Health Advisory
CDC REPORTS NEW CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE) WARRANT ADDITIONAL ACTION BY HEALTHCARE PROVIDERS

The Delaware Division of Public Health (DPH) is issuing this health advisory to provide the healthcare community with information from the Centers for Disease Control and Prevention (CDC) on new Carbapenem-resistant Enterobacteriaceae (CRE) and the need for additional steps to prevent the emergence and spread of these organisms. The CDC HAN can be found at http://emergency.cdc.gov/HAN/han00341.asp.

Summary

Carbapenem-resistant Enterobacteriaceae (CRE) are untreatable or difficult-to-treat multidrug-resistant organisms (MDROs) that are emerging in the United States. Increasing reports of these MDROs has led CDC to alert healthcare providers to act aggressively to prevent the emergence and spread of unusual CRE organisms. Although still uncommon, of 37 unusual forms of CRE that have been reported in the United States, the last 15 have been reported since July 2012. Because the vast majority of these unusual organisms were isolated from patients who received overnight medical treatment outside of the United States, additional measures described in this advisory are now recommended for use when such patients are hospitalized in the United States.

Background

Klebsiella species and Escherichia coli are examples of Enterobacteriaceae, a family of bacteria that normally live in water, soil, and the human gut. CRE are Enterobacteriaceae that have developed high levels of resistance to antibiotics, including last-resort antibiotics called carbapenems. CRE infections most commonly occur among patients who are receiving antibiotics and significant medical treatment for other conditions.

Most CRE in the United States produce a carbapenemase called Klebisella pneumoniae carbapenemase, or KPC. Unusual forms of CRE such as those with the New Delhi Metallo-β-lactamase (NDM) and Verona Integron-mediated Metallo-β-lactamase (VIM) have been very uncommon in the United States but are more common in other parts of the world.

Many countries do not actively look for CRE therefore, it is unclear which countries have experienced unusual carbapenemases (e.g., NDM, VIM) and it is difficult to know their overall incidence at any given time. However, the vast majority of CRE reported to CDC were isolated from patients with a history of an overnight stay in a healthcare facility outside the United States.

Infection Control Recommendations

1. CDC continues to recommend that facilities follow the CDC guidance for preventing the spread of CRE in healthcare settings: http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html.
2. CDC now also recommends the following:
   1. When a CRE is identified in a patient (infection or colonization) with a history of an overnight stay in a healthcare facility (within the last 6 months) outside the United States, send the isolate to a reference laboratory for confirmatory susceptibility testing and tests to determine the carbapenem resistance mechanism; at a minimum, this should include evaluation for KPC and NDM carbapenemases.
   2. For patients admitted to healthcare facilities in the United States after recently being hospitalized (within the last 6 months) in countries outside the United States, consider each of the following:
      1. Perform rectal screening cultures to detect CRE colonization.
      2. Place patients on Contact Precautions (including use of gloves and gowns for any contact with patient) while awaiting the results of these screening cultures.

Additional Information

• CDC HAN: http://emergency.cdc.gov/HAN/han00341.asp
• CDC guidance for preventing the spread of CRE in healthcare settings: http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html
• A laboratory-based screening protocol is available at (http://www.cdc.gov/HAI/pdfs/labSettings/Klebsiella_or_Ecoli.pdf)
• Patient facility transfer forms are available at http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf
• CDC’s CRE toolkit (http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html
• Delaware Division of Public Health, Bureau of Epidemiology (24/7): 1-888-295-5156

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