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CDC calls for immediate action to control spread of CRE in hospitals
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Carbapenem resistance among common Enterobacteriaceae has increased during the past 10 years, and after the release of an official health advisory in February, CDC officials yesterday called for prompt interventions to prevent further spread of the bacteria.
CDC Director Thomas Frieden, MD, MPH, and Arjun Srinivasan, MD, associate director for health care-associated infection prevention programs in CDC’s Division of Healthcare Quality Promotion, said during a telephone media briefing that carbapenem-resistant Enterobacteriaceae (CRE) has become “a very serious problem.”
Thomas Frieden
“We need to sound an alarm,” Frieden said, adding that the time to act is now — before the problem becomes widespread. “CRE is a critical public health issue facing our country.”
The call to action comes after a recent Morbidity and Mortality Weekly Report indicated that the proportion of Enterobacteriaceae resistant to carbapenems increased from 1.2% in 2001 to 4.2% in 2011, according to data from the National Nosocomial Infection Surveillance system and the National Healthcare Safety Network. Most of the increase observed from these surveillance systems occurred in Klebsiella species: 1.6% to 10.4%.
Data from the Surveillance Network–USA indicate that CRE samples increased from 0% in 2001 to 1.4% in 2010. Emerging Infections Program surveillance data from three states showed that 92% of CRE episodes occurred in patients with substantial health care exposures.
“CRE are nightmare bacteria that pose a triple threat,” Frieden said. “First, they are resistant to all or nearly all antibiotics, even some of our last-resort drugs. Second, they have high mortality rates — up to half of patients with serious infections. Third, they can spread their resistance to other bacteria.”
CRE has been reported in about 200 health care facilities throughout the United States but remains relatively uncommon. Data from the first 6 months of 2012 indicate that CRE is present in about 4% of acute care hospitals and 18% of long-term acute care hospitals.
Nearly all patients with CRE were being currently treated or were recently treated in a health care setting. However, the CDC is asking health care providers to act swiftly to quell the spread of the bacteria into the community.
Frieden said there are six important steps that health care providers can take to protect and detect this bacterial infection: 1) know if patients have CRE and request immediate alerts from the laboratory; 2) when receiving or transferring patients, ask to be alerted if the patient has CRE; 3) protect patients from CRE by following contact precautions when treating all patients; 4) wherever possible, have specific rooms, equipment and staff to care for CRE patients; 5) remove temporary medical devices, such as catheters, as soon as possible; and 6) prescribe antibiotics carefully.
Arjun Srinivasan
“We are calling for a ‘detect and protect’ strategy that we know can save patients’ lives and stop the spread of CRE,” Frieden said. “We only have a limited window of opportunity to stop this infection from spreading to the community and to more organisms.”
Srinivasan said active surveillance is important to prevent CRE from becoming a community-acquired infection, but it is not a “one size fits all” approach. The CDC’s CRE tool kit for health care providers released in 2012 includes specific recommendations regarding testing.
“These are based on the frequency with which CRE is being recovered in their facility and the area around the facility, so we recommend active surveillance to prevent the spread,” Srinivasan said.
Two promising approaches to prevent further spread of CRE include chlorhexidine bathing for patients with CRE and advanced molecular detection approaches that may shorten the time to detection.
Go to http://emergency.cdc.gov/HAN/han00341.asp to view the official CDC Health Advisory. CDC recommends that facilities follow CDC guidance for preventing the spread of CRE in health care settings (www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html). – by Cassandra A. Richards
Perspective
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Richard F. Jacobs, MD
CRE infections, which have been documented for a decade, are becoming an increasingly important cause of hospital-acquired infections leading to death. The initiatives from many professional societies (eg, Infectious Diseases Society of America and Pediatric Infectious Diseases Society) highlight the need for better control of the use of antibiotics in agriculture, the lack of development of and research funding for new antimicrobials, and the importance of antimicrobial stewardship programs and hand hygiene quality programs in our hospitals.
Perspective
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Keith S. Kaye, MD, MPH
CRE is an emerging pathogen in many parts of the United States and world. This is not a new problem, but it's continued dissemination and the fact that is has become endemic in many locales is very concerning. CRE impacts not only hospitals, but also some long-term care facilities —long-term care facilities in particular. Infections due to CRE often require treatment with older relatively toxic antimicrobials, such as polymyxins. Antimicrobial stewardship and infection control processes are need to control the spread of CRE. The dissemination of CRE across different types of health care settings is particularly challenging. Regional and public health approaches are needed to control the spread of CRE.
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