact sheets distributed on November 15 and 16 during the CDC's Get Smart About Antibiotics Week (November 14-20, 2011) focusing on antibiotic stewardship and the role of healthcare providers.
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