2012 CRE Toolkit - Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)
Part 1: Facility-level CRE Prevention
Inpatient facilities should have an awareness of whether or not CRE (at least E. coli and Klebsiella spp.) have ever been cultured from patients admitted to their facility and, if so, whether these positive cultures were collected within 48 hours of admission.
If CRE have been present, facilities should also determine:
- If there is evidence of intra-facility transmission
- Which wards/units are most affected
Facilities that do not have this information should consider performing an evaluation to quantify the clinical incidence of these organisms, such as a review of archived lab results to determine the number and/or proportion of Enterobacteriaceae that meet the CRE definition over a pre-specified time period (e.g., 6 to 12 months). In addition, facilities should consider collecting information on the basic epidemiology of patients colonized or infected with these organisms in order to understand common characteristics of these individuals. This might include patient demographics, dates of admission, outcomes, medications, and common exposures (e.g., wards, surgery, procedures, etc).
The following briefly summarizes an approach to preventing CRE transmission in healthcare settings. For a more in-depth review, please refer to the CDC HICPAC guidelines “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.”
There are 8 core measures facilities should follow.
- Hand Hygiene
Hand hygiene is a primary part of preventing multidrug-resistant organism(MDRO) transmission. Facilities should ensure that healthcare personnel are familiar with proper hand hygiene technique as well as its rationale. Efforts should be made to promote staff ownership of hand hygiene using techniques like developing local (e.g., unit) hand hygiene champions. It is not enough to have policies that require hand hygiene; hand hygiene adherence should be monitored and adherence rates should be fed directly back to front line staff. Immediate feedback should be provided to staff who miss opportunities for hand hygiene. In addition, facilities should ensure access to adequate hand hygiene stations (i.e., clean sinks and/or alcohol-based hand rubs) and ensure they are well stocked with supplies (e.g. towels, soap, etc.) and clear of clutter. Further information on hand hygiene is available at CDCs Hand Hygiene in Healthcare Settings website. This intervention is applicable to both acute and long-term care settings.
- Contact Precautions
Patients in acute care settings who are colonized or infected with CRE should be placed on Contact Precautions. Systems should be in place to identify patients with a history of CRE colonization or infection at admission so that they can be placed on Contact Precautions if not known to be free of colonization. In addition, clinical laboratories should have an established protocol for notifying clinical and/or infection prevention personnel when CRE are identified from clinical or surveillance cultures.
There is not enough information for a firm recommendation about when to discontinue Contact Precautions among infected patients; however, CRE colonization in some patients identified during CDC investigations has been prolonged (> 6 months). If surveillance cultures are used to decide if a patient remains colonized, more than one culture should be collected in an attempt to improve sensitivity. One recent study found that among rectal CRE carriers, predictors of rectal CRE carriage at a future healthcare encounter included exposure to antimicrobials (especially fluoroquinolones), admission from another healthcare facility, and less than 3 months’ elapsed time since their first positive CRE test.
The probability of being CRE positive at the next encounter increased to 50% if one predictor was present. Presence of ongoing risk factors for carriage such as these should be considered before discontinuing use of Contact Precautions in these patients. The presence of CRE infection or colonization alone should not preclude transfer of a patient from one facility to another (e.g., acute care to long-term care). Facilities should ensure that Contact Precautions are used correctly by staff caring for all patients with epidemiologically important MDROs including CRE.
Ensuring healthcare personnel (HCP) are educated about the proper use and rationale for Contact Precautions is an important part of this process. In addition, facilities should ensure that there is a process to monitor and improve HCP adherence to Contact Precautions. This might include conducting periodic surveillance on the use of Contact Precautions and providing feedback to frontline staff about these results.
