Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control

Abstract

Background: Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are "at-risk" may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E).The purpose of this guidance is to raise awareness and identify the "at-risk" patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE.

Methods: The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients "at-risk" for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for "at-risk" patients upon admission to healthcare settings.

Results: Individuals with the following profile are "at-risk" for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE.Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for "at-risk" patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures.

Conclusions: Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here.This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources.

Keywords: AMR; Active screening; Antimicrobial resistance; CRE; Carbapenem-resistant Enterobacteriaceae; Core measures; Healthcare-associated infections; MDR-E; Multidrug-resistant Enterobacteriaceae; Supplemental measures.

Fig. 1

Flowchart for assessment of carriage of carbapenem-resistant Enterobacteriaceae in patients being admitted to healthcare settings. Instructions for use of flowchart in Figure 1 for the management of “at-risk” patients being admitted to healthcare settings This guidance document was created as a practical tool, for use by frontline HCWs and IPC and control professionals, for the evaluation and management of patients admitted to a healthcare setting. The goal is to identify the “at-risk” patients carrying CRE and to implement measures to prevent the transmission of these bacteria to other patients in the healthcare setting. On admission to the healthcare setting, frontline HCWs should evaluate all patients to see whether they fall into any one of the four risk categories outlined in Table 3 and the flowchart in Fig. 1, and whether they have prior microbiological evidence for CRE carriage. See flowchart on how to manage patients who are potential carriers. All admitted patients should have core measures applied regardless of their carrier status. These should be continued for the duration of their stay. Any patient who is a potential carrier should have the following three preliminary supplemental measures implemented: a) pre-emptive isolation in a single room while waiting for results of screening b) active screening for CRE by obtaining swabs from rectal or perirectal areas and any other site that is either actively infected or considered to be colonised c) contact precautions implemented and used by anyone entering the room. If the result of the active screening is positive for CRE, the measures (patient isolation and contact precautions) are continued and additional supplemental measures are added. Timely communication of the latest microbiological results with the clinical and IPC teams is critical, the patient’s contacts should be screened for CRE carriage, enhanced environmental cleaning applied and consideration given to designated nurse cohorting, based on the clinical situation and location. If the results of active screening are negative for CRE and there is no other indication to continue contact precautions (e.g., patient colonised with another MDRO or patient with a transmissible infection, such as C. difficile) contact precautions can be discontinued, but core measures should be continued. For the patient with a previous positive result for CRE, but from whom CRE is not detected on readmission screening, the decision to continue supplemental measures should be based on a case-by-case risk assessment, in consultation with the IPC team. Factors to be taken into consideration include: the clinical area to which the patient is admitted (e.g., critical care, transplant, oncology), patient age, underlying comorbidity, invasive device use, skin breaks, incontinence, recent antimicrobial use, microbiological tests and schema used for assessing carriage, taking into account the possibility of a false negative screening test result, and interval since the last positive culture for CRE, among others