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Carbapenem-resistant Enterobacteriaceae: A growing threat

doi: 10.1097/01.NURSE.0000431154.37684.99

ON THE RISE among patients in healthcare settings, carbapenem-resistant Enterobacteriaceae (CRE) are causing hard-to-treat and often fatal infections.1 First reported in North Carolina in 2001, CRE are Gram-negative bacteria that are highly resistant to available antibiotics including carbapenems, a family of “last resort” antibiotics.

Mortality associated with CRE is as high as 40% to 50%.2 At least 4% of U.S. hospitals had at least one patient with a CRE infection during the first half of 2012; about 18% of long-term acute care hospitals had one.1

The CDC defines CRE as Enterobacteriaceae that are nonsusceptible to doripenem, meropenem, or imipenem, and resistant to all third-generation cephalosporins tested (ceftriaxone, cefotaxime, and ceftazidime).3 Two types of Enterobacteriaceae that are a normal part of the human gut bacteria, Klebsiella species and Escherichiacoli, can become CRE. CRE can transmit resistance to other bacteria in their family, increasing the risk of disease transmission.4

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Signs and symptoms

When found in a culture, CRE can represent colonization or infection. Colonization means the organism is found on the body but isn't causing any signs or symptoms. Colonizing CRE can cause infections if they gain access to areas of the body that are usually sterile.

CRE infections, which can occur almost anywhere in the body, include bloodstream infections, ventilator-associated pneumonia, and intra-abdominal abscesses.4 Most CRE infections involve the urinary tract, usually in patients with urinary catheters or who have urinary retention.4

Signs and symptoms of CRE infection vary with the site that's infected; for example, a cough if the infection is in the lungs or urinary symptoms if it's in the bladder. But it can also cause systemic signs and symptoms, such as fever or chills.4

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Transmission and infection

CRE most commonly affect patients who are receiving treatment for other conditions.5 Patients at increased risk for CRE infection include those with a poor functional status, exposure to an ICU, and mechanical ventilation.4 CRE are most commonly transmitted from person to person, usually by way of the hands of healthcare personnel or contaminated medical equipment in healthcare settings.4

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Preventing CRE transmission

Healthcare providers can help prevent CRE transmission by:

  • requesting immediate alerts when the lab tests identify CRE in a patient.
  • asking patients if they've received medical care somewhere else, including another country.
  • alerting the receiving facility when a patient with CRE leaves your facility.1
  • following contact precautions and proper hand hygiene when treating patients with CRE.1 This includes performing hand hygiene before putting on a gown and gloves; putting on the gown and gloves before entering the patient's room; and removing the gown and gloves and performing hand hygiene before leaving the patient's room.3
  • dedicating rooms, staff, and equipment to patients with CRE.
  • removing temporary devices such as central venous catheters, endotracheal tubes, and urinary catheters as soon as possible.1
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Getting infection rates down

CREs can be prevented. In Israel, infection rates in all 27 of its hospitals decreased by more than 70% in 1 year with a coordinated prevention program.1

The CDC's 2012 CRE Toolkit provides guidelines for facilities treating patients with CRE and those not yet affected by them. You can access these guidelines online at

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1. Centers for Disease Control and Prevention. Making health care safer: stop infections from lethal CRE germs now. CDC Vital Signs. 2013.
2. Guh AY, McDonald LC, Sinkowitz-Cochran R. Assessment of public health perspectives on responding to an emerging pathogen: carbapenem-resistant Enterobacteriaceae. J Public Health Manag Pract. 2013 Feb 26 [Epub ahead of print].
3. Centers for Disease Control and Prevention. Guidance for control of carbapenem-resistant Enterobacteriaceae (CRE). 2012 CRE toolkit.
4. Centers for Disease Control and Prevention. Carbapenem-resistant Enterobacteriaceae (CRE) infection: clinician FAQs. 2013.
5. Centers for Disease Control and Prevention. Carbapenem-resistant Enterobacteriaceae (CRE). 2013.
© 2013 by Wolters Kluwer Health | Lippincott Williams & Wilkins.