Introduction
Terms, definitions and tables used in this guidance
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For the purposes of harmonisation with other guidance documents and reports in the literature, carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing Enterobacteriaceae (CPE), are both referred to as CRE in this document. Where necessary to specify that carbapenem resistance is due to a carbapenemase, however, the term CPE is used.
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The measures suggested in this guidance document are not limited to CRE, but may also be applicable to any species of multidrug-resistant Enterobacteriaceae (MDR-E). The decision whether to apply to other MDR-E will be left to local decision-makers and experts.
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The terms “rectal” and “faecal” “carriage” are used in the literature interchangeably with the term “colonisation”. In this guidance document, the term “carriage” is used as an umbrella term to include both “colonisation” and “clinical infection”.
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The term “healthcare facilities” refers to any type of acute and long-term care facilities.
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The term “long-term care facility” (LTCF) refers to any of the heterogeneous types of facilities which “provide delivery of a broad range of services and assistance to people who are limited in their ability to function independently on a daily basis, i.e. to autonomously perform the basic activities of daily living, over an extended period of time. Long-term care comprises a mix of both health and social components, therefore pertaining to both health and social sectors” [7]. These can include “nursing homes, skilled nursing facilities, assisted living, rehabilitation facilities, residential homes, long-term psychiatric facilities” [8]. Countries can define their facilities as LTCFs, by applying and interpreting the general definition provided here.
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Contact precautions include: patient placement, gowns/aprons, gloves, patient transport, disposable noncritical patient-care equipment/patient-dedicated use of such equipment and environmental measures [9].
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In this guidance document, the maximum duration of carriage for “at-risk” patients post discharge is considered to be 12 months. In situations when more than 12 months have elapsed, the admitting healthcare worker (HCW), in consultation with the infection prevention and control (IPC) team, shall decide whether to consider a patient “at-risk”.
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Active screening of “at-risk” patients on admission to a healthcare setting, encompasses rectal screening, as well as screening from any other site which is either actively infected, e.g. draining wounds, or considered to be colonised.
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This guidance document includes six tables (Tables 1, 2, 3, 4, 5 and 6) and a flowchart (Fig. 1). Tables 3, 4, 5, and 6 contain answers to the three main questions posed in this guidance document. The flowchart is a tool to assist frontline workers and IPC teams in their evaluation and decision-making when admitting patients to healthcare settings.
Carbapenem-resistant Enterobacteriaceae
Acronym | Name or type | First isolated |
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KPC |
Klebsiella pneumoniae carbapenemase | 1996 |
VIM | Verona integron-encoded metallo-β-lactamase | 1997 |
OXA-48 | OXA-type carbapenemase | 2001 |
NDM | New Delhi metallo-β-lactamase | 2008 |
Carriage of CRE
Patient transfer between healthcare settings within the same country | |
Patient transfer between healthcare settings across borders | |
Prior admission to an acute care facility | |
Prior admission to a LTCF | |
Household transmission from patients discharged from healthcare settings | [47] |
Foreign travel (e.g. recreational and medical tourism) |
Objective
Methods
A systematic review
Expert meetings
Questions addressed in the guidance
Creating the tables and a flowchart
Screening, detection, and management of patients “at-risk” for CRE carriage
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If the screening test result is positive for CRE, patient isolation and contact precautions are continued, with the addition of supplemental measures in Table 6.
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If the screening test result is negative for CRE, consideration may be given to discontinuing patient isolation and contact precautions, unless there is an indication for their continuation, e.g. colonisation with a different multidrug-resistant organism (MDRO) or transmissible infection. Core measures are maintained for all patients at all times.
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If a patient has a history of CRE carriage, followed by a negative screening test result, the decision on discontinuation of patient isolation and contact precautions remains an open issue. The decision should then be based on a case-by-case risk assessment undertaken by a senior decision maker, in conjunction with advice of the IPC team. Two main concerns contribute to this uncertainty:a.The possibility of having a false negative result. False negatives can occur due to the lack of standardised protocols for sampling and microbiological testing, as well as issues, such as sampling errors and prior use of antimicrobials, amongst others. A varied approach can be seen in studies that examine duration of carriage and microbiological cultures and PCR are used alone, or in various combinations, as well as with different lengths of time between testing, e.g. two or three negative screening cultures taken a week apart [27‐32].
