Carbapenemase Producing Enterobacteriaceae CPE Policy

CARBAPENEMASE-PRODUCING ENTEROBACTERIACEAE (CPE)
POLICY
Version 1.0
Name of responsible (ratifying)
Infection Prevention Management Committee
committee
Date ratified 27 April 2016
Director of Infection & Patient Safety,
Document Manager (job title)
Infection Control Doctor
Date issued 12 July 2016
Review date 11 July 2018
Electronic location Infection Prevention and Control Policies
Trust Policies:
Hand Hygiene policy
Related Procedural Documents Isolation Policy
Standard Precautions policy
Decontamination policy
CPE, Carbapenemase-producing
Key Words (to aid with searching)
Enterobacteriaceae
Version Tracking
Version Date Ratified Brief Summary of Changes Author
1.0 27.04.2016 New document Microbiology
Carbapenemase-producing Enterobacteriaceae (CPE) policy

Version: 1
Issue Date: 12 July 2016
Review Date: 11 July 2018 (unless requirements change) Page 1 of 25
CONTENTS
QUICK REFERENCE GUIDE..................................................................................................3
1. INTRODUCTION.................................................................................................................5
2. PURPOSE........................................................................................................................ 5
3. SCOPE............................................................................................................................. 5
4. DEFINITIONS................................................................................................................... 5
5. DUTIES AND RESPONSIBILITIES..................................................................................6
6. PROCESS........................................................................................................................ 7
7. TRAINING REQUIREMENTS.........................................................................................11
8. REFERENCES AND ASSOCIATED DOCUMENTATION..............................................11
9. EQUALITY IMPACT STATEMENT.................................................................................12
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS............................13
APPENDIX A......................................................................................................................... 14
APPENDIX B......................................................................................................................... 16
APPENDIX C........................................................................................................................ 18
APPENDIX D........................................................................................................................ 20
APPENDIX F......................................................................................................................... 21
APPENDIX G........................................................................................................................ 23

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QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust
procedural documents. For quick reference the guide below is a summary of actions
required. This does not negate the need for the document author and others involved in the
process to be aware of and follow the detail of this policy.
1. Please risk-assess every patient on admission, re-admission and transfer to PHT for
Carbapenemase-producing Enterobacteriaceae status (CPE).
2. A suspected case of CPE colonisation or infection is:

(i) Any patient transferred directly from a healthcare facility abroad, and/or;
(ii) Any patient who has been an inpatient in a hospital abroad within the last 12 months,
and/or;
(iii) Any patient who has been an inpatient in a UK hospital (except Portsmouth Hospitals
NHS Trust) within the last 12 months, and/or;
(iv) Any patient previously colonised or infected with CPE, and/or;
(v) Any close contact of a person who currently is or previously has been colonised or
infected with a CPE, and/or;
(vi) Any close contact of a person who currently is or previously has been colonised or
infected with a CPE, and/or;
(vii) Renal Haemodialysis patients: Any patient who has undergone dialysis abroad or at
another UK hospital should be routinely screened on their return. They must have 3
screens taken on consecutive dialysis sessions.
3. In a patient with suspected CPE colonisation or infection, please take the following
actions:
(i) Immediate isolation in a side-room with en-suite facilities. Strict standard precautions
to prevent possible spread (see 6.2). Please contact the infection prevention and
control team if insufficient side-rooms are available.
(ii) Take rectal swabs for CPE screening on three consecutive days (day 0, day 1, day 2;
see 5.3), except in Paediatric and Haematology-Oncology patients. In Paediatric and
Haematology-Oncology patients, please obtain three stool samples for CPE
screening. Patients from high prevalence countries/regions (see appendix D), please
also send CPE screening swabs from wounds and device-related sites (see 5.3.1).
(iii) Notify the Infection Prevention team promptly.
(iv) Explain your assessment to the patient and provide a patient information leaflet
(appendix A).
(v) Inform other members of the team caring for the patient.
(vi) Assess the need for appropriate antibiotic treatment if an infection is suspected
(discuss with a medical microbiologist).
(vii) Document the infection status (whether suspected or confirmed CPE) clearly in the
patient’s records and communicate clearly to the receiving healthcare provider if the
patient is transferred.
4. Any patient previously colonised or infected with CPE:

(i) Patient must remain isolated throughout hospital stay, irrespective of current
screening results.
(ii) Manage as for confirmed case of CPE (see appendix G).

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Flowchart for the detection, management and control of Carbapenemase-
producing Enterobacteriaceae
Risk-assess every patient on; admission, re-admission and transfer to PHT for
Carbapenemase-Producing Enterobacteriaceae status (CPE).
Suspected case of CPE colonisation or infection

Any patient transferred directly from a healthcare facility abroad
Any patient who has been an inpatient in a hospital abroad within the last 12 months (this includes
emergency and elective admissions)
Any patient who has been an inpatient in a UK hospital (other than PHT) within the last 12
months)
Any patient previously colonised or infected with CPE or close contact
Renal haemodialysis patients: Any patient who has undergone dialysis abroad or at another UK
hospital (both elective ‘holiday dialysis’ and emergency dialysis)
Actions if a suspected case of CPE colonisation or infection No risk

(See Appendix F) factor for
Immediate isolation in a side-room with en-suite facilities CPE
Strict standard precautions (see 6.2). Use a long-sleeved gown for care Normal
activities where an apron does not fully protect the uniform admission
Take rectal swabs for CPE screening on three consecutive days (i.e.day 0, day process,
1 and day 2; see 5.3), except in Paediatric and Haematology-oncology including
patients. In paediatric and haematology-oncology patients, please obtain MRSA
three stool samples for CPE screening screening
Patients from high prevalence countries/ regions (see appendix D)
please also send CPE screening swabs from wounds and device-related sites
4. Notify the Infection Prevention team
5. Provide the patient with an information leaflet (appendix A)
6. Inform other members of the team looking after the patient
7. Discuss appropriate antibiotic treatment with a microbiologist
8. Document the infection status in the patient’s records and communicate
results when patient is transferred or discharged
9. Extra care taken to clean the environment after the patient had an
investigation and before another patient is seen
10. Contact Infection Prevention and microbiology if surgical intervention is
required
Positive Result
Initial screening samples negative Laboratory-confirmed CPE

