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Published on March 05, 2013

University of Colorado Hospital Advises Public About Antibiotic-Resistant Bacteria

This is an update of a news release first published in October 2012.

Over the past decade, doctors around the world have seen an increasing number of bacteria that are resistant to traditional antibiotics. 

CRE

CRE (image source: CDC)

One of these bacteria, called CRE, is highly resistant to most antibiotics and can be transmitted to other patients, especially those with compromised immune systems. In this way, CRE is similar to MRSA.

Studies have found it is usually acquired overseas, especially in India, Pakistan, Bangladesh and Britain where the organisms are much more common. The CDC says hundreds of hospitals in 41 states, including Colorado, have now seen CRE, which stands for Carbapenem-resistant Enterobacteriaceae.

This CRE is of the Enterobacteriaceae family, which lives naturally and harmlessly along with thousands of other types of bacteria in people’s digestive tract.

Studies have not shown CRE to be harmful when contained in a person’s digestive tract, but experts want to make sure the bacteria doesn’t cause an infection in another part of the body because it is highly resistant to antibiotics.

Screening tests identified patients

Like other hospitals, the Infection Prevention and Control department and infectious diseases experts at University of Colorado Hospital (UCH) identified patients in 2012 who tested positive as carrying one of these antibiotic-resistant bacteria.

Infectious diseases experts encourage all health care and long-term care facilities to be on the lookout for CRE. It is likely that other, undetected cases have occurred both in Colorado and across the nation.

UCH infectious disease experts conduct numerous screening tests to ensure that no others are exposed to the organisms. UCH experts continue to work with the Colorado Department of Public Health (CDPHE) and the Centers for Disease Control to track any infections to their sources.

The value of stringent infection control protocols

Other hospitals or long-term care facilities might not have the resources to test and identify these organisms, but strict infection control and diligent testing procedures at UCH caught the bacteria. UCH encourages other facilities to be on the lookout for CRE and to perform screenings. The infection prevention procedures for CRE are identical to procedures followed for more-common bacteria like MRSA.

Some of the actions Infection Prevention Specialists at UCH are taking for patients who test positive for a drug-resistant organism like CRE or MRSA:

  • Any hospitalized patients carrying CRE will be in contact precautions:
    • Gowns and gloves are required for all visitors, nurses, doctors and staff entering these patients’ rooms.
    • Only two visitors and no children are allowed.
    • Any hospitalized patients’ rooms are grouped together, and dedicated nurses care exclusively for these patients.
    • Infection prevention experts closely follow these patients and ensure that all staff members follow protocols.
    • These experts perform regular audits, including bacterial cultures of equipment and patient rooms, to ensure that all cleanings have been thorough and that no traces of the organism remain.
  • Experts investigate the medical and travel history of these patients to determine where and how the exposures might have happened.
  • UCH is working with the CDC and CDPHE to advise other facilities of the bacteria and to share knowledge of possible treatments.
  • Thorough cleaning of equipment and patient rooms will kill bacteria including CRE and MRSA.

Questions and Answers

What is CRE?

  • CRE, which stands for carbapenem-resistant Enterobacteriaceae, is a family of bacteria that is difficult to treat because they are resistant to most antibiotics. This means that most antibiotics no longer work against these infections.
  • Common Enterobacteriaceae include E. coli, Klebsiella and Enterobacter species, and are normally found in human intestines (gut). 
  • Enterobacteriaceae are one of the most common causes of bacterial infections in both the community and in healthcare settings.
  • CRE infection typically occurs in ill patients and people with exposure to healthcare settings like hospitals and long-term care facilities, such as skilled nursing facilities and long-term acute care hospitals. CRE infections are not usually found in the general community.
  • In healthcare settings, CRE infections usually occur among sick patients who are receiving treatment for other conditions.  Sometimes these bacteria can spread outside the gut and cause serious infections such as pneumonia, bloodstream infections, urinary tract infections, wound or surgical site infections, and meningitis.

Why is this so significant?

