As CRE Spreads, the CDC’s Toolkit Offers Helpful Containment Strategies

In about 1992, evidence first appeared that bacteria from the Enterobacteriaceae family (known to cause pneumonia and kidney, bladder and bloodstream infections) had become resistant to carbapenem antibiotics (antibiotics developed to treat bacteria resistant to most other antibiotics). These bacteria are called Carbapenem-Resistant Enterobacteriaceae or CRE.

As Peter Eisler reminds us in his recent USA Today article, “Deadly ‘Superbugs’ Invade U.S. Health Care Facilities,” four years ago CRE attacked and ultimately killed a middle-aged patient at the University of Virginia Medical Center (UVMC).  According to Eisler, “in the months that followed, it [CRE] struck again and again at the same hospital [UVMC], in various forms, as doctors raced to decipher the secret to its spread.”

More recently, NBC Nightly News reported that a strain of CRE struck at one of the premier health centers in the nation, the National Institutes of Health Clinical Center near Washington, D.C., reportedly infecting 18 patients and resulting in 11 deaths.

Today, the Centers for Disease Control and Prevention (CDC) admits that CRE

  1. has spread throughout much of the United States (up to 41 states);
  2. has the potential to spread even more widely;
  3. is insusceptible to doripenem, meropenem, or imipenem, all carbapenems, and resistant to all of the following third-generation cephalosporins that were tested: ceftriaxone, cefotaxime, and ceftazidime; and
  4. has been associated with mortality rates of up to 40 to 50 percent in some studies.

Facility-Level Prevention 

The CDC’s 2012 CRE Toolkit, entitled “Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE),” provides facility-level prevention strategies, which include:

  • hand hygiene;
  • contact precautions;
  • healthcare personnel education;
  • minimizing the use of devices with high risk of device-associated infections, such as central venous catheters, endotracheal tubes, and urinary catheters;
  • housing patients colonized or infected with CRE in single patient rooms;
  • rapid notification of appropriate staff by laboratories whenever CRE are identified;
  • antimicrobial stewardship, i.e., ensuring that antimicrobials are used for appropriate indications and duration, and that the narrowest spectrum is used; and
  • screening to identify unrecognized CRE colonization among epidemiologically linked contacts of known CRE colonized or infected patients.

Supplemental Toolkit measures for healthcare facilities with CRE transmission include: (1) active surveillance testing of high-risk patients at admission or at admission and periodically during their stay, and (2) bathing of patients with 2 percent chlorhexidine.

Regional CRE Surveillance

In addition to strategies for facility-level prevention, CDC’s CRE Toolkit sets forth recommendations for public health department engagement to prevent regional or inter-facility transmission of CRE. This recommended engagement includes options for “regional CRE surveillance,” including making CRE a laboratory-reportable event or surveying infection preventionists and laboratory directors by telephone or email.

Regional CRE Prevention Strategies 

In regions with no CRE identified, the CDC’s CRE Toolkit recommends an aggressive approach to future CRE detection, such as making CRE a laboratory-reportable event. If reporting is not possible, health departments should periodically survey healthcare facilities for the presence of CRE and provide feedback to increase awareness. Health departments should also increase awareness through healthcare facility education in the area of recommended prevention measures and the importance of timely recognition of any CRE colonized or infected patients.

According to the Toolkit, regions with few CRE identified are most in need of increased awareness regarding which facilities in the region are being most impacted by CRE.  In these regions, surveillance results should be shared with facilities, including facility administrators, to allow nearby facilities to take appropriate preventive actions. To reduce inter-facility transmission, all facilities should be encouraged to routinely complete inter-facility transfer forms whenever a patient is transferred to another facility. The transfer form should indicate whether the patient has ever been colonized or infected with CRE or other multi-resistant drug organisms (MRDOs), whether the patient has any open wounds or indwelling devices, and whether the patient is currently being administered antimicrobials.

Finally, in regions where CRE are common, the Toolkit recommends a broad public health approach. To effectively coordinate regional infection prevention, public health departments should have dedicated personnel assigned to the task. Public health departments should engage healthcare facilities by communicating the CRE prevalence in the region and the importance of a regional approach to prevention. Reinforcement of the core prevention measures and additional supplemental measures may be necessary. Public health departments should periodically (e.g., monthly) access facility compliance with recommended practices.  This can be done based on reporting by facility infection preventionists or through site visits to facilities. As described above, an inter-facility transfer form should be completed whenever a patient is transferred to another facility.