Patient to remain isolated until three sets Positive (See Appendix G)
of screening sample are negative (taken Result Patient to remain isolated
on day 0, day 1, day 2). throughout hospital stay.
All three sets of screening swabs Previously ‘known’ CPE positive,

negative and NOT previously irrespective of screening results
‘known’ CPE positive Patient must remain isolated
Can be removed from isolation, throughout hospital stay, irrespective of
following risk assessment by current screening results
Infection Prevention

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1. INTRODUCTION
Enterobacteriaceae, such as E.coli, Klebsiella spp. and Enterobacter spp., are bacteria that
usually live harmlessly in the human gastrointestinal tract. However, these organisms can also
cause urinary tract, intra-abdominal and bloodstream infections (bacteraemias). Occasionally
they cause hospital-acquired pneumonias, line infections or other types of infections. Some
strains of Enterobacteriaceae produce carbapenemases, which are enzymes that break down
carbapenem antibiotics (meropenem, ertapenem, imipenem, doripenem). Such carbapenem-
producing bacteria are often also resistant to most other antibiotics and hence infections are
extremely difficult to treat and cause high mortality. The emergence of Carbapenem-
producing Enterobacteriaceae (CPE) is a major public health concern and it is essential that
person-to-person spread in the healthcare setting is prevented or minimised. Whilst multi-drug
resistant and Carbapenem-producing Enterobacteriaceae have become endemic in several
countries (see appendix D), increasing numbers of these strains have also been reported in
the UK.
2. PURPOSE
This policy defines the actions taken by Portsmouth Hospitals NHS Trust to reduce the risk
of transmission and hence limit the risk of colonisation or infection with Carbapenem-
producing Enterobacteriaceae.
It recommends a risk assessment at every patient admission, readmission or transfer. It

describes the actions that need to be taken if a suspected case of Carbapenemase-
poducing Enterobacteriaceae (CPE) is identified, as well as providing advice on screening
and isolation of patients with either suspected or confirmed Carbapenemase-producing
Enterobacteriaceae (CPE).
This policy should be read in conjunction with:

 Standard Precautions policy
 Hand Hygiene policy
 Isolation policy
3. SCOPE
This policy should be followed by all Portsmouth Hospitals NHS Trust staff, including
agency, bank and locum staff. It should be applied to all patients admitted to the Trust,
including children as well as patients dialysed in the renal dialysis unit.
4. DEFINITIONS
Carbapenemases: Some bacteria produce Carbapenemase enzymes (such as KPC, OXA-

48, NDM and VIM), which cause destruction of the carbapenem antibiotics. This results in
resistance to the carbapenem antibiotics (meropenem, ertapenem, doripenem, imipenem) as
well as many other broad-spectrum antibiotics.
Carrier: A person who is colonised with Carbapenemase-producing Enterobacteriaceae

(CPE). These organisms can live harmlessly in the human gastrointestinal tract, without
clinical manifestations of infection. A carrier can transmit the organism to another person or
may subsequently develop an infection.


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Close contact: A person living in the same house, sharing the same sleeping space (room
or hospital bay), or a sexual partner.
Colonisation: The presence of Carbapenemase-producing Enterobacteriaceae (CPE) living

harmlessly on the skin or within the human gastrointestinal tract and causing no signs or
symptoms of infection. A carrier is colonised with Carbapenemase-producing

CPE: Carbapenemase-producing Enterobacteriaceae (CPE) is the name given to the strains
Enterobacteriaceae which produce a Carbapenemase enzyme.
Enterobacteriaceae: This is a large family of bacteria (including; Escherichia coli, Klebsiella

spp. and Enterobacter spp.) that usually live harmlessly in the human gastrointestinal tract.
However, these organisms can cause opportunistic urinary tract infections, intra-abdominal
infections, bloodstream infections (bacteraemias) and hospital-acquired pneumonias.
Infection: Carbapenemase-producing Enterobacteriaceae (CPE) can cause serious

infections, including urinary tract infections, intra-abdominal infections, blood stream
infections (bacteraemias) and hospital-acquired pneumonias. Patients with infections caused
by Carbapenemase-producing Enterobacteriaceae (CPE) require treatment. These
infections are very challenging to treat and should be discussed with a medical
microbiologist.
Modes of transmission: Carbapenemase-producing Enterobacteriaceae (CPE) is spread

person to person by faecal contamination of the hands or transfer from an environmental
source or contaminated equipment.

Rectal swab: A rectal swab is a specimen taken by gently inserting a swab inside the
rectum 3-4cms (1 – 1.5 inch) beyond the anal sphincter, rotating gently and removing.
Normal saline can be used to moisten the swab prior to insertion. After a rectal swab is
taken, it should have visible faecal material on it. The swab should be sent to the
microbiology laboratory in the swab transport tube with a request for “CPE screening”.
5. DUTIES AND RESPONSIBILITIES
Infection Prevention Team:

 Give specialist advice with regards to the isolation, screening and contact tracing of
patients with suspected or confirmed infection or colonisation with Carbapenemase-
producing Enterobacteriaceae (CPE)
 As part of the outbreak control team, advise on the screening and isolation in the
event of an outbreak, suspected outbreak or cluster of Carbapenemase-producing
Enterobacteriaceae (CPE)
 Review and update the Carbapenemase-producing Enterobacteriaceae policy
 Develop a Carbapenemase-producing Enterobacteriaceae Management Plan with
the input from the microbiology team
 Include Carbapenemase-producing Enterobacteriaceae in all induction and update
training for clinical staff. Provide training to medical and nursing staff, enabling them
to recognize patients who meet the criteria for a recent laboratory confirmed case or
suspected case of Carbapenemase-producing Enterobacteriaceae (CPE)
 Conduct regular audits and provide feedback with regards to the adherence to this
policy

