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What is Carbapenem-resistant Enterobacteriaceae (CRE)? What are recommendations to prevent an outbreak?

Enterobacteriaceae is a class (family) of bacterial microorganisms, not a specific microorganism. Members of this class are rod-shaped, gram-negative, and non-spore forming.

What is Carbapenem-resistant Enterobacteriaceae (CRE)?

CRE are a family of bacteria that are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria, which can become Carbapenem-resistant.

CRE are a serious threat to public health. Infections with CRE are difficult to treat and have been associated with mortality rates as high as 40-50%. Due to the movement of patients throughout the healthcare system, if CRE are a problem in one facility, then typically they can become a problem in other facilities in the region as well.

Where are CRE found?

CRE are typically aerobes and live in oxygen environments such as lung, blood stream, urine, water, and soil. However, CRE can become facultative anaerobes and live in nitrogen or low oxygen environments, such as the colon and deep wounds. Many are “normal flora” of the gut.

What infections are associated with Enterobacteriaceae?

Healthy people usually do not get CRE infections. In healthcare settings, CRE infections most commonly occur among patients who are receiving treatment for other conditions. Patients whose care requires devices like ventilators (breathing machines), urinary (bladder) catheters, or intravenous (vein) catheters, and patients who are taking long courses of certain antibiotics are most at risk for CRE infections.

Infections include: Blood Stream Infections, Bloodstream Sepsis, Urinary Tract Infections, Pneumonia, Abdominal sepsis, Meningitis, Peritonitis, and Endocarditis

What factors contribute to high cost and high mortality of these infections?

Enterbacteriaceae are associated with producing exotoxins or enterotoxins and may result in a debilitating side effects and lethal toxic mega colon. Antibiotic resistant enterobacteriaceae are difficult or impossible to treat. All organisms within this class have the ability to produce an ESBL (Extended spectrum beta lactamase) and can subsequently produce a KPC (Klebsiella pneumoniae Carbapenemase).

Infection Prevention and Control Recommendations from the US Centers for Disease Control and Prevention:

CRE is not a specific microorganism, but rather a microbial class; therefore, there is no specific efficacy claim from the US Environmental Protection Agency (EPA) for this classification. Different CRE organisms include bacteria that are classified as Carbapenem Resistant, EBSL producing, NDM-1 positive, and KPC-2 positive organisms. A disinfectant must demonstrate efficacy against one or more of these bacteria classes in order to be considered effective against CRE organisms.

The following PDI surface disinfectants have demonstrated efficacy against bacteria which reside in the CRE family:

Additional Infection Prevention and Control Recommendations from the US Centers for Disease Control and Prevention:

  1. Frequent Hand Hygiene with Soap and Water or Alcohol-Based Hand Sanitizers
  2. Contact Precautions, including wearing a gown and gloves when caring for these patients
  3. Healthcare Personnel Education
  4. Discontinue the use of invasive devices such as urinary catheters as soon as they are no longer necessary
  5. Patient and Staff Cohorting
  6. Properly clean and disinfect (high level disinfection or sterilization according to manufacturer’s instructions) semicritical items such as scopes used for endoscopies or other procedures
  7. Laboratory Notification
  8. Antimicrobial Stewardship, including prescribing and using use antibiotics wisely
  9. CRE Screening upon admission

Source: CRE for Healthcare Professionals, Electronically Accessed from, February 19, 2015, US Centers for Disease Control and Prevention.