CRE: The New Superbug

As if methicillin-resistant Staphylococcus aureus (MRSA) infections weren’t bad enough, hospitals are now seeing the rise of a new group of superbugs—carbapenem-resistant Enterobacteriaceae (CRE). To make matters worse, CRE infections can be deadly.

The Centers for Disease Control and Prevention (CDC) cite three major reasons why CRE infections are important:

  • They are linked to mortality rates of up to 50%.
  • They can confer high levels of resistance to other antibiotics, leaving clinicians with few therapeutic options.
  • They are endemic in several major cities and have spread to 41 states since 2001. They are likely to spread further.

Normally, Enterobacteriaceae, such as Klebsiella species and Escherichia coli, live in the intestines. When these bacteria spread outside their normal habitat, they can cause serious infections, such as pneumonia, meningitis, and bloodstream, urinary tract, and wound infections. Previously, clinicians reserved carbapenems and certain other drugs to treat severe infections, especially those caused by highly drug-resistant bacteria. Now CRE infections have appeared that are:

  • not susceptible to cabarpenems, including doripenem, meropenem, and imipenem
  • resistant to third-generation cephalosporins, including ceftriaxone, cefotaxime, and ceftazidime.

Susceptibility to CRE Infection

CRE infections primarily attack sick patients in acute and long-term healthcare facilities. These infections are more likely to occur in:

  • immunocompromised patients
  • patients with invasive devices, such as mechanical ventilators or urinary or intravenous catheters
  • patients with wounds caused by surgery or injury
  • patients who receive long courses of certain antibiotics.

CRE bacteria usually spread through contact with infected or colonized people, especially through contact with wounds or stool. Patients who are colonized with CRE can be asymptomatic and can spread the infection as they move between hospitals, nursing homes, clinics, and other facilities.


Treatment and Prevention

For patients who are colonized with CRE, treatment is unnecessary. For those with CRE infection, individualized treatment decisions are required. The care provider may consider either using one of the few antibiotics that remains effective against CRE or other treatments, such as draining the infection.

To prevent the spread of CRE, the CDC recommends following these eight core measures in acute and long-term care facilities:

  1. Perform vigilant hand hygiene.
  2. In acute care settings, follow contact precautions for patients who are colonized or infected with CRE. In long-term care settings, place CRE-colonized or infected residents on contact precautions if they are at high risk for transmission.
  3. Participate in education about preventing the transmission of multidrug-resistant organisms, including CRE.
  4. Minimize the use of devices, such as central venous catheters, endotracheal tubes, and urinary catheters, that increase the risk of CRE transmission.
  5. House colonized or infected patients in single rooms whenever possible. If not, cohort them together.
  6. Promote rapid notification of clinical and infection control staff when laboratory tests identify CRE.
  7. Work to limit antimicrobial use for appropriate indications, duration, and the narrowest spectrum antimicrobial appropriate for the patient.
  8. Use CRE screening to identify unrecognized CRE colonization among those who may come into contact with patients with known CRE infection or colonization.

For facilities with CRE transmission, the CDC suggests supplemental measures, such as conducting active surveillance and bathing patients with 2% chlorhexidine. Other experts recommend federal reporting requirements for CRE infections. For example, the use of Medicare and Medicaid billing codes for these infections could make them easier to track—and help prevent their spread.

For more information about proper hand hygiene techniques to prevent the spread of infection, look into The Joint Commission/OSHA Compliance online course from Mosby eLearning. Mosby’s Nursing Consult provides related resources, including a Clinical Update on “Winning the Battle Against Multidrug-Resistant Organisms.” Call 1-866-416-6697 for details.


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