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Microbiologists:
 Review laboratory policies and SOPs on screening and detection of
Carbapenemase-producing Enterobacteriaceae (CPE)
 Together with the Infection Prevention team, develop a Carbapenemase-producing
Enterobacteriaceae Management Plan
 Alert Infection Prevention Team and clinical teams of patients with presumptive or
confirmed Carbapenemase-producing Enterobacteriaceae isolated from clinical
samples or screens
 Advise on the antimicrobial management of patients infected or colonised with
Carbapenemase-producing Enterobacteriaceae
Patient Flow / Duty Hospital Managers:

 Prioritise placement of patients with suspected or confirmed Carbapenemase-
producing Enterobacteriaceae (CPE) into appropriate isolation rooms
 Ensure an electronic system is in place for flagging the patient’s Carbapenemase-
producing Enterobacteriaceae status
Matrons / Ward Managers:

 Ensure effective communication of patients risk and carriage status
Medical Staff:
 Include a risk assessment for Carbapenemase-producing Enterobacteriaceae (CPE)
in every admission and transfer documentation
 Follow advice of the Infection Prevention Team and microbiologists relating to
patients infected or colonised with Carbapenemase-producing Enterobacteriaceae
(CPE)
 Ensure compliance with Infection Prevention and antimicrobial prescribing policies
with emphasis on limiting use of carbapenem antibiotics
 Ensure prudent antimicrobial prescribing and stringent use/removal of indwelling
devices
All Healthcare Staff:

 Must be familiar with and adhere to the relevant infection prevention policies to
reduce the risk transmission of Carbapenemase-producing Enterobacteriaceae
(CPE)
6. PROCESS
6.1 Risk assessment and screening for Carbapenemase-producing

Every patient admitted, readmitted or transferred from another healthcare facility requires a
risk assessment during the admission procedure. Early identification and screening of
patients at risk of CPE is essential. It is the responsibility of the admitting clinician and
nursing staff to assess every patient with regards to the risk of colonisation or infection with
CPE.
A suspected case of Carbapenemase-producing Enterobacteriaceae (CPE) is:

(i) Any patient transferred directly from a healthcare facility abroad, and/or;
(ii) Any patient who has been an inpatient in a hospital abroad within the last 12 months
(this includes emergency and elective admissions), and/or;
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(iii) Any patient who has been an inpatient in a UK hospital (other than Portsmouth
Hospitals NHS Trust) (see appendix D), and/or;
(iv) Any patient previously colonised or infected with Carbapenemase-producing
Enterobacteriaceae (CPE), and/or;
(v) Any close contact of a person who currently is or previously has been colonised or
infected with Carbapenemase-producing Enterobacteriaceae (CPE). A close contact
is a person living in the same house, sharing the same sleeping space or a sexual
partner of a person with Carbapenemase-producing Enterobacteriaceae (CPE),
and/or; CONTINUE FROM HERE!!!
(vi) Renal Haemodialysis patients: Any patient who has undergone dialysis abroad (both
elective ‘holiday dialysis’ and emergency dialysis) or at another UK hospital should
be routinely screened on their return. They must have 3 screens taken on
consecutive dialysis sessions. If the patient is a recent laboratory confirmed case of
Carbapenemase-producing Enterobacteriaceae infection or colonisation during this
admission or confirmed from a transferring hospital within the UK, then isolate the
patient immediately and treat as a confirmed case (please see 5.4 and appendix G).
If a patient is identified as a suspected case of Carbapenemase-producing
Enterobacteriaceae (CPE), the following actions need to be taken (see appendix F);
(vii) Immediate isolation in a side-room with en-suite facilities; strict standard precautions
to prevent possible spread (see 5.2);
(viii) Take screening swabs for Carbapenemase-producing Enterobacteriaceae (CPE)
(see 5.3);
(ix) Please notify the Infection Prevention team promptly;
(x) Provide information and explain your assessment of possible colonisation / infection
with Carbapenemase-producing Enterobacteriaceae (CPE) to the patient. Give the
patient a patient information leaflet (appendix A). Please advise the patient to
practice good hand hygiene;
(xi) Inform other members of the team caring for the patient;
(xii) Assess the need for appropriate antibiotic treatment if an infection is suspected
(discuss with a medical microbiologist);
(xiii) Document the infection status (whether suspected or confirmed CPE) clearly in the
patient’s records. Ensure that the diagnosis is clearly communicated if the patient is
transferred to another healthcare provider;
(xiv)Investigations should be performed as clinically required with extra care taken to
cleaning the environment after the patient has left and before another patient is seen
– please discuss with the infection prevention team;
(xv) Please contact Infection prevention and microbiology if surgical intervention is
required.
6.2 Early isolation of suspected or laboratory-confirmed cases of

6.2.1 Isolation: Immediately place the patient into a single room with en suite facilities. All
suspected patients should be isolated until three sets of screening samples taken on
consecutive days (i.e. day 0, day 1 and day 2) are negative.
6.2.2 Strict standard precautions: Apply strict standard precautions, including good hand
hygiene and appropriate use of personal protective equipment (PPE). Staff must wear
gloves and a single use disposable apron for all contact with the patient and his/her
environment. Use a long-sleeved disposable gown for care activities where an apron does
not fully protect the uniform e.g. when assisting movement for a dependent patient. A mask
is not required.

