HomeMy WebLinkAboutacute-care-facility-cre-packet-adaApproved for use 02/28/19
*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 Aneeka Chaudhry, Agency Director PUBLIC HEALTH DEPARTMENT Kimi Watkins-Tartt, Director
Division of Communicable Disease Control and Prevention Nicholas Moss, MD, MPH, Director Health Officer 1100 San Leandro Kavita Trivedi, MD Communicable Disease Controller
San Leandro, CA 94577
Tel (510) 618-3452
Fax (510) 273-3744
Caring for Patients with Carbapenem-resistant
Enterobacteriaceae (CRE) in Acute-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 info rmation 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.
Approved for use 02/28/19
Dear Infection Control Practitioner(s),
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 culture or a positive
clinical culture for CRE during hospitalization, OR
•receipt of a patient with a previously identified CRE infection or colonization
Carbapenem-resistant Enterobacteriaceae (CRE) was designated by the CDC in 2013 as one of
the three most urgent drug resistant threats in the United States. CRE are a group of bacteria that
are resistant to carbapenem antibiotics and nearly all available antibiotics. They can cause
serious illness and death. Invasive bloodstream infections are fatal in 40% -50% of cases. An
estimated 9,000 CRE infections caused 600 deaths yearly in the U.S.
CRE are easily transmitted from infected or colonized patients to other patients via hands of
health care workers and/or contaminated equipment or environments. CRE that produce
carbapenemases, enzymes that rapidly destroy carbapenem antibiotics, are of special concern.
These organisms, known as Carbapenemase-producing CRE (CP CRE), can rapidly spread their
drug resistance genes in health care settings.
CRE has increasingly been recognized in Alameda County and the San Francisco (SF) Bay Area,
with cases, clusters, and outbreaks being reported, both in health care settings and the
community. On June 15th, 2017, Alameda County issued a health officer order which requires
health care providers and laboratories to report all CRE cases and positive laboratory results for
CRE defined as E. coli, Klebsiella spp, and Enterobacter spp 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)
Alameda County Public Health is committed to providing guidance and recommendations,
facilitating interfacility communications, and supporting our healthcare partners to promote safe
patient care.
Infection control designees in healthcare settings can help reduce the spread of CRE by ensuring
that their facility has policies/protocols in place to enable implementation of proper infection
control measures, intra and inter-facility communications, and reporting of CRE cases to
Alameda County Public Health Department.
In addition to ensuring that patient care practices are consistent with internal policies and
protocols, Alameda County Public Health strongly urges that the implementation of the
recommendations contained in this packet.
Respectfully,
Acute Communicable Diseases Team Alameda County Public Health
[See recommendations and resources on the following five pages]
Approved for use 02/28/19
Recommendations Checklist for Acute Care Facilities
Recommendations are subject to change on a case-by-case basis and are advised as of date sent
CP-CRE* SPECIFIC RECOMMENDATIONS
To be implemented with all known and presumed CP-CRE cases (colonized or infected)
☐a)
☐b)Patients with CP-CRE must be isolated to their room while in Acute Care settings
c)Transfer of patients with CP-CRE within the facility should be minimized and
coordinated with input from infection control staff.
☐d)
to a CP-CRE case (see section 1.c.ii below)
☐e)
settings
*Carbapenemase-producing CRE (CP-CRE), are a higher public health priority and require enhanced
infection prevention & control measures. However, all CRE, including non-carbapenemase producers
(non-CP-CRE), are considered multi-drug resistant & require intervention.
PATIENT CARE RECOMMENDATIONS
1)Contact Precautions
☐a)CRE patients must always be on Contact Precautions in Acute Care settings.
☐
b)Personal Protective Equipment (PPE) including gloves and gowns should:
i.be used, every time, by all staff and visitors entering the patient’s room,
ii.be available outside the patient’s room and donned before entering,
iii.be properly doffed (removed) and discarded directly before leaving a patient’s
room,
iv.also include masks and eye protection or face shields as indicated per
standard precautions for MDROs (section V.A.5.a/b. of infection control
guidelines)
☐
c)If this patient was not on Contact Precautions at time of admission (ED or
inpatient), identify other patients who were potentially exposed to the CRE case,
either directly or through shared rooms, bathrooms, equipment, or common
healthcare personnel prior to implementation of Contact Precautions and take
the following actions:
a.For non-CP-CRE cases: Consider screening the patients identified above,
especially those who shared a room or bathroom with the patient for
extended periods.
b.For CP-CRE cases*: Send a list of patients, identified with MRN, type of
contact, and duration of contact to ACD to determine who should be screened
☐d)Ensure staff is following your facilities policies regarding transport of patients on
Contact Precautions
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2)Isolation and Cohorting
☐ a)
whenever possible.
