Carbapenem Resistant Enterobacteriaceae

The Alphabet Soup of Infection Prevention

Aurora Health Care System Infection Prevention

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CRE-what is it?

• CRE are in a class known as multi-drug

resistant organisms (MDROs)
• You have heard of other MDROs before
– MRSA
– VRE
• First reported in North Carolina in 2001,
the U.S. is finding more and more cases
of these bacteria every year

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 CRE-Carbapenem Resistant
Enterobacteriaceae

• Enterobacteriaceae - family of bacteria commonly

found in human gastrointestinal tract.
• Sometimes these bacteria can spread outside the gut
and cause serious infections, such as urinary tract
infections, bloodstream infections, wound infections,
and pneumonia.

• In rare instances can become resistant to a group of

antibiotics called “carbapenems”, often antibiotics of
last resort

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Why are CRE considered
important?

• Resistant to multiple classes of antimicrobials

limiting treatment options.
• Some Enterobacteriaceae have become resistant to all
or almost all antibiotics.
• CRE can share their resistance with other
Enterobacteriaceae, causing resistance to spread
• High mortality rate
• Up to 50% case mortality rate associated with
invasive infections

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Who can get an infection with CRE?

• Healthy people usually don’t get CRE

infections.
• CRE primarily affect patients in acute and
long-term healthcare settings
• CRE are more likely to affect
immunocompromised patients or those
with invasive devices (i.e. central lines,
urinary catheters).

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 How does a CRE patient present?

• Infection versus Colonization

• A patient with CRE can be either infected
or colonized.

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Infection with CRE

• Infections are symptomatic

– symptoms vary based on the site that is
infected
• cough if in the lungs
• urinary symptoms if in the bladder
– can also include general symptoms like
fever or chills
• Invasive infections can have a mortality
rate of up to 50%!

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Infection with CRE

• Patients with CRE infections

– Can spread the bacteria to others
– Are symptomatic
– Need treatment

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 Colonization with CRE

• Many people with CRE will have the germ

in or on their body without it producing an
infection.
• These people are said to be colonized with CRE.
• Patients are not symptomatic.

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Colonization with CRE

• Colonized patients can spread CRE to

others.
• There is no current treatment for
decolonizing patients.
• Colonizing CRE strains can go on to
cause infections if they gain access to
body sites that are usually sterile like the
bladder, the lungs, or the bloodstream.

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How are CRE spread?

• To get a CRE infection, a person must be

exposed to CRE bacteria.
• CRE are usually spread person to person
through contact with infected or colonized
people, particularly contact with wounds or stool.
• CRE can cause infections when they enter the
body, often through medical devices like
ventilators, intravenous catheters, urinary
catheters, or wounds.

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How are CRE spread?
CRE are usually transmitted from person to
person, often via the hands of healthcare
personnel or via contaminated medical
equipment.
Prevent the exposure to CRE=prevent
transmission of CRE
Hand Hygiene
Contact Precautions

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 CRE-what can we do?

• Identify patients with CRE quickly

– No recommendations to screen patients for
CRE at this time
• Isolate them in Contact Precautions
immediately when they are found
• Communicate with your Infection
Preventionist as soon as CRE is
identified
– Lab calls with info, place patient in contact
precautions and call your Infection Preventionist

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How can we prevent
transmission of CRE?

1. Perform Hand Hygiene before & after every

patient contact.
– Either alcohol based hand rub or soap/water is
effective
– Do hand hygiene before donning gloves
– Do hand hygiene after removing gloves
– For every patient, every time
– Especially when providing wound care and
cleaning up stool

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How can we prevent
transmission of CRE?
2. Initiate Contact Precautions as soon as
CRE is found
– Contact = gown and gloves
– Maintain precautions for duration of
hospitalization and all future
hospitalizations
– Initiate automatic Contact Precautions on
re-admit.
• Do not have to re-culture these patients when
they are readmitted.

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How can we prevent
transmission of CRE?

1. Educate patients & visitors regarding prevention

measures
• Hand Hygiene
• Contact Precautions
2. Provide hand off communication on CRE to other
caregivers within the facility.
3. Provide verbal & written communication at time of
discharge or transfer to outside facilities.

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 CRE-Summary

• CRE are a group of bacteria resistant to

antibiotics
• Patients can be colonized or infected
• Any patient with CRE can transmit the bacteria
• To prevent transmission:
– Strict Hand Hygiene
– Contact Precautions for all health care
encounters
• Work with Infection Prevention when have a case

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