Carbapenem-ResistantEnterobacteriaceae: A Strategic Roadmap for Infection Control

Abstract

The incidence of carbapenem-resistant Enterobacteriaceae (CRE) has increased worldwide with great regional variability. Infections caused by these organisms are associated with crude mortality rates of up to 70%. The spread of CRE in healthcare settings is both an important medical problem and a major global public health threat. All countries are at risk of falling victim to the emergence of CRE; therefore, a preparedness plan is required to avoid the catastrophic natural course of this epidemic. Proactive and adequate preventive measures locally, regionally, and nationally are required to contain the spread of these bacteria. The keys to success in preventing the establishment of CRE endemicity in a region are early detection through targeted laboratory protocols and containment of spread through comprehensive infection control measures. This guideline provides a strategic roadmap for infection control measures based on the best available evidence and expert opinion, to enable preparation of a multifaceted preparedness plan to abort epidemics of CRE. Infect Control Hosp Epidemiol 2017;38:580-594.

NDM Metallo-β-Lactamases and Their Bacterial Producers in Health Care Settings

“…It has been reported that outbreaks due to CRE have been effectively controlled by enhanced environmental disinfection using hydrogen peroxide (326). Particular efforts should be taken to investigate possible environmental reservoirs during outbreaks (327), and if the source is identified, targeted measures are required to control the outbreak. For instance, duodenoscopes have been identified as the contamination source for several outbreaks, which were subsequently controlled by enhanced cleaning and a change from high-level disinfection to gas sterilization (328,329).…”

“…The sources of outbreaks may not be identified in many cases. In such cases, the entire environment of affected wards may become heavily contaminated, and temporary ward closures have been recommended for enhanced cleaning and limiting the further spread of the pathogen (327,(331)(332)(333). External audits of infection control measures and extensive health service-wide education have also been recommended (334).…”

“…Measures (summarized in Appendix S2 in the supplemental material) recommended by these guidance documents are evidence based and are overall highly similar (Table 6), although the emphasized points and the terminology are slightly different. In addition to the guidance documents, the Society for Healthcare Epidemiology of America (SHEA) established a step-by-step strategic roadmap for CRE infection control based on evidence and expert opinion (327). This roadmap has six successional steps, including determining whether CRE have been isolated, determining affected wards and the occurrence of intrafacility transmission, implementing early CRE detection and CRE containment measures, enhancing existing infection control requirements, regional strategy, and investigating for community spread of CRE, which should be applied in different situations, such as sporadic cases, single-hospital outbreaks, and settings of endemicity (327).…”

“…In addition to the guidance documents, the Society for Healthcare Epidemiology of America (SHEA) established a step-by-step strategic roadmap for CRE infection control based on evidence and expert opinion (327). This roadmap has six successional steps, including determining whether CRE have been isolated, determining affected wards and the occurrence of intrafacility transmission, implementing early CRE detection and CRE containment measures, enhancing existing infection control requirements, regional strategy, and investigating for community spread of CRE, which should be applied in different situations, such as sporadic cases, single-hospital outbreaks, and settings of endemicity (327). However, as the WHO guidance has identified, the quality of the evidence for the recommended measures in guidance is usually very low or low (331).…”

New and emerging infectious diseases (Ebola, Middle Eastern respiratory syndrome coronavirus, carbapenem-resistant Enterobacteriaceae, Candida auris): Focus on environmental survival and germicide susceptibility

“…Strategies to manage CRE colonized/infected patients and to control outbreaks in health care facilities have been reviewed. [109][110][111] Both the WHO 112 and the CDC 113 provide detailed guidance on methods to control CRE. The use of bundles to control horizontal transmission of CRE in health care facilities have been reviewed.…”