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2012 CRE Toolkit - Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)

Part 2: Regional CRE Prevention

Regional Prevention Strategies


Regions with No CRE Identified

Regional Surveillance and Feedback of Results

In regions that have no identified CRE colonized- or infected-patients, it is recommended that health departments take an aggressive approach to future CRE detection, such as making CRE a reportable event (e.g., laboratory reportable) to ensure that CRE are recognized when they occur.

If CRE reporting is not feasible, health departments should periodically survey healthcare facilities for the presence of CRE and provide feedback to increase awareness. The frequency of surveillance may depend on the prevalence of CRE in neighboring areas or jurisdictions. For example, in an area where nearby locations have known CRE colonized- or infected patients, quarterly or even monthly surveillance may be reasonable. To maintain an understanding of CRE prevalence in surrounding regions, neighboring health departments should consider establishing a mechanism for communicating updates with one another about the level of CRE activity within their respective jurisdictions.

Education of Healthcare Facilities

Health departments should also increase awareness among healthcare facilities about the public health importance of CRE, recommended prevention measures, and the importance of timely recognition of any CRE colonized- or infected-patients. This could include targeted education of Infection Preventionists and other healthcare personnel and could take place at conferences, training sessions, or through webinars or newsletters.


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Regions with Few CRE Identified

The prevention strategies described in this section apply to regions where the majority of healthcare facilities do not regularly have patients with CRE admitted. This would include regions where several facilities may have identified CRE colonized- or infected-patients on an infrequent basis (e.g., monthly basis or greater), as well as regions where some facilities may have several CRE colonized- or infected-patients but are surrounded by facilities with only a few or none. In these situations, health departments should still take an aggressive approach to contain CRE. This may require working more closely with specific healthcare facilities and targeting prevention efforts to certain parts of the region. Regions with few CRE are also most in need of increased situational awareness across all facilities regarding which facilities are being most impacted by CRE.

Regional Surveillance and Feedback of Results: Targeted Prevention

Health departments should consider making CRE a reportable event (e.g., laboratory reportable) to track CRE rates within their jurisdiction for the purposes of identifying new cases and assessing the efficacy of infection prevention measures. If this is not feasible, health departments should still continue to periodically survey acute and long-term care facilities for the presence of CRE.

CRE surveillance results should be shared with facilities (e.g., via newsletters, emails, or presentations at regional conferences), including facility administrators, in order to provide awareness of the current regional situation with respect to CRE; knowing which facilities have CRE colonized- or infected-patients may be one of the most important benefits of a coordinated regional approach to CRE control, allowing nearby facilities to take appropriate action. For example, patients admitted from facilities that have CRE could be placed preemptively on Contact Precautions pending surveillance culture results. Even if facility identifiers cannot be revealed, health departments can provide feedback of results stratified by facility type or by geographical distribution. Knowing which parts of the region have CRE can allow nearby facilities to intensify CRE prevention efforts (e.g., using supplemental measures) in consultation with the health department.

Implementation of Prevention Measures

In all facilities, health departments should ensure that core prevention measures (e.g., hand hygiene, Contact Precautions, patient and staff cohorting) are being implemented accordingly. Particularly in facilities that have CRE, it is recommended that health departments work closely with the infection prevention personnel to review and improve facility adherence to recommended practices. This may involve ongoing communication with infection prevention personnel, conducting site visits where feasible, providing in-service training, and engaging the facility directors and/or administrators in discussions about the importance of CRE prevention.

In facilities without CRE, health departments should take steps to ensure that a plan is in place in the event that a CRE colonized- or infected-patient is identified. Additionally, health departments should work closely with individual facilities that have not identified CRE to determine appropriate supplemental interventions. These measures may include targeting active surveillance testing and preemptive Contact Precautions to patients admitted from facilities with ongoing transmission of CRE (e.g., CRE detection on at least a weekly basis or in a CRE outbreak situation). If facility identifiers cannot be disclosed, targeted use of active surveillance testing and preemptive Contact Precautions can be guided by the local epidemiology of CRE. Specifically, in facilities without CRE but located in areas where CRE are present, active surveillance testing and preemptive Contact Precautions could be applied to the following patients: (a) those admitted from long-term care facilities (e.g., longterm acute care hospitals), where there may be a large reservoir of CRE colonized- or infected-patients as a result of inter-facility patient sharing and longer length of stay and/or (b) those with potential risk factors for CRE (e.g., patients with open wounds, presence of indwelling devices, and/or high antimicrobial usage).

