CRE TOOLKIT
Community Patient Safety Coalition (CPSC) of
Southwestern Indiana/Kentucky – Infection
Prevention Subgroup
Readiness requires both the capability to implement
new practices and the motivation to make the
necessary changes.
CDC – CRE Toolkit, 2012
Members of Community Patient Safety Coalition – Infection Prevention Subteam
Deaconess Hospital
Infection Prevention
812-450-7455
St. Mary’s Medical Center
Infection Prevention
812-485-4117
Daviess Community Hospital
Infection Prevention
Gibson General Hospital
Infection Prevention
HealthSouth Deaconess
Infection Prevention
812-437-6295
The Women’s Hospital – Deaconess Gateway
Infection Prevention
812-842-4262
Owensboro Health
Infection Prevention
270-685-7714
Perry County Hospital
Infection Prevention
Methodist Hospital
Infection Prevention
270-827-7431
Memorial Hospital/Jasper
Infection Prevention
996-482-0428
Good Samaritan/Vincennes
Infection Prevention
812-885-4370
CRE TOOLKIT
Community Patient Safety Coalition (CPSC) of Southwestern Indiana/Kentucky – Infection
Prevention Subgroup
CONTENTS
Position Statement
Definition
State Requirements
Regional Surveillance

Identification

Risk

Communication
Treatment
Best Practices

Isolation

Discontinuation of Isolation

Hand Hygiene

Device Utilization

Co-horting

Antimicrobial Stewardship

CRE Screening of Contacts

Active Surveillance Testing

Chlorhexidine Bathing

Specimen Collection

Transfers In-House and to another facility.
Education

Staff

Visitors

Patients
Community Engagement/Outreach

Public Health

Long Term Care
References
Appendix

Staff Education on CRE


Patient Education on CRE
Continuum of Care Transfer Communication Form (CPSC)

Infographic – CDC Vital Signs –CRE



Infographic – CDC Risk of CRE Infections
Infographic – CDC What Can Be Done? CRE
CDC – Laboratory Protocol for Detection of CRE or Carbapenemase Producing, Klebsiella
spp. And E. coli from Rectal Swabs

CDC Inter-facility Infection Control Transfer Form for States Establishing HAI
Prevention Collaboratives
The CPSC of Southwestern Indiana/Kentucky Infection Preventionist have coordinated this
project with the CPSC Laboratory Subgroup to assure that identification and prevention of CRE
is a system wide process.
CRE Team Position Statement
The incidence and dissemination of Carbapenem Resistant Enterobacteriacae (CRE) has
increased in the United States and poses a serious health risk to the general and medical
communities. CRE has become resistant to most available antibiotics. CRE has the potential
to spread rapidly and current studies reveal a high mortality rate with these organisms.
Identifying and containing the spread of CRE will require a coordinated effort of all regional
facilities, including hospitals, LTAC, skilled nursing facilities and public health. The CPSC
Infection Prevention Subgroup in a joint effort with CPSC Lab subgroup have proposed a
targeted effort to identify and contain CRE.
This effort for early identification and control of CRE includes the following:









