The Importance of Infection Control Practices to Prevent Spread of CRE

A cluster of carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) at a skilled nursing facility in Arizona in 2018 underscores the importance of close adherence to recommendations for preventing health care—associated transmission.

A recent Morbidity and Mortality Weekly Report from the US Centers for Disease Control and Prevention (CDC) detailed isolates of carbapenemase-producing Klebsiella pneumoniae (KPC-KP) collected from urine samples of 2 patients in July 2018 at a ventilator-capable unit in a skilled nursing facility, with subsequent screenings identifying 3 additional cases that appeared consistent with health care—associated transmission.

CDC-defined CRE represent a wide variety of bacteria broken into 3 subset categories: carbapenemase-producing, non-carbapenemase-producing, and unconfirmed CRE. According to a recent study, KPC-KP was the most common and appeared to be increasing in prevalence.

These multidrug-resistant organisms have a high fatality rate (as high as 50%) but can be difficult to detect, with only 31% to 63% of asymptomatic carriers are identified with clinical cultures, the report noted. Results of pulsed-field gel electrophoresis (PFGE) suggested health care—associated transmission occurred between the 2 index patients, who resided in neighboring rooms, both had urinary catheters and urinary tract infections and 1 was on a ventilator.

The Maricopa County Department of Public Health (MCDPH) recommended contact screening for the pathogen among residents of the unit to prevent the spread of the infection. In August, 26 residents were screened, with KPC-KP isolates detected in 5 (19%). Among those, 3 had indistinguishable PFGE patterns from the original patients.

County and state health officials visited the facility on September 6 to examine infection control practices in the ventilator-capable unit. Lapses in aseptic technique during sterile procedures and missed opportunities for proper hand hygiene were noted. MCDPH made several recommendations, including implementing contact precautions, training staff on sterile procedures, and installing additional hand sanitizer dispensers to improve hand hygiene before and after physical contact with residents.

Screening of 19 residents, including 10 who had been screened before, was conducted on November 5. All 19 cultures were negative for KPC-KP.

“Closer adherence to CDC recommendations that could prevent health care—associated KPC-KP transmission include housing together residents with infection, improving adherence to hand hygiene, using gowns and gloves when interacting with residents who require mechanical ventilation or have tracheostomies, and implementing contact precautions for uncontained body fluids,” the report noted.

In December, the CDC listed CRE on its “biggest threats” report on antibiotic-resistant pathogens. CRE emerged and rose rapidly, making the CDC’s first list of urgent threats in 2013.

Carbapenem resistance was associated with longer hospital stays and higher patient mortality, according to a study published last year. That study highlighted concerns about health care-associated transmissions, finding that patients with CRE infections were more likely to have health care exposure, intensive care, exposure to antibiotics, and surgery within the month prior to infection.