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Carbepenem Resistant Organism Prevention
Klebsiella pneumoniae and other
gram-negative bacilli have been increasing in clinical importance since they
have begun to demonstrate carbapenem resistance over the past decade. These
organisms, known as carbapenem-resistant Enterobacteriaceae (CRE), have
been associated with high mortality rates and have the potential to spread even
more widely throughout the United States. Additionally, CRE often carry
genes that confer high levels of resistance to other antimicrobials, which limit
therapeutic options and may result in "Pan-resistant" organisms. The Centers for
Disease Control (CDC) defines CRE as Enterobacteriaceae that are
nonsusceptible to doripenem, meropenem, or imipenem AND resistant to
third-generation cephalosporins, including ceftriaxone, cefotaxime, and
ceftazidime.
CRE
organisms employ mechanisms that result in the production of carbapenemases. A
carbapenemase is a beta-lactamase enzyme that confers resistance to carbapenem
antibiotics and extended spectrum cephalosporins. In the U.S., CRE isolates most
commonly produce Klebsiella pneumoniae carbapenemase (KPC). Although the
name suggests this mechanism is only associated with Klebsiella pneumoniae,
it has also been demonstrated in several other pathogens such as Klebsiella
oxytoca, Citrobacter freundii, Enterobactoer spp., Escherichia coli,
Salmonella spp., Serratia spp., and Pseudomonas aeruginosa.
The transmission
of CRE in healthcare facilities can be a great challenge to infection control
programs. In addition
to CRE, Carbapenem Resistant Acinetobacter baumanii (CRAB) is also of
concern and poses a similar challenge from and infection control standpoint.
While the
prevalence of CRE and CRAB is unknown in Florida the FDOH Investigations Unit
has been contacted to assist several facilities throughout the state with
outbreaks over the past few years. In order to further assist facilities with
methods to detect CRE and CRAB within their facilities, determine its
prevalence, and prevent additional transmissions from occurring, there is a list
of strategies and resources below:
Strategies for
preventing transmission of CRE/CRAB
Core
Strategies
1.
Hand hygiene
2.
Contact Precautions
Acute care
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Place CRE/CRAB colonized or
infected patients on Contact Precautions (CP)
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Preemptive CP might be used
for patients transferred from high-risk settings
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Educate healthcare personnel
about CP
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Monitor CP adherence and
provide feedback
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No recommendation can be
made for discontinuation of CP
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Develop lab protocols for
notifying clinicians and IP about potential CRE/CRAB
Long-term care
3.
Patient and staff cohorting
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When available cohort CRE/CRAB
colonized or infected patients and the staff that care for them even if
patients are housed in single rooms
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If the number of single
patient rooms is limited, reserve these rooms for patients with highest risk
for transmission (e.g., incontinence)
4.
Minimize use of invasive
devices
5.
Promote antimicrobial
stewardship
6.
Screening
Supplemental Strategies
1.
Conduct active surveillance
testing
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Screen high-risk patients at
admission or at admission and periodically during their facility stay for CRE/CRAB.
Preemptive CP can be used while results of admission surveillance testing are
pending
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Consider screening patients
transferred from facilities known to have CRE/CRAB at admission
2.
Chlorhexidine bathing
Resources
2012 CRE Toolkit - Guidance for Control of
Carbapenem-resistant Enterobacteriaceae
Centers for
Disease Control and Prevention
Guide to the Elimination of Multidrug-resistant Acinetobacter baumannii
Transmission in Healthcare Settings, 2010
Association
for Professionals in Infection Control
Guidelines for Prevention and
Control of Infections Due to Antibiotic-Resistant Organisms, 2010
Florida
Department of Health Bureau of Epidemiology
Guidance for Control of
Infections with Carbapenem-Resistant or Carbapenemase-Producing
Enterobacteriaceae in Acute Care Facilities,
March 20, 2009 /
58(10);256-260
Centers for
Disease Control and Prevention, Morbidity and Mortality Weekly Report
Laboratory Testing Guidance from CDC
CDC
Clinician Outreach and Communication Activity: Carbapenem-Resistant
Enterobacteriaceae: Detection and Control
(text
only version)
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