HomeMy WebLinkAboutcre-packet-ltcf-20190823*CP-CRE: Any Enterobacteriaceae that is resistant to Carbapenem antibiotics AND produces carbapenemase (or is
suspected of producing carbapenemase). Assume any CRE Klebsiella pneumoniae is CP-CRE until proven otherwise by
laboratory testing.
**non-CP-CRE: Any Enterobacteriaceae that is resistant to Carbapenem antibiotics and tests negative for the production of carbapenemases or the presence of carbapenemase genes.
ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY Colleen Chawla, Agency Director
PUBLIC HEALTH DEPARTMENT Kimi Watkins-Tartt, Director
Division of Communicable Disease Control and Prevention Erica Pan, MD, MPH, Director & Interim County Health Officer
1000 Broadway, Ste 500 Sandra Huang, MD, Communicable Disease Controller
Oakland, CA 94607
Tel (510) 267-3250
Fax (510) 273-3744
Caring for Patients with Carbapenem-resistant
Enterobacteriaceae (CRE) in Long-Term Care Facilities
COVER SHEET
Thank you for reporting the CRE case(s) at your facility. The recommendations in this packet
should be implemented immediately for any patient with a current or past infection or
colonization with Carbapenem-resistant Enterobacteriaceae (CRE). This guidance is being
provided under the direction of the Alameda County Health Officer, as a supplement to
recommendations made by the California State Department of Public Health (CDPH) and the Centers
for Disease Control and Prevention (CDC).
Patient Name:
CRE organism species:
Is this a Carbapenemase producing CRE (CP-CRE): Yes*No** Unknown
CONFIDENTIAL INFORMATION
The attached material is intended for the use of the individual or organization to whom it is addressed, and may contain information that
is confidential, privileged and exempt from disclosure under applicable law. If you are not the intended recipient, you are notified that any use, distribution or copying of this document is strictly prohibited. In the event that you receive this communication in error, please
notify us immediately. Thank you.
Note: Privacy Rule (HIPAA) permits covered entities to disclose PHI without authorization to public health authorities or other entities
who are legally authorized to receive such reports for the purpose of preventing or controlling disease. This includes the reporting of
disease, conducting public surveillance, investigations, or interventions.
version 8.23.19
Dear Infection Control Designee,
You are receiving this packet because you have reported:
• a patient with a positive admission screening culture for CRE, OR
• a patient newly identified with a positive surveillance screening or clinical culture for CRE
during hospitalization, OR
• receipt of a patient with a previously identified CRE infection or colonization
Carbapenem-resistant Enterobacteriaceae (CRE) are a group of bacteria that are resistant to
carbapenem antibiotics and nearly all available antibiotics. CRE are easily transmitted between
infected or colonized patients via hands of health care workers and contaminated equipment or
environments. CRE that produce carbapenemases, enzymes that rapidly destroy carbapenem
antibiotics, are of special concern. The organisms, known as Carbapenemase-producing CRE (CP
CRE), can rapidly spread their drug resistance genes in health care settings.
CRE has been increasingly recognized and detected in Alameda County and the San Francisco (SF)
Bay Area, with cases, clusters, and outbreaks being reported in health care settings and the
community. In effort to reduce the spread of CRE, on June 15th, 2017, the Alameda County Public
Health Department (ACPHD) issued a health office order requiring health care providers and
laboratories to report all CRE cases and positive laboratory results for CRE defined as E. coli,
Klebsiella species, and Enterobacter species that are:
• resistant to any carbapenem antimicrobial, with a MIC of ≥ 4 μg/ml for doripenem, imipenem,
or meropenem; or ≥ 2μg/ml for ertapenem; OR
• documented to produce a carbapenemase, demonstrated using a CDC-accepted test
(modified Hodge, Carba-NP, metallo-β-lactamase); OR
• demonstrated to possess a carbapenemase gene (such as KPC, NDM, VIM, IMP, OXA-
48-type) using a CDC-accepted test (PCR, Whole Genome Sequencing)
ACPHD is committed to providing guidance and recommendations, facilitating interfacility
communications and supporting our healthcare partners to promote safe patient care.
Infection control designees can help reduce the spread of CRE by ensuring that their facility has
policies and protocols in place to enable implementation of proper infection control measures,
intra/inter-facility communications, and reporting of CRE cases ACPHD
In addition to ensuring that patient care practices are consistent with internal policies and protocols,
ACPHD strongly urges Enter Facility Name to implement the recommendations contained in this
packet.
