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March 2009
Vol. 19 No. 3
Top Stories
CDC Calls for Stepped-up Efforts against Carbapenem-resistant Bugs

The Centers for Disease Control and Prevention (CDC) is advising acute care facilities to take steps to control the spread of carbapenem-resistant Enterobacteriaceae (CRE) now, before these deadly and hard-to-treat pathogens become widespread.

CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) issued new guidance on controlling these infections in the March 20 Morbidity and Mortality Weekly Report. In a March 17 conference call, CDC officials said they were highlighting the issue because CRE is a growing threat but one that can be contained with aggressive infection control measures.

“The time to act to control CRE is now,” said Arjun Srinivasan, MD, medical director of the Get Smart for Healthcare program at CDC’s Division of Healthcare Quality Promotion.

According to CDC, 8 percent of healthcare-acquired Klebsiella isolates reported to the National Healthcare Safety Network were carbapenem resistant in 2007, compared with less than 1 percent in 2000. Treatment options are limited for these extremely bad bugs, which are associated with higher mortality, longer hospital stays, and increased costs. The infections have been identified in 24 states and are regularly found in certain hospitals in New York and New Jersey.

The good news, Dr. Srinivasan said, is that they have not yet taken hold nationwide, and basic infection control procedures have successfully controlled the spread of CRE in recent outbreaks in Puerto Rico, Illiniois, and Israel.

The new guidance builds on HICPAC’s 2006 guidelines for managing multidrug-resistant organisms. It recommends that all acute care facilities implement contact precautions for patients with CRE, including isolation, glove and gown use, and hand hygiene. Clinical microbiology laboratories should put in place protocols recommended by the Clinical and Laboratory Standards Institute (CLSI) to detect resistant strains—including the use of a modified Hodge test for strains that have elevated, but still susceptible, minimal inhibitory concentrations (MICs) for carbapenems—and alert infection control staff if they are found.

CDC and HICPAC recommend that acute care facilities go back through their clinical culture data for the past six to 12 months to check for previously overlooked CRE. If positive cultures are identified, facilities should conduct active surveillance of high-risk units such as intensive care units and other wards with high antibiotic use. If any hospital-onset cases or colonized patients are found, contact precautions should be implemented, patients with epidemiologic links to the cases should be screened for CRE colonization, and periodic active surveillance should continue until no new isolates are found.

 “The history of the spread of antimicrobial resistance has taught us that without a vigorous multi-pronged approach these strains become widespread and take over from the more susceptible organisms,” said Edward Septimus, MD, FIDSA, a member of IDSA’s Board of Directors and Antibiotic Resistance Work Group. “We have already observed this with methicillin-resistant Staphylococcus aureus. The steps CDC is recommending will help us get out in front of CRE.”

Slides from the March 17 conference call, which include pictures of the modified Hodge test, are available online.
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