CRE… pose a triple threat. First, they’re resistant to all or nearly all antibiotics - even some of our last-resort drugs. Second, they have high mortality rates. They kill up to half of people who get serious infections with them. And third, they can spread their resistance to other bacteria. So one form of bacteria, for example, carbapenem-resistant Klebsiella, can spread the genes that destroy our last antibiotics to other bacteria, such as E. coli, and make E. coli resistant to those antibiotics also… We only have a limited window of opportunity.
Data from CDC’s National Healthcare Safety Network (NHSN)
and The Surveillance Network – USA (TSN) revealed the proportion of Enterobacteriaceae that were CRE rose from
1.2% in 2001 to 4.2% in 2011 in NHSN hospitals and to 1.4% by 2010 in TSN
facilities – A four-fold increase over 10 years. In Klebsiella species, the situation is dire with 10.4% classified as
CRE in 2011. By 2012, 4.6% of all facilities, 3.9% of short stay hospitals and
17.8% of long-term acute-care hospitals reported at least one CRE in their
facility. Moreover, healthcare
institutions in 42 state have now identified at least one case of CRE.
 |
| Trends in Resistance to Carbapenems and Third-Generation Cephalosporins among Clinical Isolates of Klebsiella pneumoniae in the United States, 1999–2010 |
So what are the current CDC recommendations for management
of the CRE cases? CDC continues to
recommend that facilities follow the CDC guidance for preventing the spread of
CRE in healthcare settings (http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html).
Facilities should:
- Ensure that the patient is on Contact Precautions.
- Reinforce and evaluate adherence to hand hygiene and Contact Precautions for healthcare personnel who come into contact with the patient (e.g., enter the patient’s room).
- Since clinical cultures will identify only a minority of patients with CRE, screen epidemiologically linked patient contacts for CRE colonization with stool, rectal, or perirectal cultures. At a minimum, this should include persons with whom the CRE patient shared a room but could also include patients who were treated by the same healthcare personnel. A laboratory-based screening protocol is available here: (http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf)
- Should the patient be transferred to another healthcare facility, ensure that the presence of CRE colonization or infection is communicated to the accepting facility. An example transfer form is available here (http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf).
- Dedicate rooms and staff to CRE patients when possible. It is preferred that staff caring for CRE patients do not also care for non-CRE patients.
- Remove temporary medical devices as soon as they are no longer needed.
- Use antibiotic conservatively
In addition to that guidance, CDC now also recommends the
following for patients who had overnight healthcare stays outside of the US
within the last 6 months:
- When a CRE is identified in a patient (infection or colonization) with a history of an overnight stay in a healthcare facility (within the last 6 months) outside the United States, send the isolate to a reference laboratory for confirmatory susceptibility testing and test to determine the carbapenem resistance mechanism; at a minimum, this should include evaluation for KPC and NDM carbapenemases.
- For patients admitted to healthcare facilities in the United States after recently being hospitalized (within the last 6 months) in countries outside the United States, consider each of the following:
- Perform rectal screening cultures to detect CRE colonization.
- Place patients on Contact Precautions while awaiting the results of these screening cultures.
References:
MJ Scwaber, et. al (2011). Containment of a Country-wide Outbreak of
Carbapenem-Resistant Klebsiella
Pneumoniae in Israeli Hospitals via a Nationally Implemented
Intervention. Clin Infect Dis, 52(7): 848-855
Vital Signs: Carbapenem-Resistant Enterobacteriaceae
(2013). MMWR, 62(9):165-170
CDC CRE Toolkit (http://www.cdc.gov/hai/organisms/cre/cre-toolkit)
N Braykov, et al (2013). Trends in resistance to carbapenems and
third-gen. cephalosporins among clinical isolates of Klebsiella pneumoniae in
the US, 1999-2010. Infect Control Hosp Epidemiol;34(3):259-268
