What are the recommendations for managing Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage in healthcare workers?

From the Guidelines

Healthcare workers who are carriers of Carbapenem-Resistant Enterobacteriaceae (CRE) in their fecal matter should adopt bundle interventions including contact isolation, particularly when caring for patients with CRE infections or colonization, to prevent the spread of CRE infections. This approach is based on the most recent guidelines for the diagnosis, treatment, prevention, and control of infections caused by carbapenem-resistant gram-negative bacilli, as outlined in a 2023 study published in the Journal of Microbiology, Immunology and Infection 1.

Key Recommendations

• Single room isolation is preferred for patients with CRE infections or colonization, and separate toilets should be provided for those infected or colonized with CRE.
• When resources are limited, priority for single room isolation should be given to patients with fecal or urinary incontinence, those using invasive devices or equipment, or those with continuous wound secretion.
• Nursing staff designated to care for patients with CRE infections or colonization should not participate in caring for other patients.
• Caregivers should not be permitted to stay in the ward to care for isolated patients.

The rationale behind these recommendations is that bundle management measures, including contact isolation and active screening, are closely linked to the prevention and control of nosocomial infections, as demonstrated by several studies, including those showing a significant reduction in the rate of CRE infection or colonization with the implementation of such measures 1. Although the evidence is derived from observational studies and is considered low quality, expert experience and clinical practice support the adoption of bundle management schemes, including isolation, as they are generally well accepted and feasible in most medical institutions.

Implementation Considerations

• The primary goal is to prevent the spread of CRE infections through strict adherence to infection control practices, particularly hand hygiene.
• Active screening of CRE colonization should be implemented for hospitalized patients in high-risk departments.
• Isolation measures, including single room or cohorting isolation, should be implemented for patients with CRE infections or colonization, with consideration for resource limitations and patient needs.

Overall, the management of CRE fecal carriage in healthcare workers prioritizes the prevention of transmission through infection control practices and isolation measures, rather than decolonization treatment, which is not routinely recommended unless in exceptional circumstances and under consultation with infectious disease specialists.

From the Research

CRE Fecal Carriage Rate in Healthcare Workers

• The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs 2.
• Recent exposure to antibiotics was the only parameter that was consistently associated with Carbapenem-Resistant Enterobacteriaceae (CRE), regardless of the group to which CRE was compared 3.
• Hand hygiene compliance is expected to decrease the risk of transmission of hospital-acquired infections (HAIs), with lower HAI incidence rates seeming to be achieved with hand hygiene compliance rates of approximately 60% 4.

Managing CRE Fecal Carriage in Healthcare Workers

• The use of personal protective equipment (PPE) and proper donning and doffing skills are important in preventing the transmission of pathogens to healthcare workers (HCWs) and from them to others 5.
• Antimicrobial stewardship programs (ASPs) advocate for judicious use of available antimicrobials to preserve their usefulness, with both process and outcome measures needing to be defined and assessed when evaluating an ASP 6.
• The high intensity of care, prone position requiring multiple healthcare workers, and presence of new HCWs without experience in the ICU setting may contribute to the spread of CRE in healthcare settings 2.

Recommendations

• Implementing infection control measures, such as hand hygiene and proper use of PPE, can help reduce the transmission of CRE in healthcare settings 2, 4, 5.
• Antimicrobial stewardship programs (ASPs) should be implemented to promote judicious use of antibiotics and reduce the risk of CRE acquisition 3, 6.
• Healthcare workers should be trained on proper infection control measures and antimicrobial stewardship to prevent the spread of CRE in healthcare settings 2, 6.