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6.2.3 Hand hygiene: Staff must strictly adhere to the Hand hygiene policy. In addition,
please ensure that the patient as well as any visitors observes good hand hygiene.
6.2.4 Non-essential staff: Non-essential staff (e.g. Medical students) should be excluded
from contact with a patient confirmed or suspected of having Carbapenemase-producing
6.2.5 Equipment: Single use / single patient use equipment is preferable. Equipment should
be designated for the sole use of the patient in isolation. This includes a blood pressure
monitor, tympanic thermometer, dressing trolley and commode. Once patient is discharged
the Infection Prevention team should be informed so that the room and all equipment can be
safely and adequately decontaminated.
6.2.6 Medical devices and equipment: Scrupulous infection control practices are extremely
important when caring for devices (including peripheral and central lines, urinary catheters)
or equipment (such as ventilators, renal dialysis or enteral feeding equipment, colostomy or
ileostomy or any re-usable diagnostic equipment).
6.2.7 Duration of isolation: A patient with suspected Carbapenemase-producing

Enterobacteriaceae (CPE) must remain isolated until all three sets of screening samples are
negative and the Infection Prevention team has made an assessment whether there are any
other reasons for the patient to remain isolated.
A patient with laboratory-confirmed CPE must remain isolated throughout his or her hospital
stay. A patient with previously laboratory-confirmed CPE at another hospital or during a
previous hospital admission must remain isolated throughout his or her hospital stay,
irrespective of the current screening results.
Renal dialysis patients, who are either previously or newly diagnosed with laboratory-
confirmed Carbapenemase-producing Enterobacteriaceae (CPE), should remain isolated
whilst receiving dialysis at the dialysis unit.
6.2.8 Diagnostic tests and procedures should be planned for the end of the day’s list, if the
patient has confirmed Carbapenemase-producing Enterobacteriaceae (CPE). The procedure
room and equipment must be appropriately decontaminated after use.
6.2.9 Terminal cleaning and hydrogen peroxide decontamination: Once patient is

discharged, the Infection Prevention team should be informed and the room must have
terminal cleaning, followed by hydrogen peroxide decontamination.
6.3 Screening of suspected cases and contacts of carbapenemase-producing

6.3.1 If a patient meets the criteria for a suspected case of Carbapenemase-producing

Enterobacteriaceae (CPE) infection or colonisation, the following samples should be
taken:
i) After providing appropriate information to the patient and obtaining verbal consent, please
take a rectal swab, except in paediatric and haematology-oncology patients. The rectal swab
must have faecal material on it (see ‘definitions’) and be stated on the form clearly as
‘Carbapenemase-producing Enterobacteriaceae (CPE) screening’. A rectal swab is the most
important screening sample. Alternatively, a stool sample can be sent, provided it can be
obtained within 24 hours. In paediatric and haematology-oncology patients, please obtain
three stool samples for CPE screening;
AND
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If patient is known to have been hospitalised in the last 12 months in a country with reported
high prevalence (or area known to have a Carbapenemase-producing Enterobacteriaceae
problem, see appendix D) include samples from any wounds and device-related sites as
follows:
ii) Wound swab – any surgical wounds, leg ulcers and breaks in skin or other lesions.
Please label these specimens on the form clearly as ‘Carbapenemase –producing
Enterobacteriaceae (CPE) screening’.
AND
iii) Swabs from manipulated sites (device-related sites) – lines, cannula, tracheostomy,
percutaneous endoscopic gastrostomy (PEG) and drain sites. Please label these specimens
on the form clearly as ‘Carbapenemase –producing Enterobacteriaceae (CPE) screening’.
Timing of screening samples

Three sets of screening samples must be taken on consecutive days i.e. day 0, day 1 and
day 2.
6.3.2 Screening of laboratory-confirmed cases of carbapenemase-producing

Patients with laboratory-confirmed infection or colonisation with Carbapenemase-producing

Enterobacteriaceae should be screened on readmission (see 5.3.1).
6.3.3 Screening of contacts
Provide a carbapenemase-producing Enterobacteriaceae (CPE) contact leaflet (appendix C)

and undertake screening for contacts of a positive case as directed by the Infection
Prevention team. The recommendations are to screen weekly for a period of four weeks
after the last case of carbapenemase-producing Enterobacteriaceae was detected. This is
generally required if a patient colonised or infected with carbapenemase-producing
Enterobacteriaceae was in an open ward or bay before the diagnosis was made.
6.3.4 Screening in the event of an outbreak, suspected outbreak or cluster of

As directed by the Incident/Outbreak Control Team and Infection Prevention team.
6.4 Management of a confirmed case of Carbapenemase-producing

Enterobacteriaceae
i) Immediate isolation in a side-room with en-suite facilities, if the patient is not already
isolated. The patient must remain isolated throughout their hospital stay or whilst
receiving dialysis at the renal dialysis unit. Strict standard precautions to prevent possible
spread (see 6.2). Use a long-sleeved disposable gown for care activities where an apron
does not fully protect the uniform;
ii) Inform the patient of the infection or carrier status with Carbapenemase-producing
Enterobacteriaceae (CPE). Give the patient a patient information leaflet (appendix B).
Please remind the patient that it is important to practice good hand hygiene;
iii) Inform all other members of the team caring for the patient, including physiotherapists if
applicable;
iv) Discuss the need for antibiotic treatment, including surgical prophylaxis with a Medical
Microbiologist. Review the clinical management and ensure strict infection control
practices when caring for medical devices;

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v) Document the confirmed Carbapenemase-producing Enterobacteriaceae (CPE) status
clearly in the patient’s records. Flag the patient notes with the result as well as the
electronic system;
vi) Instigate the Carbapenemase-producing Enterobacteriaceae Management Plan;
vii) Consider arranging an incident control team;
viii) Screen any contacts as directed by the infection control team (see 6.3.3);
ix) Ensure that the patient’s Carbapenemase-producing Enterobacteriaceae (CPE) status is
clearly communicated to the receiving hospital and ambulance team if the patient is
transferred. Also notify the GP and other community care providers when the patient is
transferred or discharged;
x) Investigations should be performed as clinically required with extra care taken to cleaning
the environment as well as decontaminating the equipment after the patient has left and
before another patient is seen;
xi) Please contact Infection prevention and microbiology if a surgical intervention is required.
6.5 Environmental Cleaning
Once the patient is discharged or transferred, the Infection Prevention team should be
informed so that the room and all equipment can be safely and adequately decontaminated.
A high standard of cleaning is necessary and should be audited. Terminal cleaning following
transfer or discharge of the patient includes scrupulous cleaning and disinfection of all
surfaces. The cleaning and disinfection of mattresses is especially important. Dynamic
mattresses require disassembly, cleaning and disinfection. Terminal cleaning must be
followed by hydrogen peroxide decontamination.
7. TRAINING REQUIREMENTS
 Specific training with regards to the carbapenemase-producing Enterobacteriaceae