Agreeing that the CRE organism is epidemiologically relevant
Utilization of CRE definition developed by Centers for Disease Control (CDC)
Standardization of CRE identifying breakpoints by laboratory
Identifying the prevalence of CRE in the region
To rapidly identify CRE and prevent or eliminate sources or sites of ongoing
transmission
To promote appropriate infection control interventions to prevent transmission of CRE
within or among healthcare facilities, or between healthcare facilities and the
community.
To ensure appropriate communication of CRE status to primary CRE providers, and
healthcare facilities including where the patient previously received care.
Provide education for staff, visitors and patients regarding CRE, transmission and
infection prevention interventions.
Develop education on CRE for hospitals, LTAC, Long Term Care Facilities, etc.
References:
CDC, Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE), 2012.
DEFINITION:
The Center for Disease Control and Prevention (CDC) has developed an interim surveillance
definition for CRE. The Community Patient Safety Coalition (CPSC) of Southwestern
Indiana/Kentucky will utilize this definition for identifying CRE in the region.
Definition
Enterobacteriaceae that are:
 Nonsusceptible to one of the following carbapenems: doripenem, meropenem,
or imipenem AND
 Resistant to all of the following third generation cephalosporins that were
tested: ceftriazone, cefotaxime, and ceftazidime. (Note: all three of these
antimicrobials are recommended as part of the primary or secondary
susceptibility panels for Enteriobacteriaceae)
 Klebsiella species and Escherichia coli that meet he CRE definition are a
priority for detection and containment in all settings: however, other
Enterobacteriaceae (e.g., Enterobacter species) might also be important in
some regions.
 For bacteria that have intrinsic imipenem nonsusceptibility (i.e., Morganella
morganii, Proteus spp., Providencia spp.), requiring nonsusceptibility to
carbapenems other than imipenem as part of the definition might increase
specificity.
 This CRE surveillance definition is based upon the current (M100-S22 2012)
Clinical and Laboratory Standards Institute (CLSI) interpretative criteria
(breakpoints) for Carbapenem susceptibility among Enterobacteriaceae. If
older CLSI breakpoints (pre-dating M100-S20U) are being used to determine
Carbapenem susceptibility, consideration should be given to including
ertapenem in the CRE definition to increase sensitivity.
References:
CDC, Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE), 2012.
Carbapenem
Resistant
Enterobacteriacae
(CRE)
Surveillance Definition
Nonsusceptible to
these
carbapenems
Resistant to
these 3rd gen.
Cephalosporins
Current CLSI
breakpoints
• Doripenem
• Meropenem
• Imipenem
• Ceftriazone
• Cefotaxime
• Ceftazidime
• M100-S22 2012
• Pre-dating
M100-S20U:
include
ertapenem in
CRE definition.
State Requirements for CRE:
Kentucky: Any cases of CRE should be reported to the HAI program at KDPH per the existing
regulation as this is an important emerging pathogen. The state laboratory is equipped to accept
those specimens for storage, and potential PFGE typing if warranted. Use MDRO Reporting
Form (Index).
Contact Information
Kentucky Department for Public Health
275 E. Main Street
Frankfort, KY 40621
HAI Prevention Program Manager
Infectious Disease Branch
Dept. of Epidemiology & Health Planning
Phone 502-564-3261 ext. 4248
Fax 502-564-2816
Regional Epidemiologist
Green River District Health Department
Phone: 270-852-2938
Indiana: Indiana currently has no requirements for the reporting of CRE.
A copy of the 2013 Indiana Multi-Drug Resistant Organism Survey which includes information
on CRE in Indiana can be located at: http://www.in.gov/isdh/files/IP-LAB_Survey_Report_5-132013(1).pdf
Contact Information
Indiana State Department of Health
Surveillance and Investigation Division
2 North Meridian Street
Indianapolis, IN 46204
Healthcare Associated Infections Epidemiologist
Surveillance and Investigation Division
Indiana State Department of Health
317.234.2805 office
317.771.6508 mobile
317.234.2812 fax
www.StateHealth.in.gov
Antimicrobial Resistant Epidemiologist
Surveillance and Investigation Division
Indiana State Department of Health
317.233.7825 office
317.431.5257 mobile
317.234.2812 fax
www.StateHealth.in.gov
Indiana State Department of Health Laboratories
550 W. 16th St. Suite B
Indianapolis, IN 46202
Jyl Madlem, MS, MT(AMT)
ISDH Laboratory
Laboratory Program Advisor
Phone: (317)921-5574
ISDH Laboratory
State Training Coordinator
Phone: 317-921-5890
ISDH Laboratory
Reference Microbiology Supervisor
Phone: 317-921-5860
Regional Surveillance
Identification:
CRE will be identified utilizing the CDC surveillance definition and the CLSI breakpoints for
CRE identified in the case definition.
Different forms of CRE include:


Klebsiella pneumonia carbapenmase (KPC)
New Dehli metallo-beta-lactamase (NDM)