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The duration of CRE carriage is unknown and multi-factorial. The possibility of false negative test results warrants consideration, as part of the decision to discontinue supplementary precautions.
Microbiological methods for the detection of CRE
Epidemiological exposures that place patients “at-risk”
Any patient who has one of following risk factors is “at-risk” for carriage of CRE: | |
a. A history of an overnight stay in a healthcare setting in the last 12 months b. Has been either dialysis-dependent or received cancer chemotherapy in the last 12 months c. Known history of previous carriage of CRE in the last 12 monthsa
d. Has been previously epidemiologically linked to a patient known to be a carrier of CREb
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A history of admission to a healthcare setting in the last 12 months
Patients who have been either dialysis-dependent or received cancer chemotherapy in the last 12 months
Previous carriage of, or infection with a CRE in the last 12 months
Epidemiologically linked to a patient known to be a carrier of CRE
Areas of uncertainty for active screening of specific populations
Should healthcare workers be screened for CRE upon admission to a healthcare setting?
Should all returning travellers from abroad be screened for CRE upon admission to a healthcare setting?
Core infection prevention and control measures for all patients
Antimicrobial stewardship
Hand hygiene
Microbiological capacity
Intervention (Evidence source) | Comments on measure and implementation |
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Antimicrobial stewardship (SR) | ✓ Healthcare settings should have a formally defined antimicrobial stewardship programme for assuring appropriate antimicrobial use [54] ✓ Healthcare settings should have facility-specific treatment (and prophylaxis) recommendations, based on national guidelines and local microbial susceptibility, to assist with empiric antimicrobial selection [54] ✓ Should be part of a multimodal, integrated programme, along with IPC |
Environmental cleaning (SR) | ✓ Responsibilities for environmental cleaning and equipment reprocessing must be well-defined and described in hospital internal procedures ✓ Hospitals should review the processes for environmental cleaning and equipment reprocessing, follow instructions of manufacturers, and consider screening (or auditing) to ensure quality of processes |
Equipment reprocessing (SR) | |
Faecal and medical waste management (EO) | ✓ Adequate toilet facilities should be available for all patients ✓ When patients are incontinent or have diarrhoea, bedpans or commodes may be indicated |
Guidelines and processes (EO) | ✓ Adherence to evidence-based guidelines, processes and pathways for the prevention of healthcare-associated infections (EO) |
Hand hygiene (SR) | ✓ There is evidence for the effectiveness of hand hygiene, as part of a multimodal strategy, for the reduction of transmission of MDROs [56‐58] ✓ Patients should be encouraged to perform hand hygiene, as suggested by WHO guidelines [58] |
Infrastructure and capacity for patient accommodation (EO) | ✓ Healthcare managers should ensure that the ward occupancy does not exceed the capacity for which it is designed [72] ✓ Healthcare managers should ensure that infection prevention and control building recommendations are followed |
Microbiological capacity (EO) | ✓ Healthcare settings should have access to microbiology laboratories with capacity to detect CRE from both clinical and screening specimens ✓ Healthcare settings should have systems in place to ensure that potentially significant results are communicated by the microbiology laboratory in a timely manner to the relevant staff in the healthcare setting ✓ Should be part of a multimodal, integrated programme, along with IPC and antimicrobial stewardship |
Staff education (SR) | ✓ On-going education and training should be provided to all staff with patient contact, with specific reference to CRE |
Staffing (EO) | ✓ Staffing, appropriate skill level and workload of frontline healthcare workers must be adapted to acuity of care and the number of pool/agency nurses and physicians minimised [72] |
Surveillance (EO) | ✓ Routine surveillance of healthcare-associated infections |
Supplemental measures for “at-risk” patients
Pre-emptive patient isolation and decisions on patient placement
Contact precautions
Nurse cohorting
Communication on patient/resident transfer within or between healthcare settings
Active surveillance and contact tracing when patients are epidemiologically linked to others who are CRE carriers
