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Carbapenem-Resistant Enterobacteriaceae


Carbapenem-Resistant Enterobacteriaceae (CRE) are emerging healthcare-associated infections (HAIs) that have important clinical, epidemiological, and public health implications [1]. These organisms have enzymes that break down carbapenems and make them ineffective. Infections with these germs are very difficult to treat, and can be deadly—one report cites they can contribute to death in up to 50% of patients who become infected. The most common enzyme is Klebsiella pneumoniae carbapenemase (KPC). KPC-producing CRE have spread throughout the US, including California, but still remain relatively uncommon in most hospitals [2]. CRE mediated by metallo-ß-lactamase (MBL) enzymes are more common in other countries but have been identified in the US since 2009, including in California.

The presence of KPCs and MBLs conferring multi-drug resistance highlights the need for California healthcare providers to act aggressively to prevent the emergence and spread of these unusual organisms.  A recent outbreak of carbapenem-resistant Klebsiella pneumoniae in a Colorado hospital emphasized that undetected, asymptomatically colonized patients contributed to the size of the outbreak [3].  The importance of timely active surveillance cultures when CRE is identified to direct infection control measures and limit further transmission is crucial.  Specific laboratory protocols have been developed to assist laboratories in processing active surveillance cultures for CRE [4]

In healthcare settings, CRE infections most commonly occur among patients who are receiving treatment for other conditions. 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.

In response to this healthcare threat, the Centers for Disease Control and Prevention (CDC) issued a health advisory which now includes specific recommendations for patients with a history of an overnight stay (within the last 6 months) in a healthcare facility outside the US [5].  These new recommendations expand those provided in ‘Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE): 2012 CRE Toolkit’ [6].  Antimicrobial stewardship programs that ensure the appropriate use of antibiotics can also reduce the spread of multi-drug resistant organisms (California Antimicrobial Stewardship Program Initiative).  To help facilitate improved communication between facilities, an interfacility transfer form was developed to specify infection control and multi-drug resistant organism information at the time of transfer [7]

California CRE Prevalence Survey, 2012

The CDPH HAI Program recently completed a statewide survey to assess regional differences in CRE occurrence, and to to assist facilities implement prevention strategies based on their regional prevalence as outlined by the CDC's CRE Toolkit.  Guidance for healthcare facilities and recommended public health actions are stratified by regional CRE prevalence for 1) regions with no or rare CRE, 2) regions with few CRE, and 3) regions with common CRE, although no such regions yet exist in the state.  Please follow the links below to the slide presentations for each region types and a summary overview of CRE in all regions.
*Windows Media Player is required to view the webinars.

Please contact the HAI Program at HAIProgram@cdph.ca.gov with questions or concerns regarding the prevention and management of CRE in your healthcare facility. 


CRE Prevention

Everyone has a role to play in preventing the spread of CRE. According to the CDC, these are the steps to be taken by patients, clinicians and healthcare facilities:

Patients Should:
  • Tell your doctor if you have been hospitalized in another healthcare facility or country.
  • Take antibiotics only as prescribed.
  • Expect all doctors, nurses and other healthcare providers to wash their hands with soap and water or an alcohol-based hand rub before and after touching your body or tubes going into your body.
  • Clean your own hands often, especially:
    • Before preparing or eating food
    • Before touching your eyes, nose, or mouth
    • Before and after changing wound dressings or bandages or handling medical devices
    • After using the bathroom
    • After blowing your nose, coughing, or sneezing

For more information follow the link to the CDC: CRE Patient Page [8].

Clinicians Should:
  • Know if patients with CRE are hospitalized at your healthcare facility, and stay aware of CRE infection rates. Ask if a patient has received medical care somewhere else, including another healthcare facility or country.
  • Place patients currently or previously colonized or infected with CRE on Contact Precautions. Whenever possible, dedicate rooms, equipment, and staff to CRE patients.
  • Wear a gown and gloves when caring for patients with CRE.
  • Perform hand hygiene – use alcohol-based hand rub or wash hands with soap and water before and after contact with patients or their environment.
  • Alert the receiving facility when you transfer a CRE patient, and find out when a patient with CRE transfers into your facility.
  • Make sure your laboratory immediately alerts clinical and infection prevention staff when CRE are identified.
  • Prescribe and use antibiotics wisely.
  • Discontinue devices like urinary catheters as soon as no longer necessary.

For more information follow the link to the CDC: CRE Clinician Page [9].


Healthcare Facilities Should:
  •  Require and strictly enforce CDC guidance for CRE detection, prevention, tracking, and reporting.
  • Make sure their lab can identify CRE.
  • Promote antimicrobial stewardship.
  • Recognize CRE as important to patient safety.
  • Understand CRE prevalence in the facility and in the region.
  • Identify colonized and infected CRE patients in the facility and ensure Contact Precautions are implemented.
  • When transferring a patient, require staff to notify the other facility about infections, including CRE.
  • Participate in regional and facility-based prevention efforts designed to stop the transmission of CRE.
  • Notify health departments of CRE clusters or outbreaks.

For more information follow the link to the CDC: CRE Healthcare Facility Page [10]

To learn more about CRE and other resistant bacteria, please refer to the CDC's Antibiotic Resistance Threats in the United States, 2013 [11]

  1. CDC Vital Signs- CRE
  2. Carbapenemase- Producing CRE in the United States
  3. Notes from the field: Colorado Outbreak
  4. CDC Laboratory Protocol for Detecting CRE
  5. The CDC Health Advisory
  6. The CRE Toolkit
  7. CDPH Interfacility Transfer Form
  8. CDC: CRE Patients Page
  9. CDC: CRE Clinicians Page
  10. CDC: CRE Facilities Page
  11. CDC: Antibiotic Resistance Threats in the United States, 2013


Last modified on: 10/30/2014 2:38 PM