menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities.
Bibliographic Source(s)
Centers for Disease Control and Prevention (CDC). Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR Morb Mortal Wkly Rep. 2009 Mar 20;58(10):256-60. [3 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Carbapenem-resistant Enterobacteriaceae or carbapenemase-producing Enterobacteriaceae infection

Guideline Category
Management
Prevention
Clinical Specialty
Critical Care
Emergency Medicine
Family Practice
Infectious Diseases
Internal Medicine
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Clinical Laboratory Personnel
Emergency Medical Technicians/Paramedics
Health Care Providers
Hospitals
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)

To provide updated recommendations from Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for the control of carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae in acute care (inpatient) facilities

Target Population

Patients infected with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care (inpatient) facilities

Interventions and Practices Considered
  1. Contact precautions
  2. Detection of nonsusceptibility and carbapenemase production in Enterobacteriaceae isolates, particularly Klebsiella species and Escherichia coli
  3. Active microbiologic surveillance
  4. Point prevalence surveys
Major Outcomes Considered
  • Point prevalence
  • Morbidity
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Not stated
Description of Method of Guideline Validation

Not applicable

Recommendations

Major Recommendations

This report provides updated recommendations from Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for the control of carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae in acute care (inpatient) facilities.

CDC and HICPAC Recommendations

In light of the clinical and infection control challenges posed by carbapenem-resistant Enterobacteriaceae (CRE) and advances in the ability to detect these pathogens, CDC and HICPAC have developed new guidance for CRE infection prevention and control in an effort to limit the further emergence of these organisms (see Box in original guideline document). These recommendations are based on strategies outlined in the 2006 HICPAC guidelines for management of multidrug-resistant organisms in health-care settings.

All patients colonized or infected with CRE or carbapenemase-producing Enterobacteriaceae should be placed on contact precautions. Acute care facilities should establish a protocol, in conjunction with Clinical and Laboratory Standards Institute (CLSI) guidelines, to detect nonsusceptibility and carbapenemase production in Enterobacteriaceae, particularly Klebsiella spp. and Escherichia coli, and immediately alert epidemiology and infection control staff members if identified. All acute care facilities should review microbiology records for the preceding 6-12 months to ensure that previously unrecognized CRE cases have not occurred. If previously unrecognized cases are identified, facilities should conduct a point prevalence survey (a single round of active surveillance cultures) in units with patients at high risk (e.g., intensive care units, units where previous cases have been identified, and units where many patients are exposed to broad-spectrum antimicrobials) to identify any additional patients colonized with carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli. The recommended surveillance culture methodology is aimed at detecting carbapenem resistance or carbapenemase production in Klebsiella spp. and E. coli only, because 1) this method facilitates performing the test in the microbiology laboratory without the use of molecular methods and 2) these organisms represent the majority of CRE encountered in the United States. When a case of hospital-associated CRE is identified, facilities should conduct a single round of active surveillance testing of patients with epidemiologic links to the CRE case (e.g., those patients in the same unit or patients who have been cared for by the same health-care personnel).

The goal of active surveillance is to identify undetected carriers of carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli. Identification of other cases among patients with epidemiologic links to persons with confirmed infection suggests patient-to-patient transmission; in such instances, infection prevention measures should be vigorously reinforced, and surveillance cultures repeated periodically (e.g., weekly) until no new cases are identified. Situations where periodic point prevalence surveys repeatedly fail to identify other colonized patients suggest that infection control measures at the facility are effective in controlling transmission. In such instances, consideration should be given to halting active surveillance cultures in response to clinical cases and replacing them with periodic point prevalence surveys in units with patients at high risk to ensure that carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli do not reemerge.

Because the prevalence of CRE is low in the majority of U.S. hospitals, routine microbiologic surveillance of persons admitted, such as that performed in some facilities to detect carriage of methicillin-resistant Staphylococcus aureus, is not recommended. However, in some areas of the United States, notably New York City, CRE are routinely recovered, including from many patients who are admitted from the community. In these settings, point prevalence surveys in response to detected clinical cases might be less useful in controlling transmission of CRE. Facilities in regions where CRE are endemic should monitor clinical cases of CRE and implement the intensified (i.e., Tier 2) infection control strategies outlined in the 2006 HICPAC guidelines if rates of CRE are not decreasing. The challenges to hospitals of allocating additional resources to prevent and control CRE are balanced by the fact that an aggressive infection control strategy, such as that recommended in this report, offers an opportunity to limit the impact of these problematic pathogens while CRE prevalence remains low in most U.S. hospitals.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate prevention and management of carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae in acute care settings

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
  • References to non-Centers for Disease Control and Prevention (CDC) sites on the Internet are provided as a service to Morbidity and Mortality Weekly Report (MMWR) readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Centers for Disease Control and Prevention (CDC). Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR Morb Mortal Wkly Rep. 2009 Mar 20;58(10):256-60. [3 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Mar 20
Guideline Developer(s)
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

Advisory Committee on Immunization Practices (ACIP)

Healthcare Infection Control Practices Advisory Committee (HICPAC)

Composition of Group That Authored the Guideline

Authors: W Lledo; M Hernandez; E Lopez, MD; OL Molinari, MD; RQ Soto, MD; E Hernandez; N Santiago; M Flores; GJ Vazquez, MD; IE Robledo, MD, Univ of Puerto Rico; E García-Rivera, MD; A Cortes; M Ramos, Puerto Rico Dept of Public Health; R Goering, PhD, Creighton Univ, Omaha, Nebraska; A Srinivasan, MD; C Gould, MD; N Stine; M Bell, MD; K Anderson; B Kitchel; B Wong; JK Rasheed, PhD; J Patel, PhD, Div of Healthcare Quality Promotion, National Center for the Preparedness, Detection, and Control of Infectious Diseases; K Tomashek, MD, Div of Vector-Borne Infectious Diseases, National Center for Vector-Borne, Enteric, and Mycotic Diseases; E Llata, MD; CJ Gregory, MD, EIS officers, CDC

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site External Web Site Policy.

Print copies: Available from the Centers for Disease and Control Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on December 23, 2010.

Copyright Statement

No copyright restrictions apply.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...