policy will be provided by the Infection Prevention team during Trust induction,
mandatory training sessions as well as via Infection Prevention Link Practitioners
 Clinical and non-clinical staff will receive practical hand hygiene training on induction
and every 2 years thereafter (Infection Prevention Team)
 Clinical and non-clinical staff will receive face-to0face induction training on aspects of
infection prevention, MSSA/MRSA, Clostridium difficile and Carbapenemase-
producing Enterobacteriaceae (Infection Prevention Team)
 Update training to be delivered as part of Patient Safety & Quality Days,
departmental and drop in days, Link Advisor days and Senior Doctors Training
(Infection Prevention Team)
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Centres for Disease Control (2009) Guidance for Control of Infections with Carbapenem-
Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities, 2009
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm Accessed
23.9.2015.
European Centre for Disease Prevention and Control (2011) Risk assessment on the spread
of Carbapenemase-producing Enterobacteriaceae (CPE), ECDC, available at:
http://ecdc.europa.eu/en/publications/Pages/Publications.aspx Accessed 23.9.2015.
Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare

Associated Infection and the Health Protection Agency. Advice on Carbapenemase

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Producers: Recognition, infection control and treatment. London: Health Protection Agency;
2011, available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1294740725984
Loveday, H. Wilson, J. Pratt, R. et al (2014). EPIC 3 National Evidence-Based Guidelines for

Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of
Hospital Infection. S1 – S70.
Public Health England. (2013). Acute trust toolkit for the early detection, management and
control of Carbapenemase-producing Enterobacteriaceae. PHE, London.
Public Health England. (2014). Patient Safety Alert ‘Addressing rising trends and outbreaks
in Carbapenemase-producing Enterobacteriaceae’. NHS/PSA/Re/2014/004.
Public Health England (2014) Letter, Re: Addressing the infection risk from Carbapenemase-
producing Enterobacteriaceace and other Carbapenem-resistant organisms, PHE Gateway
number: 2013 – 499.
UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 (2013) published at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130
902_ UK_5_year_AMR_strategy.pdf
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably

practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any
grounds.
This policy has been assessed accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish.
They are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its
vision to be the best hospital, providing the best care by the best people and ensure that our
patients are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of
our Trust:
Respect and dignity

Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.

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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum Lead Tool Frequency of Report Reporting arrangements Lead(s) for acting
requirement to be of Compliance Recommendatio
monitored
Surveillance of Infection Apex, Quartery report to Policy audit report to: Infection prevention
cases of CPE prevention VitalPAC Infection prevention Infection Prevention control team
infection or and control management Management Committee
colonisation team committee
Review of new Infection Apex, Quartery report to Policy audit report to: Infection prevention
acquisitions of CPE prevention VitalPAC Infection prevention Infection Prevention control team
infection or and control management Management Committee
colonisation team committee
This document will be monitored to ensure it is effective and to assurance compliance.

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APPENDIX A
Carbapenemase-producing Enterobacteriaceae: I may be a carrier (or have an

infection) – what does this mean?
What does ‘Carbapenemase-producing Enterobacteriaceae’ mean?

Enterobacteriaceae are bacteria that usually live harmlessly in the gut of humans. This is
called ‘colonisation’ (a person is said to be a ‘carrier’). However, if the bacteria get into the
wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems
are one of the most powerful types of antibiotics. Carbapenemases are enzymes
(chemicals), made by some strains of these bacteria, which allow them to destroy
carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics.
Why does carbapenem resistance matter?

Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until
now, doctors have relied on them to successfully treat certain ‘difficult’ infections when other
antibiotics have failed to do so. Therefore, in a hospital, where there are many vulnerable
patients, spread of these resistant bacteria can cause problems.
Does carriage of Carbapenemase-producing Enterobacteriaceae need to be treated?

If a person is a carrier of Carbapenemase-producing Enterobacteriaceae (sometimes called
CPE), they do not need to be treated. As mentioned, these bacteria can live harmlessly in
the gut. However, if the bacteria have caused an infection then antibiotics will be required.
How will I know if I am at risk of being a carrier or having an infection?

Your doctor or nurse may suspect that you are a carrier if you have been in a hospital
abroad, or in a UK hospital that has had patients carrying these bacteria, or if you have been
in contact with a carrier elsewhere. If any of these reasons apply to you, screening will be
arranged for you and you will be accommodated in a single room with your own toilet
facilities at least until the results are known.
How will I be screened for Carbapenemase-producing Enterobacteriaceae?

Screening usually entails taking a rectal swab by inserting it just inside your rectum (bottom).
Alternatively, you may be asked to provide a sample of faeces. The swab/sample will be
sent to the laboratory and you will normally be informed of the result within two to three days.
If the result is negative, the doctors or nurses may wish to check that a further two samples
are negative before you can be accommodated on the main ward. These measures will not
hinder your care in any way. If all results are negative no further actions are required.
Advice for patients who have a positive result
What happens if the result is positive?

If the result is positive, ask your doctor or nurse to explain this to you in more detail. You will
continue to be accommodated in a single room whilst in hospital. If you have an infection,
you will need to have antibiotics. However, if there are no signs of infection and you are
simply ‘carrying’ the bacteria, no treatment is required.
How can the spread of Carbapenemase-producing Enterobacteriaceae be prevented?