Intervention (Evidence source) | Comments on measure and implementation |
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Pre-emptive isolation of patients on admission (SR) | ✓ Isolation in single rooms either upon admission or when patients are actively screened for carriage of CRE ✓ Decision for patient placement should be made after individualised risk assessment by, and consultation with the IPC team ✓ En suite or bathrooms designated for use by known carriers, or commodes are strongly suggested for all patients on contact precautions for CRE |
Active screening on admission (SR)a
| ✓ Active screening of all “at-risk” patients on admission to healthcare setting |
Contact precautions (SR) | ✓ Contact precautions should be used for direct contact with patient or their environment ✓ En suite or bathrooms designated for use by known carriers, or commodes are strongly suggested for all patients on contact precautions for CRE |
Intervention (Evidence source) | Comments on measure and implementation |
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Contact precautions (SR) | ✓ Contact precautions should be continued when patient is suspected positive or confirmed positive ✓ Contact precautions should be used for direct contact with patient or their immediate surroundings and/or surfaces ✓ En suite or bathrooms designated for use by known carriers, or commodes are strongly suggested for all patients on contact precautions for CRE |
Patient isolation or patient cohorting (SR) | ✓ When patients were previously pre-emptively isolated they should remain isolated if results of active screening are suspected positive or confirmed positive ✓ If not already isolated, the patient should be isolated upon receipt of suspected or confirmed positive microbiological result |
Case communication (SR) (Communication about microbiological results within healthcare settings) | ✓ Communication on patient/resident transfer within a healthcare setting ✓ Positive results should be communicated by the microbiology laboratory in a timely manner to the relevant staff ✓ Healthcare record flagging and use of patient administration IT system flagging if feasible within healthcare setting, regarding any positive microbiological information ✓ Consider including patient’s carriage or infection status for CRE as a separate diagnosis ✓ Positive microbiological data should be communicated in a timely fashion when patients are transferred between units |
Communication on patient/resident transfer between healthcare settings ✓ Transfer documentation must accompany patient/resident, with information about known carriage or infection status ✓ Consider including patient’s carriage for CRE as a separate diagnosis ✓ Positive microbiological data should be communicated in a timely fashion when patients are transferred between healthcare settings within regions, country and across borders ✓ The responsibility to notify the receiving healthcare setting of patient’s/resident’s relevant microbiological data rests with the referral healthcare setting ✓ Ensure communication by a responsible person of local current or recent clusters or outbreaks to the receiving institution when patients/residents are transferred | |
Communication on patient transfer between healthcare settings in different countries ✓ Transfer documentation must accompany patient, with information about patient’s carriage or infection status ✓ Consider including patient’s carriage or infection status for CRE as a separate diagnosis ✓ Recognise the importance of implementing the cross-border Directivea in preventing inter-country spread of CRE ✓ Ensure timely communication with receiving healthcare setting for all positive patient microbiological data ✓ Ensure that patient’s rights for personal data protection are secured when sharing patient data between healthcare settings1 | |
Active screening of contacts (SR) | ✓ Active screening of patients/residents who are epidemiologically linked to a known CRE carrier |
Nurse cohorting (SR) | ✓ While acknowledging existing limitations in staffing and other resources, cohorting or designated nursing staff is strongly suggested for the care of patients with CRE |
Enhanced environmental cleaning (EO) | ✓ Enhanced cleaning should be performed, especially for areas in close proximity to CRE carriers ✓ Terminal disinfection of rooms should be performed upon transfer or discharge of patients |
Bathing in antiseptic (SR) | ✓ Data mostly available from Gram-positive organisms; can be used as a horizontal approach for other MDROs [73] ✓ Due to lack of strong evidence, can be considered for use in difficult-to- control situations |