2012 CRE Toolkit - Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)
Part 2: Regional CRE Prevention
Inter-facility Transmission of CRE
Patients colonized or infected with CRE may seek medical care in more than one hospital and serve as a reservoir that can facilitate the spread of CRE from one facility to another. With the pressure to reduce length of stay in acute care hospitals, patients who require complex medical treatment are often transferred to longterm care facilities (e.g., long-term acute care hospitals and skilled nursing homes) to complete their treatment. These patients frequently require readmission either to the same or different hospitals. This extensive inter-facility sharing of patients across the continuum of care has the potential to facilitate widespread regional transmission of CRE.
Regional Approach to CRE Control
To prevent the emergence and further spread of CRE, a coordinated regional control effort among healthcare facilities is recommended. The implementation of such an approach was successful in controlling vancomycin-resistant enterococci in the Siouxland region of the United States and for reducing CRE incidence at the national level in Israel. Given the ability of state and local health departments to interface with different types of facilities, public health is in a unique position to coordinate the local and regional response to MDROs, like CRE, by providing situational awareness within their jurisdiction and facilitating the implementation of appropriate control measures.
The optimal public health response will vary depending on the prevalence of CRE within a given jurisdiction. Based on an initial evaluation of the prevalence or incidence of CRE, prevention strategies can be tailored for geographical regions according to the following classifications: regions without CRE, regions with few CRE colonized- or infected-patients, and regions where CRE are common. (Although there is no standard definition for the latter two categories, some criteria that can be considered to determine a region’s classification are provided below.) In regions where there are no or few CRE colonized- or infected-patients, there may be a critical opportunity to prevent further emergence of CRE by taking an aggressive approach early in the process. For regions where CRE have already become common, certain general prevention measures may need to be applied more broadly as outlined in the respective section. However, because of the challenges associated with high CRE prevalence, it is recommended that further tailoring of supplemental measures be determined in consultation with CDC and in accordance with the 2006 CDC HICPAC “Guidelines for Management of Multidrug-Resistant Organisms in Healthcare Settings [PDF - 234 KB]”
For this document, a region could represent part of a state, a whole state, or even multiple states. In some regions, patients may be shared between facilities located in different jurisdictions and/or states. Ideally for MDRO control, state health departments would take the lead and coordinate with local health departments. However, depending on the region targeted, prevention strategies may also require coordination between states.
Health departments should understand the prevalence or incidence of CRE in their jurisdiction by performing some form of regional surveillance for these organisms. As described above, the interim CDC surveillance definition for CRE is Enterobacteriaceae that are nonsusceptible to one of the carbapenems and resistant to all of the third-generation cephalosporins that were tested. At a minimum, initial surveillance efforts should focus on key organisms (i.e., K. pneumoniae, E. coli, and Enterobacter spp. that meet the CRE definition).
Options for performing surveillance include making CRE a laboratory-reportable event or surveying Infection Preventionists and/or laboratory directors of healthcare facilities by telephone or email (e.g., using online survey). An example of a survey for Infection Preventionists in acute care and long-term acute care hospitals can be found in Appendix C; this survey could also be modified for use in other long-term care facilities.
It is recommended that CRE surveys conducted by health departments collect, at a minimum, the following facility-level data:
- Facility demographics including location and facility name if possible
- Overall frequency of CRE detection (e.g., daily, weekly, monthly, etc.)
- Frequency of CRE cases by timing of detection (e.g., within 48 hours or greater than 48 hours of admission)
- If surveying Infection Preventionists, determine whether recommended surveillance and infection prevention measures are being implemented, as outlined in Part 1
Email reminders or phone calls to nonresponders are encouraged to facilitate survey completion in a timely fashion (e.g., 1-2 weeks) and increase response rates. Based on survey/surveillance results, prevention strategies can be tailored accordingly as outlined below and in the algorithms provided in appendix D.