Verona Integron metallo-beta-lactamase (VIM)
Facilities should determine if CRE has been identified in their facility within 48 hours of
admission. If the information is not currently available, a review of cultures collected during a
12 month time frame is recommended.
Risk factors for CRE

Intensive Care

Indwelling devices (such as endotracheal tubes, central venous catheters, urinary

catheters
Healthcare exposure
Communication:
Internal communication is essential in the control of CRE and its transmission. Hospitals should
have processes in place to notify Infection Prevention and appropriate clinical staff when CRE is
identified. This will assure that control measures can be quickly implemented.
Patient with suspected/known CRE should be placed immediately in Contact Precautions.
If a patient is transferred to another facility, the facility should be notified, prior to transfer.
Treatment
CRE is difficult to treat so prevention is paramount in preventing the incidence of CRE.
BEST PRACTICES
Isolation
Patients colonized or infected with CRE should be placed on Contact Precautions in a private
room.
Discontinuation of Isolation
There is currently not enough information available to determine when isolation should be
discontinued for patients with CRE. CRE colonization has been shown through studies to extend
for long periods of time (≥ 6 months).
According to CDC, if surveillance cultures are used to determine if a patient remains colonized,
more than one culture should be obtained to improve sensitivity.
Facilities should have a process in place to determine when CRE isolation can be discontinued.
At a minimum, consultation with Infection Prevention/Hospital Epidemiologist should be
considered prior to discontinuing isolation.
Hand Hygiene
Hand Hygiene remains fundamental in all infection prevention practices. Prevention of multidrug resistant organisms (MDRO) transmission includes proper hand hygiene technique. Hand
Hygiene should be performed following Center for Disease Control and Prevention and/or World
Health Organization (WHO) guidelines.
To prevent transmission of CRE, staff must remain vigilant when performing hand hygiene.
Facilities should assure that staff have adequate supplies available for hand hygiene including:
clean sinks, soap, alcohol based hand rubs, paper towels, etc.
Device Utilization
Since device utilization (i.e. central lines, endotracheal tubes, urinary catheters, etc.) increases
the risk of MDRO transmission, minimizing their use is an important effort. Prevention of
device related infections includes daily necessity and prompt discontinuation when no longer
needed.
Patient and Staff Co-horting
Patients should be on Contact Precautions in single patient rooms. If single rooms are not
available, patients can be cohorted together.
Facilities may consider co-horting CRE patients in specific areas with dedicated staff.
Antimicrobial Stewardship
Antimicrobial Stewardship is important in the control of MDRO’s. In some studies, restricting
the use of carbapenems has been associated with a lower incidence of CRE. For more information
on antimicrobial stewardship: http://www.cdc.gov/getsmart/healthcare.
CRE Screening
Screening of contacts may be conducted to identify transmission of CRE among epidemiologically
linked contacts of CRE patients.
Stool, rectal or peri-rectal swabs should be collected for screening. If wounds or devices are
present (urinary catheter, etc.), specimens may also be collected from these areas.
Keep a record of screening culture results and “flag” in EMR any CRE colonized patient.
Staff should be trained on the culture collection for CRE.
Active Surveillance Testing
Active surveillance Testing (AST) may include any of the following or a combination thereof (to
be determined by the facility):

All admissions to the facility

Patients admitted to high risk areas (e.g. ICU, etc.)