Respectfully,
Acute Communicable Diseases Team
Alameda County Public Health Department
version 8.23.19
Use the following CRE Transmission Risk Assessment Questions to assess the current risk factors of
your patient with a current infection/colonization or history of infection/colonization with CRE. Factors
that affect the risk of transmitting CRE to others can change frequently in the long-term care
environment, therefore these questions/factors should be frequently reassessed. [a]
CRE Transmission Risk Assessment Questions: Reassess frequently [a]
ventilator dependent? ☐ Yes ☐ No
Is this patient highly or totally dependent on staff for ADLs? ☐ Yes ☐ No
Is this patient incontinent AND stool and/or urine cannot be reliably
contained?
☐ Yes ☐ No
Does this patient have indwelling medical devices such as tracheostomy
tube, urinary catheter, feeding tube, surgical drains, etc.? ☐ Yes ☐ No
draining wounds or other secretions ☐ Yes ☐ No
cognitively unable to maintain personal hygiene? ☐ Yes ☐ No
If YES to ANY of the above, your patient is considered High Risk for spreading CRE to others
Based upon your patient’s current risk factors for transmission, and the type of CRE organism identified
(CRE vs CP-CRE), implement the following infection control measures to prevent transmission of CRE
at your facility. There is an in-depth explanatory statement for each measure following the table.
Contact the Alameda County Acute Communicable Disease Section with any questions by emailing us
or by calling 510-267-3250. Please provide the patient’s name and DOB when calling.
RISK FOR SPREADING CRE (based on questions above)
High Risk Not High Risk
Recommended Infection Control
Measures
CP-CRE* CRE** CP-CRE* CRE**
Frequently reassess patients with a
history of CRE using the CRE
Transmission Risk Assessment
[a]
Yes Yes Yes Yes
N/A N/A
N/A N/A
if possible [g] if possible [g]
available, cohort patient [h] CDPH HAI Program before
[h]
of shift if able to do so without
compromising patient safety [k]
Yes
Yes
Yes
Yes
Recommendations continue on the next page
version 8.23.19
RISK FOR SPREADING CRE
Measures CP-CRE* CRE** CP-CRE* CRE**
Enhanced environmental cleaning [l] Yes Yes Yes Yes
Terminally clean room at discharge [l] Yes Yes Yes Yes
items (e.g., glucometer, ventilator,
thermometer,
[m]
Yes Yes Yes Yes
equipment that cannot be dedicated to
CRE patient (e.g., PT parallel bars and
gym mats,
[m]
Yes
Yes
Yes
Yes
Frequently re-evaluate the need for
and minimize the use of
invasive/indwelling devices [n]
Yes
Yes
Yes
Yes
Chlorhexidine bathing of
patient [o] Yes transmission
[o]
transmission
[o]
No
CRE [p] Not Recommended [p]
the transport company of CRE/MDRO
status prior to transferring patient [q]
Yes, send the Interfacility Infection Control Transfer
Form***
and notify the facility/agency of MDRO status verbally
when new cases of CRE are identified,
and when transferring CRE patient to
another facility or discharging to home
[r]
For new cases: Call (510-267-3250) and fax Confidential
Morbidity Report (CMR) to (510) 273-3744
For patient transfers: Fax a copy of the Interfacility
Infection Control Transfer Form*** to (510) 273-3744
Recommendations for visitors [s] See footnote [s]
*CP-CRE: Any Enterobacteriaceae that is resistant to Carbapenem antibiotics AND produces
carbapenemase (or is suspected of producing carbapenemase). Assume any CRE Klebsiella pneumoniae is
CP-CRE until proven otherwise by laboratory testing.
**non-CP-CRE: Any Enterobacteriaceae that is resistant to Carbapenem antibiotics and tests negative for the
production of carbapenemases or the presence of carbapenemase genes.
***Interfacility Infection Control Transfer Form
A brief explanation of each measure follows.
If you have any questions, please call 510-267-3250.
