CDC guidelines target prevention of CRE

Appropriate hand hygiene tops the list of important practice measures for preventing the spread of carbapenem-resistant Enterobacteriaceae across health care facilities, according to guidelines issued by the CDC.

The guidelines expand on the 2009 CDC and Healthcare Infection Control Practices Advisory Committee recommendations. According to background information in the guidelines, carbapenem-resistant Enterobacteriaccae (CRE) has been associated with up to 40% to 50% mortality rates. Besides being resistant to carbapenem, CRE is also resistant to many other antimicrobials.

The CDC defines CRE as non-susceptible to carbapenems and resistant to the third-generation cephalosporins ceftriaxone, cefotaxime and ceftazidime. Currently, Klebsiella spp. and Escherichia coli that meet the definition of CRE are a priority for detection and containment.

“Since most carbapenem resistance mediated by carbapenemases in the United States is found among Klebsiella spp. and E. coli, individual facilities or public health authorities might choose to apply the CRE surveillance definition only to these specific Enterobacteriaceae,” the CDC wrote.

Awareness of CRE

For surveillance, inpatient facilities should be aware of whether CRE has ever been cultured from any of their patients and whether the cultures were obtained within 48 hours of the patient’s admission. The CDC recommends that facilities without the information perform evaluations to determine the incidence of CRE. In addition, the CDC recommends that facilities determine the epidemiology of patients with CRE, including information such as patient demographics, dates of admission, outcomes, medications and common exposures.

To prevent the spread of CRE, the CDC recommends that health care personnel follow appropriate hand hygiene measures. Not only should hand hygiene policies be in place, but hand hygiene practices should also be monitored, with adherence being reported to frontline staff.

The CDC also advises that health care facilities take contact precautions with patients who are infected or colonized with CRE. However, they do not have a firm recommendation for how long the patient should remain on contact precautions.

“Ensuring health care personnel are educated about the proper use and rationale for contact precautions is an important part of this process,” the CDC wrote. “In addition, facilities should ensure that there is a process to monitor and improve health care personnel 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.”

Educating health care personnel

The CDC recommends that all health care personnel be educated in preventing the transmission of CRE. At minimum, the information they receive should include use of contact precautions and hand hygiene. Education is important for personnel at both acute and long-term care settings.

Minimizing device use is also recommended because these devices, such as central venous catheters, endotracheal tube and urinary catheters, pose a risk for device-associated infections. Device use should be monitored and discontinued and discarded properly.

Patients with CRE should be in single rooms or in rooms with other patients with CRE, in both acute and long-term care settings. In addition, laboratories are urged to have protocols to rapidly inform clinical staff and infection control staff when they identify CRE. Also, CRE screening is necessary among epidemiologically linked contacts of known CRE colonized or infected patients.

Lastly, antimicrobial stewardship programs should be in place, which ensure that “antimicrobials are used for the appropriate indications and duration and that the narrowest spectrum antimicrobial that is appropriate for the specific clinical scenario is used,” the CDC wrote.

For more information:

CDC. Guidance for control of carbapenem-resistant Enterobacteriaceae (CRE). Available at: http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf.