Carbapenem Resistant Organism Prevention
Klebsiella pneumoniae and other gram-negative bacilli have been increasing in clinical importance since they have begun to demonstrate carbapenem resistance over the past decade. These organisms, known as carbapenem-resistant Enterobacteriaceae (CRE), have been associated with high mortality rates and have the potential to spread even more widely throughout the United States. Additionally, CRE often carry genes that confer high levels of resistance to other antimicrobials, which limit therapeutic options and may result in "Pan-resistant" organisms. The Centers for Disease Control (CDC) defines CRE as Enterobacteriaceae that are nonsusceptible to doripenem, meropenem, or imipenem AND resistant to third-generation cephalosporins, including ceftriaxone, cefotaxime, and ceftazidime.
CRE organisms employ mechanisms that result in the production of carbapenemases. A carbapenemase is a beta-lactamase enzyme that confers resistance to carbapenem antibiotics and extended spectrum cephalosporins. In the U.S., CRE isolates most commonly produce Klebsiella pneumoniae carbapenemase (KPC). Although the name suggests this mechanism is only associated with Klebsiella pneumoniae, it has also been demonstrated in several other pathogens such as Klebsiella oxytoca, Citrobacter freundii, Enterobactoer spp., Escherichia coli, Salmonella spp., Serratia spp., and Pseudomonas aeruginosa.
The transmission of CRE in healthcare facilities can be a great challenge to infection control programs. In addition to CRE, Carbapenem Resistant Acinetobacter baumanii (CRAB) is also of concern and poses a similar challenge from and infection control standpoint. While the prevalence of CRE and CRAB is unknown in Florida the FDOH Investigations Unit has been contacted to assist several facilities throughout the state with outbreaks over the past few years.
Healthcare facilities will need to educate staff on the key prevention strategies for preventing the spread of multidrug resistant organisms. CRE and CRAB prevention strategies are below, however Acinetobacter is quite virulent in the environment and requires special attention environmental cleaning to ensure the proper cleaning of the patient care environment as well as medical equipment.
Strategies for preventing transmission of CRE/CRAB
2. Contact Precautions
3. Patient and staff cohorting
4. Minimize use of invasive devices
5. Promote antimicrobial stewardship
1. Conduct active surveillance testingScreen high-risk patients at admission or at admission and periodically during their facility stay for CRE/CRAB. Preemptive CP can be used while results of admission surveillance testing are pending
2. Chlorhexidine bathing
Centers for Disease Control and Prevention
Association for Professionals in Infection Control
Florida Department of Health Bureau of Epidemiology
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report
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