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Explanation of measures:
a. Assessing if your patient is High Risk for transmitting CRE to others:
Patients with the following risk factors are considered higher risk for transmitting CRE to others: ventilator
dependence, dependence on staff to perform all or most ADLs, incontinence of stool or urine that cannot
be reliably contained, indwelling medical devices including tracheostomy tube, urinary catheter, feeding
tube, surgical drains, etc., draining wounds that cannot be reliably contained, and/or cognitive impairment
that prevents maintenance of personal hygiene.1, 3, 15 These risk factors should be regularly reassessed by
staff and the presence of risk factors should lead to the implementation of appropriate infection control
measures. Patients should be frequently reassessed, using the CRE Transmission Risk Assessment
Questions or a similar tool during their time in a facility and any time there is a significant change in the
patient’s health status.
b. Hand Hygiene:
Proper hand hygiene ensured by ongoing monitoring of adherence remains the single most important
measure for preventing CRE transmission.4-5 Staff should always clean their hands before and after patient
care, before donning and after doffing gloves.2,4 Patients and visitors should also be taught to perform hand
hygiene correctly to prevent the spread of infection in the care setting and at home. The CDC recommends
the following techniques for effective hand hygiene2,6:
i. When cleaning your hands with soap and water: wet your hands first with water, apply soap, and
rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and
fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the
faucet.
ii. When cleaning your hands with an alcohol-based sanitizer: Put product on hands and rub hands
together, covering all surfaces until hands feel dry. This process should take around 20 seconds.
c. Standard Precautions:
Assume that an infectious agent could be present in any patient’s blood or body fluids. Decisions about
personal protective equipment (PPE) use are determined by the type of clinical interaction with the patient,
the degree of blood and body fluid contact that can be reasonably anticipated and by whether the patient
has been placed on isolation precautions.6 The CDC recommends the following PPE guidelines for
Standard Precautions2-3,6:
i. Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for
touching mucus membranes and non-intact skin
ii. Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin
with blood/body fluids, secretions, or excretions is anticipated
iii. Mask and goggles or a face shield – Use during patient care activities likely to generate splashes
or sprays of blood or other body fluids
d. Enhanced Standard Precautions:
For some residents, the risk of transmission can be reduced by infection control measures that are less
restrictive than contact precautions. Along with All Facilities Letter 19-22, the Enhanced Standard
Precautions for Skilled Nursing Facilities, 2019 15 provides a practical, resident-centered and activity-
based approach to implement measures to prevent MDRO transmission in SNFs. Recommendations for
the use of gowns and gloves by health care providers should be based on the activities being performed by
staff and an assessment of a resident’s risk for being colonized and likelihood of transmitting an MDRO.
The full guidance is available from CDPH and AFL 19-22
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e. Contact Precautions:
In addition to Standard Precautions, use Contact Precautions when caring for patients known or suspected
to have a serious illness easily transmitted by direct patient contact or by indirect contact with items in the
patient’s environment. Contact Precautions consist of wearing a gown and gloves for all patient
contact and contact with environmental surfaces in the patient’s room.2-3,6-7 A surgical mask and
goggles or face shield are also appropriate if contact with bodily fluids is anticipated. PPE should be readily
available immediately outside the patient’s room.
f. Door Signage:
A noticeable, easy to read sign should be placed on the outer threshold of the door for a patient who is on
contact or any other type of precaution. The sign should outline the appropriate Personal Protective
Equipment (PPE) needed for healthcare providers and visitors.
g. Private Rooms:
Patients with CRE should be placed in private rooms, especially patients with CP-CRE and patients with
non-CP CRE who are at high risk of transmitting this infection to others.8-9 If the number of single patient
rooms is limited, consult the “Patient Cohorting” section [h] below.
h. Patient Cohorting:
If private rooms are unavailable, it may be necessary to cohort patients based on the CRE organism of
each patient, the presence or absence of carbapenemase genes (CP-CRE), any other MDRO infections, risk
factors for transmitting CRE and other MDROs, risk factors for acquiring CRE or other MDROs, and the
ability to cohort staff for patient care. 1-3, 8-9 These decisions can be very complex and improper
cohorting can put other patients at increased risk of infection with CRE. Staff should confer with their
ID physician and may consult with the CDPH HAI Program email or call510-412-6060) whenever
assistance is needed to make a cohorting decision.
i. Restricting movement outside of rooms:
Patients with a current assessment that they are at low risk for transmitting CRE to others (“no” to all CRE
Transmission Risk Assessment questions), do not need to be confined to their rooms. However, patient
care that is high risk for contaminating the environment or staff should be done in the patient’s room with
appropriate PPE for the activity. Further guidance, including examples can be found in the Enhanced
Standard Precautions for Skilled Nursing Facilities (SNF), 2019 document (see footnote [d]).
