CRE Infection Prevention and Control Measures for Health Care Personnel (Fact Sheet)
Minnesota Department of Health
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For the management of patients colonized or infected with a CRE, we recommend the following infection prevention and control strategies be implemented in addition to those included in your hospital’s infection control policy/protocols for multidrug resistant organisms (MDROs). Ensure that compliance with the MDRO policy is high among all staff interacting with the CRE positive patient and/or patient environment. This includes, but is not limited to: Isolation precautions, donning/doffing of appropriate personal protective equipment (PPE), hand hygiene, and environmental cleaning and disinfection.
1. Laboratory testing
Ensure the hospital laboratory is utilizing appropriate laboratory methods for detection of CRE (see MDH CRE Surveillance Activities).
Adopt a standardized definition for CRE (see MDH CRE Surveillance Activities) and ensure the definition is being utilized by all departments including laboratory, infection prevention, and pharmacy, in addition to hospitalists and infectious disease physicians.
Communicate positive CRE results immediately to infection prevention and staff providing patient care.
2. Patient placement
Preferentially place patients with a CRE in a single room with Contact Precautions, or if no single room is available, cohort in the same room with another patient colonized or infected with CRE, regardless of species.
3. Laboratory retrospective review
- Infection prevention, in collaboration with the clinical laboratory, should conduct a one-time retrospective review (6 – 12 months) of laboratory records to identify previously unrecognized patients with CRE.2 This one-time retrospective review will serve as a baseline for your hospital and ensure proper processes are in place for prospective CRE surveillance.
- If previously unrecognized CRE positive patients are identified, conduct a single round of active surveillance testing (AST) of patients on units where these cases have been identified. For information regarding laboratory protocols for CRE active surveillance testing (AST), please see the CDC Protocol for AST at: http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf.
- If no previously unrecognized cases are identified, continue to monitor for CRE in clinical cultures.
4. Active surveillance testing (AST)/Screening
- The goal of AST is to identify undetected carriers of CRE who are a potential source of transmission. There is insufficient evidence to recommend routine screening of patients (including screening of patients with epidemiologic risk factors) for colonization with CRE.
- If a patient with previously unrecognized CRE or hospital-onset CRE infections are identified through clinical cultures or point prevalence surveys:
- Consider conducting AST of patients with epidemiologic links to the CRE-positive patient.
- Place newly identified patients with CRE in a single room with Contact Precautions.
- Recommended sites for AST are rectal or peri-rectal swabs.
- There is no indication for AST of health care workers, family members or visitors.
5. Discontinuation of Contact Precautions
- No recommendations exist for discontinuing Contact Precautions during the current or future admissions to any health care facility.
- When considering discontinuation of Contact Precautions, recognize that prolonged carriage of CRE has been documented.
- At a minimum, maintain Contact Precautions for the duration of the current hospitalization.
- Determine a method of identifying patients with a history of CRE upon readmission (e.g., flag medical records of CRE positive patients).
6. Intra-facility communication
- Implement measures to ensure timely communication between the clinical laboratory and infection prevention when a CRE is detected in a clinical or AST culture.
7. Inter-facility communication
- Communicate patient’s CRE status to the receiving health care facility upon patient transfer.
- If a patient is identified with CRE following transfer to another health care facility, the receiving facility should be notified of the results.
- Admission to the receiving health care facility should not be denied solely on the basis of CRE status.
- Implement measures to educate staff and ensure compliance with hospital MDRO and CRE-specific prevention and control strategies.
9. Visitors to CRE patients
- The use of gowns, gloves, or masks by visitors in health care settings to prevent transmission of MDROs has not been addressed specifically in the scientific literature.
- Visitors to patients with CRE should follow hospital policy for visitors to patients with other MDROs, including:
- Wear PPE to perform direct patient care.
- Perform hand hygiene upon entering and exiting the patient room.
- Avoid roaming on the unit or entering other patient rooms.
10. Antimicrobial Stewardship
The hospital should have in place an antimicrobial stewardship program to promote judicious use of antibiotics.
Recommended Enhanced Strategies for on-going CRE transmission
If there is evidence of possible CRE transmission (e.g., two or more epidemiologically-linked CRE positive patients, regardless of Enterobacteriaceae species), infection prevention or the clinical laboratory should contact MDH, reinforce infection prevention measures, and implement enhanced control measures including one or more of the following:
- Perform AST on all patients who may have had contact with the CRE positive patient (e.g., patients with epidemiologic links to this patient such as patients in the same patient room or on the same unit).
- If new cases are detected, continue weekly AST on patients with epidemiologic links to the CRE positive patient(s) until no new cases are identified.
- Periodically conduct point prevalence surveys to detect patients colonized with CRE on units where CRE transmission has been detected.
- Recommended sites for AST are rectal or peri-rectal swabs.
- There is no indication for AST on health care workers, family members or visitors.
- Consider admission CRE screening for high-risk patients (e.g., facility or patients with a history of CRE).
- Place patients in pre-emptive Contact Precautions until screening results are available.
- If negative, discontinue Contact Precautions, unless otherwise indicated, and cohort with CRE negative patients.
- If positive, continue Contact Precautions and cohort in the same area on a given unit with other CRE positive patients.
- This process should be repeated upon every readmission.
- Monitor cleaning and disinfection practices to ensure consistent implementation of hospital environmental service protocols.
- Focus on cleaning and disinfection of surfaces in close proximity to the patient and high touch surfaces (e.g., bedrails, bedside commodes) in the patient room.
- If enhanced strategies are ineffective and transmission continues, consider cohorting CRE positive patients in the same area on a given unit, temporarily closing unit to new admissions, and/or providing dedicated nursing staff.
- If a novel resistance mechanism is identified for the first time in a facility, perform AST on all patients who may have had contact with the CRE positive patient (see1 under MDH Enhanced CRE Infection Prevention and Control Measures for Hospitals).