Guest Columns

Combatting CRE in long-term care

Rosie Lyles
Rosie Lyles

In recent years the growing threat of multi-drug resistant organisms has put pressure on long-term care facilities to focus on infection control and improve antibiotic stewardship efforts. While most long-term care providers are familiar with pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff), many are not aware of Carbapenem-resistant Enterobacteriaceae, a lesser known but dangerous type of bacteria that the U.S. Centers for Disease Control and Prevention has dubbed “nightmare bacteria”[1] and classified as an immediate public health threat. In the U.S., the most common type of this bacteria is Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae.[2]

KPC-producing Enterobacteriaceae is a type of bacteria that can cause different types of healthcare-associated infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Infections caused by this type of bacteria are resistant to all or nearly all antibiotics available today making them untreatable or very difficult to treat.

To become infected, a person must be exposed to the bacteria and KPC-producing Enterobacteriaceae bacteria can spread from person to person via the contaminated hands of healthcare personnel or others, and also through contact with contaminated environmental surfaces. The bacteria do not spread through the air.[3]

While rare among healthy people, these infections are on the rise in hospitals, nursing homes and other healthcare settings where up to half of all bloodstream infections caused by this type of bacteria result in death. Patients and residents at greatest risk are those whose care requires devices like ventilators, urinary or intravenous catheters, or taking long courses of antibiotics.[4] In long-term care settings were patients and residents are often already at greater risk for infection and up to 70% receive an antibiotic every year,[5] awareness and proactive infection prevention measures are especially critical because KPC infections and carriage can be difficult to diagnose or detect. 

Since the bacteria can cause different types of HAIs, symptoms and clinical presentation are not always the same and sometimes KPC-positive patients show no symptoms at all and are therefore not recognized as carriers when first admitted.[6] The best way to confirm KCP carriage is through active surveillance and lab testing.

Tracing the Rise of a Deadly Bacteria

Following initial outbreaks in hospitals in 2003, KPC-producing bacteria have rapidly spread throughout the country.[7] Infections caused by KPC-producing bacteria are also detected outside of hospital settings in long-term care facilities[8],[9] and long-term acute care hospitals.

I was able to see the colonization burden of these bacteria firsthand in my previous role as study director and physician researcher with the Division of Infectious Diseases and CDC Epicenter and Prevention Program for Chicago, Cook County Health and Hospital Systems.

In 2010 and 2011 we studied 24 short-stay acute care hospitals with adult intensive care units and all seven LTACHs in the Chicago region to assess the prevalence of KPC-producing Enterobacteriaceae and to test our theory that LTACH patients, who commonly have risk factors for MDRO carriage, would have a higher rate of colonization compared to ICU patients in short-stay acute care hospitals.[10] 

We were right. We found an extremely high prevalence of KPC-carriage among LTACH patients which was 9-fold higher than that of short-stay acute care hospital ICU patients.

To experienced long-term care professionals, this may not come as a surprise since LTCs and LTACHs specialize in the care of patients with serious chronic or prolonged illness, and who often have other risk factors associated with MDRO carriage such as advanced age, pre-existing health conditions and prolonged use of ventilators or catheters.[11] What makes this so interesting, however, are the broader implications for infection control at the facility, health system and regional level.

Facility-Level Prevention Strategies  

To help prevent the spread of infections between patients, long-term care facilities should focus on a “horizontal approach” to infection control which includes  hand hygiene, thorough daily environmental cleaning and disinfecting, prudent use of contact precautions, staff education and ongoing training, antimicrobial stewardship and daily chlorhexidine bathing to help reduce the prevalence of MDRO carriage among patients.

Enterobacteriaceae can commonly be found in stool or wounds. The use of personal protective equipment during and good hand hygiene following exposure to the patient's environment, especially when cleaning up stool or changing wound dressings, is important.[12]

Chlorhexidine bathing has been used successfully to prevent certain types of healthcare-associated infections (e.g., bloodstream infections) and to decrease colonization with specific MDROs, primarily in ICUs.[13] Daily chlorhexidine bathing has also been shown to effectively reduce the amount of KPC-producing Enterobacteriaceae skin carriage among LTACH patients.[14]

In long-term care settings this type of intervention can be used universally as part of the facility's usual bathing protocols or on targeted high-risk residents.