In facilities with known CRE, health departments should promote implementation of surveillance measures to identify additional cases in order to prevent further intra-facility CRE transmission. These interventions may include screening patients with epidemiologic links to previously unrecognized cases and conducting periodic point prevalence surveys in high-risk settings (e.g., ICUs). Health departments should also promote inter-facility communication as described in the following section. As needed, health departments should consult with CDC and/or regional experts for additional guidance.

Inter-facility Communication

To reduce inter-facility transmission of all MDROs, all facilities should be encouraged to routinely complete inter-facility transfer forms whenever a patient is transferred to another facility; this becomes especially important when a patient with known CRE colonization or infection is to be transferred to another facility. The form should indicate whether the patient has ever been colonized and/or infected with CRE and other MDROs (if available, the dates and results of any relevant clinical and/or surveillance cultures should be provided) and whether the patient has any open wounds and/or indwelling devices. In addition, if the patient is currently being given antimicrobials, information should be included describing why the patient is receiving them and how much longer treatment is required. An example of an inter-facility transfer form [PDF - 176 KB] developed by CDC is available for facilities to use ( [PDF - 176 KB])

Education of Healthcare Facilities

Education for healthcare facility staff about CRE and recommended surveillance and prevention measures should continue to be provided as described above. This might be especially important for facilities that have not detected CRE in order to increase their vigilance.

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Regions Where CRE are Common

In general, CRE are considered common in regions where the majority of healthcare facilities have identified cases, and these facilities regularly have CRE colonizedor infected-patients admitted (e.g., CRE detected at least weekly).

Whereas a targeted approach to prevention may be successful in regions with few CRE cases, limited experiences indicate that a broad, public health approach is required when CRE are common. The national implementation of a centrally coordinated intervention in Israel succeeded in containing CRE. Their success was attributed in part to the creation of a task force dedicated to ensuring that all hospitals complied with national CRE guidelines. Based on Israel’s experience and the 2006 CDC HICPAC “Guidelines for Management of Multidrug-Resistant Organisms in Healthcare Settings [PDF - 234 KB]”, the following prevention measures are recommended for regions where CRE are common:

Dedicated Personnel

To effectively coordinate infection prevention across the region, health departments should have dedicated personnel assigned to this task. Ideally, these personnel should have an adequate understanding of CRE/MDRO prevention practices. As needed, a health department–led advisory panel consisting of experienced professionals in infection prevention and clinical microbiology can be established to provide additional technical support to facilities.

Engagement of Healthcare Facilities

As an initial step to engaging all facilities in the region, health departments should first communicate to appropriate personnel the CRE prevalence within the region and the importance of a regional approach to prevention. This may involve discussions with the facility directors and/or administrators in addition to the infection prevention personnel. The purpose of these discussions is to convey the urgency of the situation and to obtain facility leadership support to prioritize CRE prevention.

Reinforcement of Core Prevention Measures

Health departments should review current infection control policies and practices related to CRE at all acute and long-term care facilities within the region. At a minimum, all facilities should be implementing the core measures for CRE prevention (e.g., hand hygiene, Contact Precautions, patient and staff cohorting). To reinforce best practices, targeted education and in-service training may need to be provided to individual facilities.

Implementation of Supplemental Measures

Additional measures to be implemented by facilities should be determined in close consultation with the health department and in accordance with the interventions summarized in Part 1 of this document and the Tier 2 recommendations of the 2006 CDC HICPAC Guidelines for Management of Multidrug-resistant Organisms in Healthcare Settings [PDF - 234 KB]. These interventions may include performing active surveillance testing and/or chlorhexidine bathing.

Assessing Facility Compliance to Prevention Measures

Health departments should periodically assess for facility compliance to recommended practices (e.g., on a monthly basis). This may be based on reporting by facility Infection Preventionists or assessed through site visits to individual facilities if feasible. Depending on compliance rates, additional educational outreach, such as in-service trainings and webinars, may need to be provided to individual facilities. To increase staff adherence, performance feedback should be shared with facility directors and/or administrators. Health departments can also consider providing feedback of aggregate compliance data stratified by facility type and/or by geographical distribution, so that individual facilities can compare their performance with others.

Inter-facility Communication

As described previously, an inter-facility transfer form [PDF - 176 KB] should be completed whenever a patient is being transferred to another facility. This should indicate the CRE status of the patient and the presence of open wounds and indwelling devices and antimicrobial usage.

Regional Surveillance and Feedback of Results

Health departments should continue to perform periodic regional surveillance to assess efficacy of infection prevention measures and to feedback results to facilities. Although it may not be practical to make every CRE case reportable in a region where CRE are common, certain events to consider making reportable could be an increase in CRE rate above baseline or CRE cases with unique features (e.g., all fatalities or healthy patients with fatal outcome).

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