Preemptive Contact Precautions, often in conjunction with surveillance cultures, might be used on patients transferred from high-risk settings (see supplemental interventions) pending results of screening cultures. Examples include transferred patients from hospitals in countries or areas in the United States where CRE are common or patients transferred from facilities known to have outbreaks or clusters of CRE colonized or infected patients. In long-term care settings, Contact Precautions are still indicated for residents infected or colonized with CRE; however, these might be modified to fit the inherent differences between acute and long-term care facilities. Contact Precautions should be used for residents with CRE who are at higher risk for transmission, including patients who are totally dependent upon HCP for their activities of daily living, are ventilator-dependent, are incontinent of stool, or have wounds with drainage that is difficult to control. For other residents who are able to perform hand hygiene, are continent of stool, are less dependent on staff for their activities of daily living, and are without draining wounds, the requirement for Contact Precautions might be relaxed. However, in these situations Standard Precautions should still be observed, including the use of gloves and/or gowns when contact with colonized/infected sites or body fluids is possible.
- Healthcare Personnel Education
HCP in all settings who care for patients with MDROs, including CRE, should be educated about preventing transmission of these organisms. At a minimum this should include information on the proper use of Contact Precautions and hand hygiene. This intervention is applicable to both acute and long-term care settings.
- Use of Devices
Use of devices (e.g., central venous catheters, endotracheal tubes, urinary catheters) puts patients at risk for device–associated infections and minimizing device use is an important part of the effort to decrease the incidence of these infections. Additionally, device use has been associated with carbapenem resistance among Enterobacteriaceae. Therefore, minimizing device use in all healthcare settings should be part of the effort to decrease the prevalence of all MDROs including CRE. In acute and long-term care settings, device use should be reviewed regularly to ensure they are still required and devices should be discontinued promptly when no longer needed. For more information on preventing device-associated infection including appropriate use of devices please see Guidelines for the Prevention of Intravascular Catheter-Related Infections and Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009.
- Patient and Staff Cohorting
When available, patients colonized or infected with CRE should be housed in single patient rooms and if not available these patients should be cohorted together. In addition, consideration should be given to cohorting patients with CRE in specific areas (e.g., units or wards), even if in single patient rooms, and to using dedicated staff to care for them. This recommendation applies to both acute and long-term care settings. Preference for single rooms should be given to patients at highest risk for transmission such as patients with incontinence, medical devices, or wounds with uncontrolled drainage.
- Laboratory Notification
Laboratories should have protocols in place that facilitate the rapid notification of appropriate clinical and infection prevention staff whenever CRE are identified from clinical specimens to ensure timely implementation of control measures. This is true for both facilities with on-site laboratories and those sending cultures off-site and is applicable to acute and long–term care settings.
- Antimicrobial Stewardship
Antimicrobial stewardship is another primary part of MDRO control. Although the role of this activity specifically for CRE has not been well studied, multiple antimicrobial classes have been shown to be a risk for CRE colonization and/or infection. Further, restricting use of carbapenems has been associated with a lower incidence of carbapenem-resistantPseudomonas aeruginosa in one ecological analysis. As part of an antimicrobial stewardship program designed to minimize transmission of MDROs, facilities should work to ensure that 1) antimicrobials are used for appropriate indications and duration and 2) that the narrowest spectrum antimicrobial that is appropriate for the specific clinical scenario is used. For more information on antimicrobial stewardship in healthcare settings please see CDCs GetSmart for Healthcare website. This intervention is applicable to both acute and long-term care settings.
- CRE Screening
Screening is used to identify unrecognized CRE colonization among epidemiologically linked contacts of known CRE colonized or infected patients as clinical cultures will usually identify only a fraction of all patients with CRE. Generally, this screening has involved stool, rectal, or peri-rectal cultures and sometimes cultures of wounds or urine (if a urinary catheter is present). A laboratory protocol for evaluating rectal or peri-rectal swabs for CRE [PDF - 110 KB] is available however, it is important to note that this procedure has only been validated for E. coli and Klebsiella spp. CRE screening of epidemiologically linked patients is a primary prevention strategy for all healthcare facilities; however, it is particularly important for healthcare facilities with CRE outbreaks or facilities that do not or only rarely admit patients with CRE infection or colonization. This intervention is applicable to both acute and long-term care settings.