Accommodating you in a single room (if the result is positive) helps to prevent spread of the
bacteria. Healthcare workers should wash their hands regularly. They will use gloves and
aprons when caring for you. The most important measure for you to take is to wash your

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hands well with soap and water, especially after going to the toilet. You should avoid
touching medical devices (if you have any) such as your urinary catheter tube and your
intravenous drip, particularly at the point where it is inserted into the body or skin. Visitors
will be asked to wash their hands on entering and leaving the room and may be asked to
wear an apron.
What about when I go home?

Whilst there is a chance that you may still be a carrier when you go home, quite often this
will go away with time. No special measures or treatment are required; any infection will
have been treated prior to your discharge. You should carry on as normal, maintaining good
hand hygiene. If you have any concerns you may wish to contact your GP for advice.
Before you leave hospital, ask the doctor or nurse to give you a letter or card advising that
you have had an infection or been colonised with Carbapenemase-producing
Enterobacteriaceae. This will be useful for the future and it is important that you make health
care staff aware of it. Should you or a member of your household be admitted to hospital,
you should let the hospital staff know that you are, or have been, a carrier and show them
the letter/card.
Where can I find more information?

If you would like any further information please speak to a member of your care staff, who
may also contact the Infection Prevention and Control Team for you. The Public Health
England website is another source of information:
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/CarbapenemResistance/
(Adapted from Public Health England ‘Acute trust toolkit for the early detection, management
and control of Carbapenemase-producing Enterobacteriaceae’)

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APPENDIX B
Carbapenemase-producing Enterobacteriaceae: I am colonised / have an

infection – what does this mean?


antibiotics have failed to do so. In a hospital, where there are many vulnerable patients,
spread of resistant bacteria can cause problems.
Does carriage of carbapenemase-producing Enterobacteriaceae need to be treated?

If a person is a carrier of carbapenemase-producing Enterobacteriaceae (sometimes called
CPE), they do not need to be treated. However, if the bacteria have caused an infection then
antibiotics will be required.
How did I ‘pick up’ carbapenemase-producing Enterobacteriaceae?

Do ask your doctor or nurse to explain this to you in more detail. As mentioned above,
sometimes these bacteria can be found, living harmlessly, in the gut of humans and so it can
be difficult to say when or where you picked it up. However, there is an increased chance of
picking up these bacteria if you have been a patient in a hospital abroad or in a UK hospital
that has had patients carrying the bacteria, or if you have been in contact with a carrier
elsewhere.
How will I be cared for whilst in hospital?

You will be accommodated in a single room with toilet facilities whilst in hospital. You may be
asked to provide a number of samples, depending on your length of stay, to check if you are
still carrying the bacteria. These will probably be taken on a weekly basis. The samples
might include a number of swabs from certain areas, such as where the tube for your drip (if
you have one) enters the skin, a rectal swab i.e. a sample taken by inserting a swab briefly
just inside your rectum (bottom), and / or a faecal sample. You will normally be informed of
the results within two to three days.
How can the spread of carbapenemase-producing Enterobacteriaceae be prevented?

Accommodating you in a single room helps to prevent spread of the bacteria. Healthcare
workers should wash their hands regularly. They will use gloves and aprons when caring for
you. The most important measure for you to take is to wash your hands well with soap and
water, especially after going to the toilet. You should avoid touching medical devices (if you
have any) such as your urinary catheter tube and your intravenous drip, particularly at the
point where it is inserted into the body or skin. Visitors will be asked to wash their hands on
entering and leaving the room and may be asked to wear an apron.
What about when I go home?

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Whilst there is a chance that you may still be a carrier when you go home quite often this will
go away with time. No special measures or treatment are required; any infection will have
been treated prior to your discharge. You should carry on as normal, maintaining good hand
hygiene. If you have any concerns you may wish to contact your GP for advice. Before you
leave hospital, ask the doctor or nurse to give you a letter or card advising that you have had
an infection or been / are colonised with carbapenemase-producing Enterobacteriaceae.
This will be useful for the future and it is important that you make health care staff aware of
it. Should you or a member of your household be admitted to hospital, you should let the
hospital staff know that you are, or have been a carrier and show them the letter / card.

If you would like any further information please speak to a member of your care staff, who
may also contact the Infection Prevention and Control Team for you. The Public Health
England website is another source of information:
and control of carbapenemase-producing Enterobacteriaceae’)

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APPENDIX C
Carbapenemase-producing Enterobacteriaceae – I am a contact of someone

who is a carrier or has an infection – what does this mean?


antibiotics have failed to do so. Therefore, in a hospital, where there are many vulnerable
patients, spread of resistant bacteria can cause problems.
Does carriage of Carbapenemase-producing Enterobacteriaceae need to be treated?

If a person is a carrier of Carbapenemase-producing Enterobacteriaceae (sometimes called
CPE), they do not need to be treated. As mentioned, these bacteria can live harmlessly in
the gut. However, if the bacteria have caused an infection then antibiotics will be required.
How is Carbapenemase-producing Enterobacteriaceae spread?

If a patient in hospital is carrying these bacteria it can get into the ward environment and can
also be passed on by direct contact with that particular patient. For that reason, the patient
will normally be accommodated in a single room. Effective environmental cleaning and good
hand hygiene by all, staff and patients, can reduce the risk of spread significantly.
Do I need to be screened?
Occasionally, it isn’t immediately known that a patient is carrying these bacteria and so they
may not be placed into a single room straight away. Screening will be offered if you have
shared the same bay (or ward) with a patient who has been found to be carrying
Carbapenemase-producing Enterobacteriaceae. This screening is offered as there is a slight
chance that you could have picked up the bacteria and are carrying it too.
How will I be screened for Carbapenemase-producing Enterobacteriaceae?

Screening usually entails taking a rectal swab by inserting it just inside your rectum (bottom).
Alternatively, you may be asked to provide a sample of faeces. The swab/sample will be
sent to the laboratory and you will normally be informed of the result within two to three days.
If the result is negative nothing further is required unless you are staying in hospital for some
time. In that case, you will probably be asked to provide a sample on a regular basis e.g.
once a week, as a precautionary measure.
What if the result is positive?

