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