Patients admitted from Long Term Care Facilities
Patients transferred from other facilities
Chlorhexidine Bathing
Chlorhexidine bathing may be utilized in specific patient populations (e.g. ICU’s, etc.) to decrease
the colonization/prevalence of CRE. If chlorhexidine bathing is performed it is often used for all
patients regardless of colonization status in a designated area or during an outbreak.
Specimen Collection
Specimens should be collected from stool, rectal or peri-rectal swabs. If wounds or devices are
present (urinary catheter, etc.), specimens may also be collected from these areas.
CRE Rectal Screening Specimen Collection
Rectal, Perirectal or Stool Culture
1. Premoisten the sterile swab in liquid transport media in the accompanying culturette tube
2. Insert moistened tip of swab into the anal canal and turn 2-3 times
(a) Alternatively, sample stool for culture if visible on the perianal skin or in an ostomy
bag.
3. Replace swab in culturette tube and secure top.
4. Label specimen with at least 2 patient identifiers, date, site and collector’s initials. Place
in sealed specimen bag.
5. Send specimen to lab.
**Specimens should be plated ideally within 4 hours of collection. If significant delay on
plating specimens occurs, store swabs at 4º Celsius for up to 3 days.
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Transfers In-house and to another Facility
If a patient is transferred internally or to another facility, be sure that the receiving area is
aware that the patient has CRE. A phone report and transfer form should include information
about CRE including the date, source and culture results. At discharge, the patient’s primary
provider should be notified to assist during future medical treatment or admissions.
Education
An important part of CRE prevention is ensuring that healthcare providers (HCP) are educated
about contact precautions and transmission of CRE. Real time education should be conducted with
staff and patients when a patient is identified as having CRE. (Staff and Patient/Visitor Education
Guides are located in the appendix).
Community Engagement/Outreach
Public Health
Coordination with Public Health officials should be instituted. CRE should be reported if indicated
by state guidelines.
Long Term Care
In order to prevent and control CRE, coordination with long term care facilities is essential.
Education, early identification and communication for transferring and receiving facilities is
imperative in controlling the spread of CRE. This CRE toolkit should be shared with long term care
facilities. Hospital Infection Preventionists can serve as a valuable resource for long term care
facilities.
References
U. S. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic
Infectious Diseases, Division of Health care Quality Promotion Guidance for Control of Carbapenem
Resistant Enterobacteriaceae, 2012 CER Toolkit. Atlanta, GA: CDC. www.cdc.gov/hai/pdfs/cre/CREguidance-508.pdf
Kochar S, Sheard T, Sharma R, et. Al. Success of an infection control program to reduce the spread of
carbapenem-resistant Klebsiella pneumonia. Infect Control Hospital Epidemiology. 2009 May;
30(5):447-52.
Borer A, Eskira S, Ntiv R, et. Al. A multifaceted intervention strategy for eradication of a hospital
wide outbreak caused by carbapenem-resistant Klebsiella pneumonia in Southern Israel. Inf Control
Hosp. Epidemiology: 2011 Dec; 32(12):1158-65.
U. S. Agency for Healthcare Research and Quality, U. S. Department of Health and Human Services,
Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit. Rockville, MD: No.
14-0028-EF, April 2014.
APPENDIX
Carbapenem Resistant Enterobacteriaceae (CRE)
Staff Education
What are Enterobacteriaceae?
Enterobacteriaceae are a family of bacteria commonly found in the human bowel. CRE stands for Carbapenem
Resistant Enterobacteriaceae. Specifically three types of bacteria in the Enterobacteriaceae family – Klebsiella,
Enterobacter and Escherichia, have built up resistance to a group of antibiotics called “carbapenems”. This
group of antibiotics are often used as the last line of treatment when other antibiotics are not able to treat
infections caused by Enterobacteriaceae and include: Eratapenem, Meropenem, Imipenem and Doripenem.
How do individuals get CRE infections?
CRE is spread from person to person by direct contact with an infected person or by contact with infected body
fluids, such as wound drainage or stool. Hands can become contaminated after contact with infected persons or
materials. If hands are not washed after contact, they can spread CRE.
Who is at risk for developing a CRE infection?
Healthy individuals do not usually get CRE infections. Patients who are hospitalized and who are treated with
devices such as catheters and ventilators, or who are taking antibiotics, are at highest risk of becoming infected
with CRE. Additional risk factors for developing CRE infections include organ or stem cell transplantation and
long hospital stays. Residents of long term care facilities are also at risk of acquiring CRE infections.
Can CRE be treated?
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, and they do not need antibiotics for CRE. If CRE is causing an infection, the
antibiotics that will work against it are limited but some options are often available. In addition, some infections
might be able to be treated with other therapies, like draining the infection. Strains that have been resistant to
all antibiotics are very rare but have been reported.
What is the difference between colonized patients and infected patients?
Colonized Patient – A patient who has CRE on or in their body but does not have any signs or symptoms of
disease/infection.
Infected Patient – A patient who has CRE on or in their body, who DOES have signs or symptoms of
disease/infection.
Why is CRE prevention in healthcare important?
CRE infections are more difficult to treat and cause increased deaths, healthcare costs and length of stay in the
hospital. Carbapenem resistance can spread among types of bacteria in the Enterobacteriaceae family, which
can cause increased resistance.
What steps should healthcare providers take to prevent and/or reduce
transmission of CRE?