For patients with current risk factors that increase the likelihood of transmission (“yes” to any of the CRE
Transmission Risk Assessment questions) the facility should strongly consider limiting patient movement
outside of their room to limit these risks. In addition, it is essential that high risk activities such as wound
care or manipulating devices, must be done in the patient’s room with strict implementation of standard
and contact precautions.
Examples of minimizing the risk of CRE transmission include: dressing the patient in clean, freshly
laundered clothing prior to leaving the room; ensuring the patient thoroughly washes their hands with soap
and water prior to leaving the room and maintains hand hygiene while outside the room; promptly
disinfecting surfaces that the patient comes in contact with (hand rails, wheel chairs, table tops, medical
devices or equipment, etc.); containing body fluids (wounds, secretions, incontinence) while the patient is
outside their
version 8.23.19
room; providing sitters to monitor patient behavior and to take corrective action to prevent
transmission as needed. If your facility has questions regarding these recommendations after reading
this packet, please email your inquiries to AcuteCD@acgov.org and we can provide you with
additional clarification.
j. Staff Cohorting:
Cohort nursing staff that care for patients with CP-CRE as resources allow. 1-3, 9-8 This is most important
and more feasible in facilities with ≥2 patients with CP-CRE. Nursing ratios as low as 1:1 have been
key to preventing further transmission in several outbreaks.8
k. Clustered Care:
Care by specialty staff such at Physical Therapy, Occupational Therapy, or Wound Care should be
clustered at the end of the staff’s shift whenever possible. This limits cross contamination if there is a
breakdown in Contact Precautions or other infection control measures. Care should never be delayed
or postponed if doing so will compromise patient safety or care.
l. Environmental Cleaning: Ensure that rooms of patients on Contact Precautions are prioritized for
frequent cleaning and disinfection (e.g., multiple times per day and at least once per shift).
Consideration should be given to providing and keeping disinfectant wipes in the room so that
bedside staff can clean and disinfect when environmental service staff are not available.
i. Enhanced Environmental Cleaning: Alert housekeeping and monitor environmental cleaning
of the room of a patient with CRE. Encourage frequent thorough cleaning of high-touch
surfaces (i.e. light switches, door handles, bed rails, overbed table, bedside commode, call
button, fixtures and surfaces in patient’s bathroom, cables/cords, etc.), particularly those near
the patient, and common areas outside the room. Ensure housekeeping is properly using an
EPA-registered disinfectant labeled for use in health care settings. 8,10-12
ii. Terminal Cleaning: Evaluate terminal cleaning using visual inspection plus quantitative
strategies such as UV fluorescence marker or ATP monitor before placing another patient in
that room. Please see the CDC environmental cleaning monitoring tool.
iii. Equipment Cleaning: Transmission of many healthcare acquired pathogens (HAPs) is related
to contamination of near-patient surfaces and equipment. Facilities are encouraged to
develop programs to optimize the thoroughness of cleaning reusable medical equipment
(e.g., infusion pumps, walkers, and call light buttons). Special consideration should be given
to ensure all surfaces and reusable parts are sufficiently cleaned and disinfected with an
approved cleaning solution/product.10-11
m. Dedicated patient care items:
Use patient-dedicate equipment for care of patients with CRE (e.g., glucometer, ventilator,
thermometer, BP cuff, stethoscope). If common use of equipment for multiple patients is unavoidable,
clean and disinfect such equipment before leaving the resident’s room and before use on another
patient (e.g., PT parallel bars and gym mats, wheelchair, lift equipment).2, 5-6,11 Additionally, limit
disposable supplies (i.e. gauze, tape, alcohol swabs, lancets) in the patient’s room to essential items.