  • CRE was identified in Colorado for the first time in 2012, though according to the CDC it has now been seen in 41 other states. However, it is common in several foreign countries.
  • Treating people with CRE infections is very difficult because there are few treatment options. Infections caused by these organisms have been associated with high rates of morbidity (disease) and mortality (death).
  • Patients can carry CRE, but might not be sick or show symptoms of an infection. However, these bacteria can be transmitted to other patients who might develop a serious infection, especially in healthcare settings.
  • CRE are an emerging and significant threat to public health.

What is University of Colorado Hospital doing to address the appearance of CRE?

  • Immediately after discovering the presence of CRE, infectious disease physicians and the hospital’s infection control department responded to provide the patients impacted immediate and appropriate care as well as to begin the process of eradicating the bacteria from the hospital.
  • Subsequent tests have not detected any presence of the bacteria, and those tests show no other patients have been exposed.

How can CRE spread?

CRE bacteria are usually spread person to person through direct contact (such as touching) with infected or colonized people.

How can CRE transmission be prevented?

The spread of CRE can be prevented by:

  • Washing hands with soap and water or an alcohol-based hand sanitizer before and after caring for a patient.
  • Thorough cleaning and disinfection of medical equipment and rooms.
  • Detecting patients who carry CRE as soon as possible.
  • Adhering to precautions that prevent healthcare workers from transmitting the bacteria to other patients, such as wearing gloves and a gown before entering the room of a patient with CRE.
  • Using antimicrobials appropriately and only when necessary.
  • Clear communication between facilities when a patient is transferred from one facility to another.

The Centers for Disease Control and Prevention (CDC) provides health care facilities with specific actions they can take to stop CRE (see "Resources" below).

Who can get CRE?

Any person can carry CRE in their gastrointestinal tract; however, not all people will develop an infection.  People are said to be colonized when they have the bacteria in or on their body without it causing an infection.

 

People who are at higher risk of developing infection might:

  • Be immunocompromised (have a weakened immune system)
  • Have indwelling devices, such as urinary catheters or central venous catheters
  • Be mechanically ventilated  (on a breathing machine)
  • Have multiple exposures to healthcare facilities (especially long term care facilities)
  • Have poor functional status (unable to perform usual daily activities)
  • Have taken antibiotics inappropriately

Healthy people are at a lower risk for developing an infection with CRE.

How can I protect myself from CRE?

  • The best way to protect yourself from bacteria-related illnesses is to wash your hands frequently.
  • Follow appropriate usage when taking antibiotics.
  • Make sure you, staff members, patients and visitors all use the anti-bacterial foam that’s around the hospital.

What is CDPHE doing to prevent this from spreading to other facilities?

CDPHE, CDC, local health departments, and any healthcare facilities with identified CRE patients are collaborating to:

  • Limit the spread of CRE.
  • Ensure appropriate communication with other healthcare facilities that might receive a patient who tested positive for CRE, in order to initiate precautions and proper infection control strategies to prevent the spread of CRE.

What is NDM?

  • NDM stands for New Delhi Metallo-Beta-Lactamase. NDM is a type of enzyme that bacteria can carry, and most antibiotics no longer work against these infections.
  • NDM is one of several mechanisms that can lead to the development of CRE. In the US, NDM is not the most common mechanism. Prior to the cases identified in Colorado, only 15 NDMs had been reported to CDC.
  • The NDM resistance gene in bacteria was first identified in a patient from New Delhi, India but it has been identified from patients in several different countries including the United States.Colorado is the ninth state to identify CRE with this resistance mechanism.

It is currently unknown how NDM-carrying bacteria were introduced into UCH.

What are carbapenems?

Carbapenems are a group of antibiotics that are usually reserved to treat serious infections, particularly when these infections are caused by bacteria that are highly resistant to other antibiotics.

 

Resistance to carbapenems makes these antibiotics ineffective in killing the resistant bacteria.

Resources

Further information about CRE can be found on the CDC website at: http://www.cdc.gov/HAI/organisms/cre/index.html

 

CDC recommendations to control CRE, which can be found in the CDC “2012 CRE Toolkit - Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE)” at:  http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html

 

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