Strict adherence to hand hygiene. Use of alcohol hand sanitizers effectively inactivate CRE. If hands are
visibly soiled, wash with soap and water.
Promptly place patient with current or past histories of CRE into CONTACT precautions. Place patients in
private room with bathroom and wear gown and gloves upon each entry to the patient’s room.
Movement of patients outside their rooms should be limited to medical purposes only.
Immediately discard disposable patient care items and equipment after use or clean and disinfect reusable items and equipment before removing from the patient room.
Always notify receiving facilities or other healthcare services (e.g. home health) about a patient’s history
of CRE infection.
Only prescribe antibiotics when necessary
Remove temporary medical devices (e.g. urinary catheters, ventilators, central lines, etc.) as soon as
possible.
When can isolation be discontinued?
Currently there are no recommendations available on when isolation can be discontinued for those colonized or
infected with CRE. Consultation with Infection Prevention/Hospital Epidemiologist is required prior to
discontinuing isolation.
Patient Information Sheet for Carbapenem resistant Enterobacteriaceae (CRE)
What is CRE?
CRE stands for Carbapenem Resistant Enterobacteriacae. CRE are bacteria that live in the bowel
and that cannot be treated by certain antibiotics, known as carbapenem antibiotics.
Can CRE be harmful?
In most people, CRE bacteria are harmless and do not cause infection. This is called colonization.
This is because the person’s immune system keeps CRE in check in the bowel and prevents it from
spreading elsewhere in the body. Sometimes CRE can cause infection in patients, for example, when
they need intensive care or while receiving chemotherapy, etc.
CRE can cause urinary tract infections, wound infections, pneumonia, blood stream infections and
other serious infections.
How do people get CRE?
Patient who have taken lots of antibiotics are more at risk of getting CRE. The more bacteria are
exposed to antibiotics, the more likely they will develop “resistance” to that antibiotic so that
antibiotic no longer works.
CRE can spread from one patient to another in hospitals and long term care facilities. Healthcare
workers, and visitors should perform hand hygiene before contact with patients or their environment.
What are the special precautions for patients with CRE?
The precautions are designed to prevent CRE spreading between patients on the unit. Anybody
found to have CRE is placed on CONTACT precautions in a private room with their own bathroom.
Staff or visitors must wear gloves and gowns before entering the room or coming in contact with the
patient. Patients, staff and visitors must pay special attention to hand hygiene.
How do you know if a patient has CRE?
A rectal swab is the quickest way to check for CRE. The swab will be sent to the laboratory to be
checked for CRE.
Is there a treatment for CRE?
Many people with CRE will have the germ in their body without it producing an infection. These
people are said to be colonized with CRE, and they do not need antibiotics for CRE.
If CRE is causing an infection, the antibiotics that will work against it are limited but some options are
often available.
What should I do if I am diagnosed with CRE in a healthcare facility?
If you have CRE you will be placed in a private room on CONTACT precautions.
Perform hand hygiene before eating, after using the bathroom, coughing or sneezing and after
contact with wound drainage or other body fluids.
Always let your physician and healthcare providers know if you have had a positive CRE result
before, so they can prevent spread to other patients.
What happens when I go home?
Clothes, bed linen and dishes can be washed as usual. It is always important to wash your hands
carefully after using the toilet and before preparing meals or eating to stop CRE spreading to other
people. Follow any other instructions you healthcare provider gives you.
People providing care at home for patient with CRE should be careful about washing their hands,
especially after contact with wounds or helping the CRE patient to use the bathroom or after
cleaning up stool.