Do not return unused supplies from a patient’s room to community supplies/stockroom.12
n. Minimizing the use of invasive devices:
Invasive devices such as indwelling urinary catheters, central venous catheters, and endotracheal
tubes pose a significant risk for the development of Healthcare-Associated Infections (HAIs). The need
for these devices should be assessed daily and discontinued as soon as possible. 2, 8
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o. Chlorhexidine (CHG) Bathing:
Chlorhexidine bathing with 2% Chlorhexidine or 2% Chlorhexidine impregnated wipes may be used to
bathe patients daily while in high risk settings or when at high risk for transmission. Also, consider
unit-wide CHG bathing, particularly if >1 CRE patient in a section/ward is identified.2,8 CHG bathing
reduces CRE skin contamination and has been a component of several successful CRE care bundles.8
p. Repeat testing:
Repeated bacterial cultures to demonstrate CRE clearance are not recommended. CRE can be shed
intermittently and patients may be colonized with CRE for an indefinite amount of time. Efforts to “clear”
CRE patients may lead to transmission in the future and are discouraged by ACPHD and CDPH.1
q. Interfacility Transfers:
Inform the receiving facility, transport vehicle personnel, and ACPHD in advance about patient’s
CRE and contact precaution status. We recommend using the Interfacility Infection Control
Transfer Form and informing ACPHD Communicable Disease unit by phone at 510-267-3250 prior to
transfer. 1,8,13 Document CRE status on the transfer form & ensure that the transporting agency and
receiving facility are aware of the patient’s condition. Ensure wounds, stool, and urine are
adequately contained, the patient performs hand hygiene prior to transport, and the patient is in
freshly laundered clothes/gown that have not been stored in the patient’s room.2,8,12
r. Public Health notification:
CRE is a reportable condition in Alameda County. Cases must be reported to the Alameda County
Public Health Department within 1 business day of lab results. Notify the Acute Communicable
Diseases Section of the Alameda County Public Health Department by phone at 510-267-3250 and fax
lab reports to 510-273-3744.13
s. Visitors:
Visitors should adhere to all infection control procedures implemented by the facility, including
donning PPE when indicated. Visitors should also wash their hands thoroughly after visiting the
patient, avoid eating and drinking in the patient’s room and avoid visiting if they are feeling ill.14 Please
educate patients and their families about their role in protecting other patients from infection.
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Links to Additional Resources
• Alameda County CRE Health Officer Order
• CDC Hand Hygiene Resources:
• Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
• CDC Environmental Checklist for Monitoring Terminal Cleaning (CDC, 2010)
• Antimicrobial Stewardship Resources and Implementation Toolkit
• CDPH Enhanced Standard Precautions Guidance (2019):
• Contact Precaution Resources
• CDC CRE in Healthcare Settings website
• CDC CRE Toolkit
References
1. California Department of Public Health (CDPH). CPO Quicksheet. Sacramento, CA: California Department of Public Health 2. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee
(HIPAC). Center for Disease Control & Prevention (CDC). 2007 Guideline for isolation precautions: preventing
transmission of infectious agents in healthcare settings.
3. National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion. Facility
guidance for control of carbapenem-resistant enterobacteriaceae (CRE). Washington, DC: US Department of Health
and Human Services, Center for Disease Control & Prevention; 2015.
4. World Health Organization (WHO). Glove use information leaflet. Geneva, Switzerland: World Health Organization;
2009.
5. Center for Disease Control & Prevention (CDC). Hand Hygiene in Healthcare Settings. Published March
15, 2016. Updated March 24, 2017.
6. California Department of Public Health (CDPH). Enhanced Barrier Precautions: Additional Considerations for CA
SNFs
7. Center for Disease Control & Prevention (CDC). Precautions to prevent spread of MRSA. Published August 25,
2015. Updated March 24, 2016.
8. California Association of Communicable Disease Controllers (CACDC), CRE Workgroup. Recommendations for
infection control for residents with CRE in long-term care facilities. Sacramento, CA: California Department of Public
Health; 2016.
9. Smith PW, Bennett G, Stevenson K, et al. SHEA/APIC Guideline: infection prevention and control in the long-term care
facility. American Journal of Infection Control [serial online]. September 2008;36(7):504-535. Available from: CINAHL
Complete, Ipswich, MA.
10. United States Environmental Protection Agency (EPA). Selected EPA-registered disinfectants. Updated July 31, 2017.
11. Center for Disease Control & Prevention (CDC) Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 12. California Department of Public Health (CDPH). Enhanced standard precautions. Sacramento, CA: California
Department of Public Health
13. Alameda County Public Health Department (ACPHD). Health officer order for reporting carbapenem-resistant
enterobacteriaceae (CRE) and submitting CRE isolates. Published June 13, 2017.
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14. Association for Professionals in Infection Control and Epidemiology (APIC). How to be a good visitor at a nursing home. Published January 22, 2014. 15. California Department of Public Health (CDPH). Enhanced Standard Precautions for Skilled Nursing Facilities
(SNF), 2019. Sacramento, CA: California Department of Public Health; 2019.