☐
b)
patients who are at increased risk of transmitting CRE to others including those with
incontinence of stool or urine, draining wounds, or cognitive impairment that
prevents maintenance of personal hygiene.
☐
c)
made in collaboration with the CDPH Hospital Acquired Infection (HAI) Liaison’s
Office (email or 510-412-6060).
☐ d)
Liaison’s Office to determine if it is appropriate to cohort staff to care for multiple
☐ e)
policy for Contact Precautions and terminally cleaned upon transfer or discharge.
3)Communicate CRE status clearly whenever transferring or discharging patient
☐
another facility
Control Transfer Form (IICTF) to notify the receiving facility, the transport company,
and the Alameda County Public Health Department.
☐
home with home health referral
Interfacility Infection Control Transfer Form (IICTF) to notify the home health agency,
the transport company, and the Alameda County Public Health Department.
☐ home without home health referral
Interfacility Infection Control Transfer Form (IICTF) to notify the transport
company, and the Alameda County Public Health Department.
The IICTF is available on the Alameda County Provider Reporting Page
4)Staff Education
☐
Care Staff:
Like other infectious diseases such as C. diff and MRSA, staff should be familiar with CRE
and why aggressive infection control measures are needed to prevent transmission.
•Existing policies for CRE/MDRO management, Contact Precautions,
equipment/room disinfection, and patient transfers should be reinforced regularly.
•Staff should be supported in providing patients and visitors with appropriate
materials and education (see below).
•Staff should be comfortable must also be trained in filling out the Interfacility
Infection Control Transfer Form and notifying the appropriate people when planning
to transfer or discharge a patient with CRE.
Care Staff Education Materials/Resources:
•Carbapenem-resistant Enterobacteriaceae in Healthcare Settings
•CDC CRE Toolkit
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☐
Environmental Services (EVS) Staff:
•Provide in-service/education to EVS staff to reinforce and refresh on
cleaning/disinfecting policies for Contact Precautions and/or CRE cases.
•Ensure all patient care staff are educated regarding the appropriate cleaning of
critical equipment used for patients
a)EVS Staff Education Materials/Resources:
•Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008:
b)CDC Environmental Checklist for Monitoring Terminal Cleaning (CDC, 2010)
5)Patient, Family, and Visitor Education
☐ steps that they can take to prevent spread such as notifying healthcare providers of
CRE/MDRO diagnosis.
☐ donning and doffing of PPE.
☐
In addition to CRE specific recommendations described above, the following facility wide infection
control strategies are recommended for acute care facilities in Alameda County based on our
current MDRO incidence.
FACILITY WIDE RECOMMENDATIONS
1)Promote hand hygiene
☐ More information and resources are available on the CDC website.
2)Minimize the use of Invasive Devices
☐
•CDC Guidelines for the Prevention of Intravascular Catheter-Related
Infections, 2011
•HICPAC Guideline for Prevention of Catheter-associated Urinary Tract Infections
2009
3)Promote Antimicrobial Stewardship
☐
4)Flag patients with CRE infection or colonization
☐ measures. CRE cases should be placed on Contact Precautions upon every re-
admission. Re-screening to “clear” patients is NOT recommended.
(CONTINUED ON FOLLOWING PAGE)
5)Consider active surveillance for CRE cases such as admission screening
and pre-emptive isolation of patients at higher risk of CRE
☐
Risk factors for CRE colonization or infection include history of receiving healthcare in a
foreign country, history of extended hospitalizations, high antimicrobial use, presence of
indwelling devices (such as endotracheal tubes, feeding tubes, and catheters), open
wounds, and multiple medical problems.
6)Chlorhexidine Bathing
☐
Chlorhexidine bathing has been shown to prevent HAIs and reduce levels of colonization in
certain MDROs including CRE. Consider daily chlorhexidine bathing of patient in high risk
settings such as ICUs and for patients with indwelling medical devices.
Links to Resources
•Alameda County CRE Health Officer Order, June 13, 2017
•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
•General Infection Control Resources
•Contact Precaution Resources
•CDC CRE in Healthcare Settings website
•CDC CRE Toolkit