If the result is positive do ask your doctor or nurse to explain this to you in more detail and to
provide a leaflet relating to positive results (Card C.4).You will be given a single room until
you leave hospital. No treatment is necessary unless you have an infection when antibiotics
will be given.

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The Public Health England web site is another source of information:

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APPENDIX D
Countries and regions with reported high prevalence of healthcare-associated

Carbapenemase-producing Enterobacteriaceae
Bangladesh North Africa (all)

The Balkans Malta
China Middle East (all)
Cyprus Pakistan
Greece South East Asia
India South/Central America
Ireland Turkey
Israel Taiwan
Italy USA
Japan
This is not an exhaustive list; admission to any hospital abroad should be considered when
making a risk assessment. Lack of data from a country not included in this list may reflect
lack of reporting/detection rather than lack of a carbapenemase problem
UK regions areas where problems have been noted in some hospitals:
North West especially:

Manchester
London
IMPORTANT: Healthcare providers have a ‘duty of care’ to proactively communicate any

problems they are experiencing with Carbapenemase-producing Enterobacteriaceae, not
only with colleagues in healthcare settings which are co-terminus, but with any organisation
they deal with on the patient pathway, either routinely or sporadically
Please refer to www.hpa.org.uk for updates.


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Flowchart for the detection, management and control of Carbapenemase-
producing Enterobacteriaceae
Risk-assess every patient on; admission, re-admission and transfer to PHT for
Carbapenemase-Producing Enterobacteriaceae status (CPE).
Suspected case of CPE colonisation or infection

Any patient transferred directly from a healthcare facility abroad
Any patient who has been an inpatient in a hospital abroad within the last 12 months (this includes
emergency and elective admissions)
Any patient who has been an inpatient in a UK hospital (other than PHT) within the last 12
months)
Any patient previously colonised or infected with CPE or close contact
Renal haemodialysis patients: Any patient who has undergone dialysis abroad or at another UK
hospital (both elective ‘holiday dialysis’ and emergency dialysis)
Actions if a suspected case of CPE colonisation or infection No risk

(See Appendix F) factor for
Immediate isolation in a side-room with en-suite facilities CPE
Strict standard precautions (see 6.2). Use a long-sleeved gown for care Normal
activities where an apron does not fully protect the uniform admission
Take rectal swabs for CPE screening on three consecutive days (i.e.day 0, day process,
1 and day 2; see 5.3), except in Paediatric and Haematology-oncology including
patients. In paediatric and haematology-oncology patients, please obtain MRSA
three stool samples for CPE screening screening
Patients from high prevalence countries/ regions (see appendix D)
please also send CPE screening swabs from wounds and device-related sites
4. Notify the Infection Prevention team
5. Provide the patient with an information leaflet (appendix A)
6. Inform other members of the team looking after the patient
7. Discuss appropriate antibiotic treatment with a microbiologist
8. Document the infection status in the patient’s records and communicate
results when patient is transferred or discharged
9. Extra care taken to clean the environment after the patient had an
investigation and before another patient is seen
10. Contact Infection Prevention and microbiology if surgical intervention is
required
Positive Result
Initial screening samples negative Laboratory-confirmed CPE

Patient to remain isolated until three sets Positive (See Appendix G)
of screening sample are negative (taken Result Patient to remain isolated
on day 0, day 1, day 2). throughout hospital stay.
All three sets of screening swabs Previously ‘known’ CPE positive,

negative and NOT previously irrespective of screening results
‘known’ CPE positive Patient must remain isolated
Can be removed from isolation, throughout hospital stay, irrespective of
following risk assessment by current screening results
Infection Prevention

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APPENDIX F
Actions to be taken if a patient is identified as having a suspected infection or

colonisation with carbapenemase-producing Enterobacteriaceae (CPE)
1. Immediate isolation in a side-room with en-suite facilities. Strict standard precautions

to prevent possible spread (see 5.2);
2. Take screening swabs for Carbapenemase-producing Enterobacteriaceae (CPE) on
days 0, 1 and 2 (see 5.3);
3. Notify the Infection Prevention team promptly;
4. Provide information and explain your assessment of possible colonisation/infection
with Carbapenemase-producing Enterobacteriaceae (CPE) to the patient. Give the
patient a patient information leaflet (appendix A). Please advise the patient to
practice good hand hygiene;
5. Inform other members of the team caring for the patient. Assess the need for
appropriate antibiotic treatment if an infection is suspected (discuss with a medical
microbiologist);
6. Document the infection status (whether suspected or confirmed CPE) clearly in the
patient’s records. Ensure that the diagnosis is clearly communicated if the patient is
transferred to another healthcare provider;
7. Investigations should be performed as clinically required with extra care taken to
cleaning the environment after the patient has left and before another patient is seen;
8. Contact Infection prevention and microbiology if surgical intervention is required;
9. If all three sets of screening samples are negative, discuss with the Infection Control
team whether the patient can be removed from isolation, provided there are no other
reasons for the patient to remain isolated;
10. If one of the screens or other clinical samples are positive with Carbapenemase-
producing Enterobacteriaceae, please follow the actions for laboratory-confirmed
Carbapenemase-producing Enterobacteriaceae (CPE) (see 5.4 and appendix G).

