CRE - Washington State Hospital Association

Carbapenem-Resistant Enterobacteriaceae (CRE):
Testing and Response
CRE identified at clinical laboratory
Rapid notification to clinicians and facility infection preventionists to implement appropriate treatment and infection control precautions
E. coli or Klebsiella spp. resistant to all third generation
cephalosporins tested AND non-susceptible to 1 or more
carbapenem (exception: if only non-susceptible to
ertapenem, or if ertapenem is the only carbapenem tested, isolate must be resistant to ertapenem with MIC >=2
mcg/ml or zone <=18 mm)
Lab submits to Washington State Public Health Lab (PHL)
with antimicrobial susceptibility test result
CRE confirmed 1
Carbapenem-resistant Proteus spp.,
Providencia spp. and Morganella spp.
that are non-susceptible ONLY to
imipenem but susceptible to other
carbapenems
Healthcare provider/Infection Preventionist
reports to local health and asks lab to submit
to PHL with antimicrobial susceptibility test
“Tier 3 ” 3 Intrinsic CRE
No need to submit to PHL
Public Health Lab
Testing
PCR testing for common carbapenemase genes
+ positive
Any CRE isolate, including genera other than E.
coli and Klebsiella spp., which meets CRE susceptibility profile at left AND is obtained from a
patient who was hospitalized outside of
Washington or Oregon in the prior 6 months
- negati
CRE ruled out 2
PHL sends results to submitter
3
“Tier 2” Non-carbapenemase
CRE
ve
“Tier 1” 3 Carbapenemase-positive CRE (CP-CRE)
PHL sends results to submitter, LHJ and facility
ACTIONS BY LOCAL HEALTH
 Investigate case to identify source and if transmission to other patients
occurred.
 Strongly consider surveillance cultures of epi-linked patients, or a
point prevalence survey on affected ward.
 Recommend contact precautions in all healthcare settings.
 Ensure healthcare providers and facilities are aware of infection
transmission risk.
Updated Mar 2014 DOH 420-99

Ensure educational materials go to patient, family members and
home caregivers.
 Request review of facility microbiology records for additional cases.
 LHJ reports case through PHIMS as a “Rare Disease of Public Health
Significance” and complete and fax supplemental DOH CRE report
form to DOH Communicable Disease Epidemiology (206-418-5515).
 Dept of Heath Communicable Disease Epidemiology reports case to
CDC.
1
CRE confirmed
 Meets state surveillance case definition (Enterobacteriaceae resistant to all third generation cephalosporins tested AND non-susceptible to 1 or
more carbapenem [exception: if only non-susceptible to ertapenem, or if ertapenem is the only carbapenem tested, isolate must be resistant to
ertapenem with MIC >=2 mcg/ml or zone <=18 mm] using CLSI M100-S22 breakpoints for carbapenems).
2
CRE ruled out
 Does not meet state surveillance case definition (Enterobacteriaceae not carbapenem resistant, or not resistant to all third generation cephalosporins tested).
3
Definitions of Tier 1, 2 and 3 CRE:
 Tier 1: Enterobacteriaceae (all spp.) that are polymerase chain reaction (PCR) positive for carbapenemase production). Carbapenemase-producing
CRE (CP-CRE) are very rare in Washington, critically important for public health, and require the most aggressive infection control measures.
 Tier 2: CRE that have acquired resistance NOT due to carbapenemase production. These organisms are regularly identified by clinical laboratories in
Washington, are important to control at the facility level, and require intensified infection control measures, including contact precautions. Most
CRE reported in Washington qualify as Tier 2 organisms.
 Tier 3: Certain CRE resistant due to intrinsic (natural) resistance. These tier 3 CRE are similar to other drug-resistant Gram-negative pathogens (ESBL)
and require the same infection control precautions applied to other similar multidrug resistant organisms. CRE in this category include Proteus spp.,
Providencia spp., and Morganella spp. which demonstrate ONLY imipenem non-susceptibility (and test doripenem, ertapenem, or meropenem susceptible). For example, a Morganella morganii isolate that tests imipenem-resistant AND ertapenem susceptible is included in Tier 3.
4
Common Carbapenemases:
 KPC—Klebsiella pneumoniae carbapenemase
 NDM—New Delhi metallo-β-lactamase
 VIM—Verona integron encoded metallo-β-lactamase
 IMP—Imipenemase metallo-β-lactamase
 OXA-48—Oxacillinase-48
Infection Control for CRE
Acute Care Facilities
Long Term Care Facilities
Tier 1
(Infected or
colonized)
Contact precautions, private room Permanent contact precautions (do not use the word “Isolation”), private room or patient and/or staff
or patient and/or staff cohorting. cohorting, sign on the door of the resident's room; permanent dedication of ALL personal care equipment; best possible hand hygiene for both employees and resident (before leaving room); best possible
sanitizing and disinfecting resident's room and ALL care items touching the resident.
Tier 2
(Infected or
colonized)
Contact precautions, with private Time-limited contact precautions (do not use the word “Isolation”), including private room or patient and/
room or patient and staff
or staff cohorting, sign on the door of the resident's room; dedication of ALL personal care equipcohorting, if feasible.
ment; best possible hand hygiene for both employees and resident (before leaving room); best possible
sanitizing and disinfecting resident's room and ALL care items touching the resident. See Oregon CRE
Toolkit for guidance on discontinuation of contact precautions in LTC settings.
Tier 3
Facility specific precautions as for ACTIVE infection with MDRO or Tier 3 CRE—contact precautions.
MDRO organisms such as ESBL.
COLONIZED with MDRO or Tier 3 CRE—standard precautions, unless uncontained drainage, incontinent, or
other behavioral transmission risk.
Updated March 2014

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