CDC Warns About Carbapenem-Resistant Enterobacteriaceae

Miriam E. Tucker

March 05, 2013

Carbapenem-resistant Enterobacteriaceae (CRE) are an increasing and deadly threat in US healthcare facilities, according to the Centers for Disease Control and Prevention.

Healthcare facilities need to act now by implementing "detect and protect" strategies to prevent CRE from spreading to the community, CDC Director Thomas Frieden, MD MPH, said March 5 in a telebriefing announcing a special report of new CRE data in the Morbidity and Mortality Weekly Report.

He said the CDC is issuing an early warning now, while the resistant infection is so far limited to inpatient facilities. "The good news is that we now have a window of opportunity to prevent its further spread."

Enterobacteriaceae, a large family of gram-negative bacilli that normally live in the human gastrointestinal tract, are a common cause of both community- and healthcare-acquired infections. Although resistance to broad-spectrum antibiotics has been seen for several decades, resistance to the carbapenem antimicrobial class is recent and appears to be spreading.

In the first half of 2012 alone, nearly 200 hospitals and long-term acute-care facilities in 42 states treated at least 1 CRE-infected patient compared with just 1 facility in 1 state in 2011, according to Dr. Frieden.

He called CRE "nightmare bacteria" that post a "triple threat," because the organisms are resistant to nearly all antibiotics, they kill up to half of those infected, and they are capable of spreading their resistance to other bacteria.

He advised that hospitals, nursing homes, and long-term care institutions adopt the recommendations issued previously in a CRE prevention toolkit. It advises measures such as requesting information about CRE-infected patients from laboratories; enforcing standard infection control and contact precautions; grouping CRE-infection inpatients together, using dedicated staff and equipment if possible; and prudent antimicrobial use.

Hospitals that have adopted the toolkit's recommendations have seen dramatic reductions in CRE infections, Dr. Frieden said.

New Data

The new data come from the CDC's National Healthcare Safety Network and its predecessor, the National Nosocomial Infection Surveillance System.

Among 3918 US acute-care hospitals that perform surveillance for either catheter-associated urinary tract infections or central-line-associated bloodstream infections, the proportion reporting having 1 or more CRE infections during the first 6 months of 2012 was 4.6% (181) for short-stay hospitals and 17.8% (36) for long-term acute-care hospitals.

Hospitals reporting CRE infections were most often in the Northeastern United States and were more commonly larger and teaching hospitals.

In the last decade, a significant increase was seen in the proportion of reported Enterobacteriaceae that were CRE, going from just 1.2% in 2001 to 4.2% in 2011. The greatest increase by CRE species was for Klebsiella, which went from 1.6% to 10.4%.

A separate 5-month analysis of laboratory results from within the CDC's Emerging Infections Program at 3 sites (Minneapolis, Atlanta, and Portland) found a total of 72 total CRE infections among 64 patients. The majority (89%) were isolated from urine, and 10% from blood.

Although most were collected outside of acute-care hospitals, the majority of those had recent healthcare exposures such as hospitalization.

"Everyone involved in medical care, from [chief executive officers] to patient care staff to health departments, needs to act rapidly in a coordinated fashion to stop CRE before our window to control these bacteria closes," Dr. Frieden said.

Dr. Frieden has disclosed no relevant financial relationships.