HCWs are put on alert for ‘nightmare’ bacteria

CDC: PPE, hand hygiene compliance are key

A new “nightmare” bacteria has put renewed emphasis on health care worker use of personal protective equipment and compliance with hand hygiene.

Health care workers are not at increased risk of getting the latest multi-drug resistant bacteria, carbapenem-resistant enterobacteriaceae (CRE), but how well they follow infection control practices, including contact precautions and proper environmental cleaning, could make a difference in its spread.

That was part of the message as Tom Frieden, MD, MPH, director of the Centers for Disease Control and Prevention, warned the nation of the spread of CRE, which is resistant to “all or nearly all” antibiotics and has a mortality rate of up to 50%. CRE also can spread its antibiotic resistance to other pathogens, Frieden said.

“It’s not often that our scientists come to me to say that we have a very serious problem, and we need to sound an alarm, but that’s exactly what we’re doing today,” Frieden said in a telephone press conference.

Antibiotic resistant organisms have been a problem in health care for some time. For example, Clostridium difficile is linked to 14,000 deaths a year, CDC says. But CRE’s “triple threat” presents a newly emerging danger. In 2001, CRE was detected in one health care facility in one state; in the first half of 2012, about 200 hospitals and long-term acute care facilities treated at least one patient infected with CRE. It has now been found in 42 states.

Yet the spread of CRE can still be contained, Frieden said. “We only have a limited window of opportunity to stop this infection from spreading to the community and spreading to more organisms,” he said. “We’re calling for a “detect and protect” strategy that we know can save patients’ lives and stop the spread of CRE.”

PPE compliance lags

Too often, health care workers are either complacent or don’t understand the importance of proper use of personal protective equipment (PPE) or hand hygiene, studies show. For example, the Respirator Use Evaluation in Acute Care Hospitals (REACH) project found that health care workers were confused about when to wear a respirator or mask and many (40%) received only 1 to 15 minutes of education in respiratory protection in a year.1

An observational study in Canada found gaps in all kinds of PPE use when health care workers cared for patients with febrile respiratory illness. Only 26% of health care workers were observed performing hand hygiene after removing their gloves. Overall, they were most lax in their use of eye protection (37%), but compliance lagged in all areas: 88% for gloves, 83% for gowns and 88% for masks. Almost half of the workers removed their PPE in the wrong sequence.2

These types of findings cry out for more research into what works to improve compliance with infection control, says Irena L. Kenneley, PhD, APRN-BC, CIC, assistant professor at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland, OH, and chair of the Research Committee of the Association for Professionals in Infection Control and Epidemiology (APIC).

“We need more funding from CDC and other agencies and to stop blaming clinicians and start funding the science to assist our infection prevention efforts,” she says. “If we don’t have any new antibiotics coming out, we have to start getting serious about infection prevention.”

The continued emergence of CRE creates an imperative to renew an emphasis on infection control — including boosting education of health care workers and placing a greater emphasis on environmental cleaning and infection control.

“The occurrence of this organism is an emergency. And it’s happening right now and it’s not just in a single hospital, but it’s across the entire country,” Kennely says. “For the most part, we are completely failing to address this problem.”

How to boost compliance

Even if your hospital has not (yet) seen a patient with CRE, this is a good time to review the basics — and the importance — of hand hygiene, environmental cleaning, and PPE, says Kennely. Here are some ways to improve compliance:

Make education engaging. It’s easier to provide the information in an online module, but making it active and innovative will get your employees’ attention. You can create a game show format, such as “Jeopardy” or “Who Wants to be a Millionaire,” with questions that relate to infection control. Or borrow a case from another institution (or make up a sample case) and encourage employees to role-play. “Since [CRE] is in the media, it’s time to seize the day and do a set of educational sessions,” she says. “You have their attention. They’re listening. Annual competencies don’t necessary bring about the same type of attention.”

Provide feedback. In coordination with infection control practitioners, you can conduct observations of hand hygiene and PPE use. APIC has a hand hygiene monitoring tool in its new C. diff guidelines (ow.ly/k9F7w). Feedback to employees about the compliance level of their unit and how they compare with other units can help spur change, says Kennely.

Tailor education to employees. Environmental services workers need the education about CRE and infection control, but they need a format that focuses on their job tasks and is presented for their knowledge level. Preventing CRE transmission doesn’t require special chemicals, but it does require sufficient time to clean rooms properly, says Arjun Srinivasan, MD, associate director for Healthcare-associated Infection Prevention Programs in CDC’s Division of Healthcare Quality and Promotion. “Standard hospital cleaners will do a perfect job of killing CRE on surfaces,” he says. “The key is not that we need to use different chemicals. The key is that the chemicals need to be applied.”

Editor’s note:For more information see the CDC toolkit on CRE, which is available at www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html.


1. Brosseau L, Franko E, Materna B, et al. Respirator evaluation in acute care hospital (Reach II) regional Results. Presentation to the NIOSH National Personal Protective Technology Laboratory Stakeholders’ Meeting, March 20-21, 2012, Pittsburgh, PA.

2. Mitchell R, Roth V, Gravel D, et al. Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals. Am J Infect Control 2013; 41:240-244.