Addressing the Bigger Picture

Our research suggests that LTCF patients with serious medical care needs are also a major source reservoir of KPC-producing Enterobacteriaceae in the larger healthcare system. When admitted from facilities with high levels of KPC-carriage, patients are at heightened risk of infection and can spread KPC-producing bacteria to other patients.

To combat the spread of highly resistant pathogens, facilities need to take a broader view of the problem and its implications across the spectrum of care, because effective infection control responses require a coordinated, regional effort – involving both acute and long-term facilities.care/.

Rosie D. Lyles, MD, MHA, MSc, is the Head of Clinical Affairs at Clorox Professional Products Company. Dr. Lyles is a physician-scientist with more than a decade of experience studying the epidemiology and prevention of multidrug-resistant organisms (MDROs) and infections such as C. difficile, MRSA and CRE. She is an active member of the Association of Professionals in Infection Control and Epidemiology, the Infectious Disease Society of America, the Society for Healthcare Epidemiology of America and has served as a peer reviewer for the National Institutes of Health.  

[1] Frieden T. “New CDC Vital Signs: Lethal, Drug-resistant Bacteria Spreading in U.S. Healthcare Facilities.” Centers for Disease Control and Prevention, 28 Feb. 2014. Date accessed: 10 Dec. 2014.

[2] Nordmann P, Naas T, Poirel L. “Global spread of carbapenemase-producing Enterobacteriaceae.” Emerging Infectious Diseases 17 (2011): 1791-1798.

[3] Klebsiella pneumoniae in Healthcare Settings. Centers for Disease Control and Prevention, 27 Aug. 2012. Date accessed: 15 Dec. 2014.

[4] Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention, 16 Sept. 2013.

[5] Antibiotic Use In Nursing Homes. Centers for Disease Control and Prevention, 2 Mar. 2014. Date accessed: 10 Dec. 2014.

[6] Qureshi S, Bronze MS. Klebsiella Infections Clinical Presentation. Medscape, 19 Aug. 2014. Date accessed: 15 Dec. 2014.

[7] Arnold RS, Thom KA, Sharma S, Phillips M, Johnson JK, Morgan DJ. “Emergence of Klebsiella pneumoniae Carbapenemase (KPC)-Producing Bacteria.” Southern Medical Journal 104.1 (2011): 40-45.

[8] Urban C, Bradford PA, Tuckman M, et al. “Carbapenem-resistant Escherichia coliharboring Klebsiella pneumoniae carbapenemase β-lactamases associated with long-term care facilities.” Clinical Infectious Diseases 46 (2008):e127-130.

[9] McGuinn M, Hershow RC, Janda WM. “Escherichia coli and Klebsiella pneumoniaecarbapenemase in long-term care facility, IL, USA.” Emerging Infectious Diseases 15 (2009): 988-989.

[10] Lin MY, Lyles RD, Lolans K, Hines DW, Spear JB, Petrak R, Trick WE, Weinstein RA, Hayden MK; Centers for Disease Control and Prevention Epicenters Program. “The importance of long-term acute care hospitals in the regional epidemiology of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae.” Clinical Infectious Diseases 57.9 (2013): 1246-1252.

[11] Chitnis AS, Edwards JR, Ricks PM, et al. “Device-associated infection rates, device utilization, and antimicrobial

resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010.” Infection Control & Hospital Epidemiology 33 (2012):993–1000.

[12] Carbapenem-resistant Enterobacteriaceae (CRE) Infection: Clinician FAQs. Centers for Disease Control and Prevention, 5 Mar. 2013. Date accessed: 15 Dec. 2014.

[13] “Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE) 2012 CRE Toolkit.” Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (2012): 9-12.

[14] Lin M, Lolans K, Blom D, Lyles  RD, Weiner S, Polurus KB, Moore N, Hines DW, Weinstein RA, Hayden MK. “The Effectiveness of Routine Daily Chlorhexidine Gluconate Bathing in Reducing Klebsiella pneumonia Carbapenemase–Producing Enterobacteriaceae Skin Burden among Long-Term Acute Care Hospital Patients.” Infection Control and Hospital Epidemiology

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