1. © Aurora Health Care, Inc. Carbapenem Resistant Enterobacteriaceae The Alphabet Soup of Infection Prevention Aurora Health Care System Infection Prevention

2. © Aurora Health Care, Inc. CRE-what is it? CRE are in a class known as multi-drug resistant organisms (MDROs) You have heard of other MDROs before –MRSA –VRE First reported in North Carolina in 2001, the U.S. is finding more and more cases of these bacteria every year

3. © Aurora Health Care, Inc. CRE-Carbapenem Resistant Enterobacteriaceae Enterobacteriaceae - family of bacteria commonly found in human gastrointestinal tract. Sometimes these bacteria can spread outside the gut and cause serious infections, such as urinary tract infections, bloodstream infections, wound infections, and pneumonia. In rare instances can become resistant to a group of antibiotics called “carbapenems”, often antibiotics of last resort

4. © Aurora Health Care, Inc. Why are CRE considered important? Resistant to multiple classes of antimicrobials limiting treatment options. Some Enterobacteriaceae have become resistant to all or almost all antibiotics. CRE can share their resistance with other Enterobacteriaceae, causing resistance to spread High mortality rate Up to 50% case mortality rate associated with invasive infections

5. © Aurora Health Care, Inc. Who can get an infection with CRE? Healthy people usually don’t get CRE infections. CRE primarily affect patients in acute and long-term healthcare settings CRE are more likely to affect immunocompromised patients or those with invasive devices (i.e. central lines, urinary catheters).

6. © Aurora Health Care, Inc. How does a CRE patient present? Infection versus Colonization A patient with CRE can be either infected or colonized.

7. © Aurora Health Care, Inc. Infection with CRE Infections are symptomatic –symptoms vary based on the site that is infected cough if in the lungs urinary symptoms if in the bladder –can also include general symptoms like fever or chills Invasive infections can have a mortality rate of up to 50%!

8. © Aurora Health Care, Inc. Infection with CRE Patients with CRE infections –Can spread the bacteria to others –Are symptomatic –Need treatment

9. © Aurora Health Care, Inc. Colonization with CRE Many people with CRE will have the germ in or on their body without it producing an infection. These people are said to be colonized with CRE. Patients are not symptomatic.

10. © Aurora Health Care, Inc. Colonized patients can spread CRE to others. There is no current treatment for decolonizing patients. Colonizing CRE strains can go on to cause infections if they gain access to body sites that are usually sterile like the bladder, the lungs, or the bloodstream. Colonization with CRE

11. © Aurora Health Care, Inc. How are CRE spread? To get a CRE infection, a person must be exposed to CRE bacteria. CRE are usually spread person to person through contact with infected or colonized people, particularly contact with wounds or stool. CRE can cause infections when they enter the body, often through medical devices like ventilators, intravenous catheters, urinary catheters, or wounds.

12. © Aurora Health Care, Inc. How are CRE spread? CRE are usually transmitted from person to person, often via the hands of healthcare personnel or via contaminated medical equipment. Prevent the exposure to CRE=prevent transmission of CRE Hand Hygiene Contact Precautions

13. © Aurora Health Care, Inc. CRE-what can we do? Identify patients with CRE quickly –No recommendations to screen patients for CRE at this time Isolate them in Contact Precautions immediately when they are found Communicate with your Infection Preventionist as soon as CRE is identified –Lab calls with info, place patient in contact precautions and call your Infection Preventionist

14. © Aurora Health Care, Inc. How can we prevent transmission of CRE? 1.Perform Hand Hygiene before & after every patient contact. –Either alcohol based hand rub or soap/water is effective –Do hand hygiene before donning gloves –Do hand hygiene after removing gloves –For every patient, every time –Especially when providing wound care and cleaning up stool

15. © Aurora Health Care, Inc. How can we prevent transmission of CRE? 2. Initiate Contact Precautions as soon as CRE is found –Contact = gown and gloves –Maintain precautions for duration of hospitalization and all future hospitalizations –Initiate automatic Contact Precautions on re-admit. Do not have to re-culture these patients when they are readmitted.

16. © Aurora Health Care, Inc. How can we prevent transmission of CRE? 1.Educate patients & visitors regarding prevention measures Hand Hygiene Contact Precautions 2.Provide hand off communication on CRE to other caregivers within the facility. 3.Provide verbal & written communication at time of discharge or transfer to outside facilities.

17. © Aurora Health Care, Inc. CRE-Summary CRE are a group of bacteria resistant to antibiotics Patients can be colonized or infected Any patient with CRE can transmit the bacteria To prevent transmission: –Strict Hand Hygiene –Contact Precautions for all health care encounters Work with Infection Prevention when have a case