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Deconstructing the infection control bundles for the containment of carbapenem-resistant Enterobacteriaceae

Munoz-Price, L. Silviaa,b,c,d; Quinn, John P.e

Current Opinion in Infectious Diseases: August 2013 - Volume 26 - Issue 4 - p 378–387
doi: 10.1097/01.qco.0000431853.71500.77

Purpose of review Rates of carbapenem-resistant Enterobacteriaceae (CRE), especially Klebsiella pneumoniae carbapenemase (KPC)-producing Gram-negatives, have increased worldwide. Infections caused by these organisms have been associated with a high mortality, which might be due in part to the limited availability of antibiotic options. Therefore, prevention of acquisition of these organisms is essential. This review summarizes published infection control interventions (bundles) that have been implemented for the control of outbreaks caused by KPC-producing organisms.

Recent findings A total of 15 bundles of interventions aimed at controlling CRE outbreaks are presented. The interventions included combinations of increased compliance with hand hygiene and contact precautions, environmental cleaning, early identification of asymptomatic carriers, and physical separation of CRE-positive patients and their staff. Three bundles had staggered implementation of interventions with their later phase involving a combination of rectal surveillance cultures for identification of asymptomatic CRE carriers, cohorting of CRE-positive patients, and cohorting of the staff caring for CRE carriers. All three staggered bundles successfully decreased their CRE acquisition rates after implementation of their later phases.

Summary Bundles combine multiple interventions targeting different levels of the transmission pathways and most include increased hand hygiene and contact precautions. However, bundles implemented in phases would seem to indicate that active surveillance cultures and the subsequent cohorting of patients and staff based on these results might be particularly beneficial for controlling horizontal transmission.

aDepartment of Medicine

bDepartment of Anesthesiology

cDepartment of Epidemiology and Public Health, University of Miami

dJackson Memorial Hospital, Miami, Florida

eAstra Zeneca, Waltham, Massachusetts, USA

Correspondence to L. Silvia Munoz-Price, MD, LSMP Park Plaza West L-302, 1611 N.W. 12th Avenue, Miami, FL 33136-1096, USA. Tel: +1 305 585 6820; fax: +1 305 585 0201; e-mail:

© 2013 Lippincott Williams & Wilkins, Inc.