As infections due carbapenem-resistant Enterobacteriaceae (CRE) continue to increase, here are four take-home points about this problematic pathogen.
Patient risk factors: The main risk factors for CRE acquisition in the United States include exposure to healthcare and exposure to antimicrobials. Healthcare-related risk factors include poor functional status, exposure to an intensive care unit, and mechanical ventilation. Outbreaks of CRE have also been associated with exposure to long-term care settings. Several antimicrobials have been associated with CRE acquisition, including carbapenems, cephalosporins, fluoroquinolones, and vancomycin.
Infections: CRE can cause infections in almost any body part including bloodstream infections, ventilator- associated pneumonia, and intra-abdominal abscesses. Based on information from a CDC pilot surveillance system, most CREinfections involve the urinary tract, often in people who have a urinary catheter or have urinary retention. It is important to note that CRE kills up to half of patients who get bloodstream infections from them.
Transmission: In healthcare settings, CRE are usually transmitted from person to person, often via the hands of healthcare personnel or by contaminated medical equipment. As Enterobacteriaceae can commonly be found in stool or wounds, contact with these might be particularly concerning. Ensuring the use of personal protective equipment during and good hand hygiene following exposure to the patient’s immediate environment, especially when cleaning up stool or changing wound dressings, is very important. The role of transmission directly from the environment to patients is controversial and requires further investigation. Strategies to eliminate CRE transmission in healthcare settings focus primarily on recognizing cases, placing colonized or infected patients on contact precautions, and using medical devices and antimicrobials wisely.
Discontinuing contact precautions: There is currently not enough information for CDC to make a general recommendation on when isolation can be discontinued for patients colonized or infected with CRE. Of note, in investigations in which CDC has participated, it is clear that patients can be colonized for long periods of time (e.g., months). In addition, if discontinuing contact precautions based on the results of surveillance cultures, it is probably best not to base this decision on a single negative culture as previous experience suggests that patients can be intermittently positive on serial surveillance cultures.
Source: Centers for Disease Control & Prevention. For more information see the CDCinfection control toolkit on CRE at: http://1.usa.gov/1as2SZB