CRE

Carbapenem-resistant enterobacteriaceae (CRE)

Antibiotic resistant bacteria occur throughout the world. They are of particular concern when found in places where there are likely to be individuals more susceptible to infection, such as hospitals. Almost every hospital in New Zealand will have experienced instances of antibiotic resistant bacteria. This is a long-standing and well-known problem not only in New Zealand but internationally.

Over-prescribing - of antibiotics, including poor prescribing and wide-spread use in animals and agriculture, has been a factor worldwide in development of antibiotic resistant bacteria.

The public has an important role in preventing the emergence and spread of antibiotic resistant organisms.

Individuals should become more aware of the common causes of illness and accept that every visit to the doctor should not result in a prescription. Many common diseases are caused by viruses against which antibiotics, and most medicines, are ineffective. Prescribing and taking antibiotics in these instances increase the exposure of bacteria to antibiotics and can help unnecessarily increase resistance to antibiotics.

FREQUENTLY ASKED QUESTIONS

What are CRE?

CRE stands for “carbapenem-resistant enterobacteriaceae.” Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals. They can cause infections both in community and healthcare settings. Some Enterobacteriaceae have become resistant to all or almost all antibiotics. 

What are carbapenems?

Carbapenems are a powerful group of broad spectrum beta-lactam (penicillin-related) antibiotics which, in many cases, are our last effective defence against multi-resistant bacterial infections. What is of concern, however, is that resistance is beginning to emerge to carbapenems. New antibiotics need to be developed to counter bacteria with this type of resistance; what is more, hospitals need good infection control to prevent their spread. 

Why does carbapenem resistance matter?

Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until now, doctors have relied on them to successfully treat certain ‘difficult’ infections when other antibiotics have failed to do so. In a hospital, where there are many vulnerable patients, spread of resistant bacteria can cause problems. 

How does someone pick up CRE?

Sometimes this bacteria can be found, living harmlessly, in the gut of humans and so it can be difficult to say when or where it is picked it up. However, there is an increased chance of picking up these bacteria if someone has been a patient in a hospital overseas or in a hospital that has had patients carrying the bacteria, or if been in contact with a carrier elsewhere. 

How is CRE spread?

If a patient in hospital is carrying this bacteria it can get into the ward environment and can also be passed on by direct contact with that particular patient.  In healthcare settings, CRE are usually transmitted from person to person often via the hands of healthcare personnel or via contaminated medical equipment. For this reason, patients will normally be accommodated in a single room, or cohorted together, and increased environmental cleaning carried out.

Does carriage of CRE need to be treated?

If a person is a carrier of CRE they do not need to be treated. However, if the bacteria have caused an infection then antibiotics will be required. 

Who gets ill from antibiotic resistant bacteria?

An infection usually develops in hospital patients who are vulnerable for some other reason – they are elderly or very sick, or who have an open wound (such as a bedsore) or a tube (such as a urinary catheter) going into their body. 

What can be done to reduce the rate of antibiotic resistant bacteria infections?

GPs have a role to play by not over-prescribing antibiotics and patients can help by taking any antibiotics as directed. Hospitals and other healthcare facilities should not over use broad spectrum antibiotics and use good infection prevention and control measures including:

Hand hygiene

Perform hand hygiene using alcohol gel or with soap and water before and after any patient contact, before and after a procedure, after contact with blood and body fluids or after having contact with the patient surroundings. Hand hygiene must also be performed before the donning of gloves and after the removal of gloves.

Gloving

Wear gloves when there is a potential to have contact with blood, body fluids, mucous membranes, secretions, excretions, and contaminated items. Perform hand hygiene and don gloves immediately before a procedure and remove gloves promptly after use and perform hand hygiene. This should be before touching other uncontaminated items and environmental surfaces, and before going to another patient, to avoid transfer of bacteria to other patients or environments.

Masking and gowning

Wear a gown, mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions

Appropriate handling of devices/equipment

All patient equipment should be cleaned and disinfected between patients. Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of bacteria to other patients and environments.

Appropriate handling of laundry
Linen soiled with blood, body fluids, and secretions must be disposed of in a linen bag with a disposable liner.

 

What precautions can care givers take outside healthcare facilities?

In places such as at home, in a childcare facility, school or other institution, there is little risk of causing disease from antibiotic resistant bacteria because healthy people are at low risk of getting infected. However, good hygiene procedures should be followed:

Hand hygiene

Care givers should wash their hands with soap and water, or use alcohol gel after physical contact with the infected or colonised person and before leaving the home.

Gloving

Disposable gloves should be worn if contact with body fluids is expected and hands should be washed or use alcohol gel after removing the gloves.

Laundry

Towels used for drying hands after contact with anyone known to have an infection should be used only once. Linens should be changed and washed on a routine basis or immediately if they are soiled.

General hygiene

The environment should be cleaned routinely and when soiled with body fluids.

Notification

Advise doctors and other healthcare personnel who provide care for the patient if the patient is colonised or infected with an antibiotic resistant organism.

Is it safe to be in the same room as a person with an infection caused by antibiotic resistant bacteria?

Healthy people are at very little risk of getting infected. As long as family members or other visitors are healthy, it's okay for them to be in the same room with an infected patient. Casual contact, such as touching or hugging, is okay but any visitors must wash their hands before leaving the hospital room or patient's home.

Anyone who is already ill or who have weak immune systems should avoid handling the body substances of a person with an infection and should limit their physical contact to no more than casual touching. They should also wash their hands after physical contact with any infected person.

Other resources

Some of information sourced from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/329227/Acute_trust_toolkit_for_the_early_detection.pdf (external link)  

The following CDC site has information for Health Care Workers: http://www.cdc.gov/hai/organisms/cre/cre-clinicianFAQ.html (external link)