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APPENDIX G
Actions to be taken if a patient is a confirmed case of carbapenemase-

producing Enterobacteriaceae (CPE)
1. Immediate isolation in a side-room with en-suite facilities, if the patient is not already
isolated. The patient must remain isolated throughout their hospital stay or whilst
receiving dialysis at the renal dialysis unit. Strict standard precautions to prevent
possible spread (see 5.2). Use a long-sleeved disposable gown for care activities
where an apron does not fully protect the uniform;
2. Inform the patient of the infection or carrier status with Carbapenemase-producing
Enterobacteriaceae (CPE). Give the patient a patient information leaflet (appendix B).
Please remind the patient that it is important to practice good hand hygiene;
3. Inform all other members of the team caring for the patient, including
physiotherapists if applicable;
4. Discuss the need for antibiotic treatment, including surgical prophylaxis with a
Medical Microbiologist. Review the clinical management and ensure strict infection
control practices when caring for medical devices;
5. Document the confirmed Carbapenemase-producing Enterobacteriaceae (CPE)
status clearly in the patient’s records. Flag the patient notes with the result as well as
the electronic system;
6. Instigate the Carbapenemase-producing Enterobacteriaceae Management Plan;
7. Consider arranging an incident control team;
8. Screen any contacts as directed by the infection control team (see 5.3.3);
9. Ensure that the patient’s Carbapenemase-producing Enterobacteriaceae (CPE)
status is clearly communicated to the receiving hospital and ambulance team if the
patient is transferred. Also notify the GP and other community care providers when
the patient is transferred or discharged;
10. Investigations should be performed as clinically required with extra care taken to
cleaning the environment as well as decontaminating the equipment after the patient
has left and before another patient is seen;
11. Contact Infection prevention and microbiology if a surgical intervention is required.

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Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the

appropriate committee for consideration and approval for service and policy
changes/amendments.
Stage 1 - Screening
Title of Procedural Document: CPE Policy
Date of Assessment 11/05/2016 Responsible Infection Prevention

Department
Name of person Kathryn Noble Job Title Infection Prevention
completing Manager/Analyst
assessment
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No Comments
 Age No
 Disability No
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
 Ethnic Origin (including gypsies and travellers) No
 Gender reassignment No
 Pregnancy or Maternity No
 Race No
 Sex No
 Religion and Belief No
 Sexual Orientation No
If the answer to all of the above questions is NO,

the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link

below
www.legislation.gov.uk/ukpga/2010/15/contents

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Stage 2 – Full Impact Assessment
What is the impact Level of Mitigating Actions Responsible
Impact (what needs to be done to minimise / Officer
remove the impact)
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance Committee

Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee
Corporate Procedural Document: Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee

Version: 1

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CARBAPENEMASE-PRODUCING ENTEROBACTERIACEAE (CPE)

Review date 11 July 2018

Electronic location Infection Prevention and Control Policies

Carbapenemase-producing Enterobacteriaceae (CPE) policy

Carbapenemase-producing Enterobacteriaceae (CPE) policy

2. A suspected case of CPE colonisation or infection is:

4. Any patient previously colonised or infected with CPE:

Carbapenemase-producing Enterobacteriaceae (CPE) policy

Suspected case of CPE colonisation or infection

Actions if a suspected case of CPE colonisation or infection No risk

Initial screening samples negative Laboratory-confirmed CPE

All three sets of screening swabs Previously ‘known’ CPE positive,

Carbapenemase-producing Enterobacteriaceae (CPE) policy

It recommends a risk assessment at every patient admission, readmission or transfer. It

This policy should be read in conjunction with:

Carbapenemases: Some bacteria produce Carbapenemase enzymes (such as KPC, OXA-

Carrier: A person who is colonised with Carbapenemase-producing Enterobacteriaceae

Carbapenemase-producing Enterobacteriaceae (CPE) policy

Colonisation: The presence of Carbapenemase-producing Enterobacteriaceae (CPE) living

Enterobacteriaceae: This is a large family of bacteria (including; Escherichia coli, Klebsiella

Infection: Carbapenemase-producing Enterobacteriaceae (CPE) can cause serious

Modes of transmission: Carbapenemase-producing Enterobacteriaceae (CPE) is spread

5. DUTIES AND RESPONSIBILITIES

Infection Prevention Team:

Carbapenemase-producing Enterobacteriaceae (CPE) policy

Patient Flow / Duty Hospital Managers:

Matrons / Ward Managers:

All Healthcare Staff:

6.1 Risk assessment and screening for Carbapenemase-producing

A suspected case of Carbapenemase-producing Enterobacteriaceae (CPE) is:

6.2 Early isolation of suspected or laboratory-confirmed cases of

Carbapenemase-producing Enterobacteriaceae (CPE) policy

6.2.7 Duration of isolation: A patient with suspected Carbapenemase-producing

6.2.9 Terminal cleaning and hydrogen peroxide decontamination: Once patient is

6.3 Screening of suspected cases and contacts of carbapenemase-producing

6.3.1 If a patient meets the criteria for a suspected case of Carbapenemase-producing

Timing of screening samples

6.3.2 Screening of laboratory-confirmed cases of carbapenemase-producing

Patients with laboratory-confirmed infection or colonisation with Carbapenemase-producing

6.3.3 Screening of contacts

Provide a carbapenemase-producing Enterobacteriaceae (CPE) contact leaflet (appendix C)

6.3.4 Screening in the event of an outbreak, suspected outbreak or cluster of

As directed by the Incident/Outbreak Control Team and Infection Prevention team.

6.4 Management of a confirmed case of Carbapenemase-producing

Carbapenemase-producing Enterobacteriaceae (CPE) policy

6.5 Environmental Cleaning

 Specific training with regards to the carbapenemase-producing Enterobacteriaceae

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare

Carbapenemase-producing Enterobacteriaceae (CPE) policy

Loveday, H. Wilson, J. Pratt, R. et al (2014). EPIC 3 National Evidence-Based Guidelines for

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably

This policy has been assessed accordingly.

Respect and dignity

Carbapenemase-producing Enterobacteriaceae (CPE) policy

This document will be monitored to ensure it is effective and to assurance compliance.

Carbapenemase-producing Enterobacteriaceae (CPE) policy

Carbapenemase-producing Enterobacteriaceae: I may be a carrier (or have an

What does ‘Carbapenemase-producing Enterobacteriaceae’ mean?

Why does carbapenem resistance matter?

Does carriage of Carbapenemase-producing Enterobacteriaceae need to be treated?

How will I know if I am at risk of being a carrier or having an infection?