Carbapenemresistant Enterobacteriaceae CRE Isolation Jennifer Sanguinet CoChair NVASP

Carbapenem-resistant Enterobacteriaceae (CRE) Isolation Jennifer Sanguinet, Co-Chair, NVASP BSIS, FAPIC, MBA-HCM Director Infection Prevention, Sunrise Hospital

Why Worry? • CRE is associated with mortality rates up to 50% • Enterobacteriaceae are known to be a common cause of community-associated infections • CRE have historically primarily been associated with healthcareacquired/associated infections or exposure BUT SO WAS MRSA ONCE………

CRE Definition • CDC defines CRE as Enterobacteriaceae that are: • Resistant to any carbapenem antimicrobial (i. e. , minimum inhibitory concentrations of ≥ 4 mcg/ml for doripenem, meropenem, or imipenem OR ≥ 2 mcg/ml for ertapenem) OR • Documented to produce carbapenemase • In addition: • For bacteria that have intrinsic imipenem nonsusceptibility (i. e. , Morganella morganii, Proteus spp. , Providencia spp. ), resistance to carbapenems other than imipenem is required.

Surveillance • Identify through microbiology in conjunction with infection prevention routine surveillance • Quantify on a regular basis (annually or biannually) to determine number or proportion within a facility • Consider basic epidemiology review of cases to determine commonalities among exposures, wards, facilities, etc. • In Nevada, the Health Department will follow up with the facility on lab positive cases, however it is suggested to report any positive cases proactively. Soon mandatory reporting of CRE will be implemented.

Intervention: Hand Hygiene • Promote staff ownership • Monitor adherence and communicate the rates directly • Provide immediate, none punitive feedback for missed opportunities • Be sure products are well stocked including towels, soap, and alcohol-based hand sanitizer. • Be the example you expect of others

Intervention: Contact Precautions • All patients colonized or infected with CRE should be placed on contact precautions, patient and family education is paramount • Wash hands Before PPE Donning • Gloves & Gowns Upon Entry for all • Remove Gloves & Gowns upon Exit & Wash hands • Contact Precautions are intended to limit the organism transmission outside of the patient room

Contact Precautions for how long? • Recommendations per SHEA/CDC & NVASP are Contact precautions should be maintained until: • Patient is off antibiotics and asymptomatic • At least 3 -6 months has passed since the last positive result • Patient is no longer within the index hospital stay when the organism was identified- if feasible • Patient is negative on at least two separate occasions for surveillance rectal cultures during the 3 to 6 month observation period

Other Interventions • Education of Healthcare Workers in PPE, Isolation (why, who and duration), and risks of transmission • Assure all high contact room points are sanitized by staff daily • Minimize invasive devices. Use Disposables • Early Notification from lab to infection prevention • Bathe patients with Chlorhexidine 2% • Screening Contacts should be done based on links to colonized patients • Active surveillance should be done for high risk admissions from known high risk populations

COMMUNICATION IS KEY • Communication within Nevada should be done using the Infection Control Transfer Form where the information can easily be checked off and caregiver to caregiver notification occurs • Reiterate to staff that in the transfer report the CRE must be referred to and the need for contact isolation must be part of the information that the sending nurse communicates. If they also include a reference to the Infection Control Transfer Form for contact information of the facility IP, it will help their IP with any questions. Attach all positive cultures in the transfer packet. • Ensure all readmitted patients can be identified easily by history

Thank you! References: CDC: Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) updated November 2015 https: //www. cdc. gov/hai/pdfs/cre/CRE-guidance 508. pdf AHRQ CRE Control and Prevention Toolkit https: //www. ahrq. gov/hai/patientsafety-resources/cre-toolkit/index. html Inter-facility transfer form example: https: //www. cdc. gov/hai/pdfs/toolkits/Interfacility-IC-Transfer-Form-508. pdf