Carbapenemase-Resistant Organism Clearance Guidelines
Immediate Infection Control Protocol
All patients colonized or infected with carbapenemase-resistant organisms must be placed in contact precautions immediately and maintained throughout hospitalization, regardless of clinical symptoms. 1, 2
Core Isolation Requirements
- Place patient in single-room isolation to prevent nosocomial transmission 2
- Healthcare personnel must wear gowns and gloves before entering the room and remove them immediately after patient contact, followed by mandatory hand hygiene 2
- Implement strict hand hygiene with alcohol-based solutions before and after each patient contact (inadequate adherence of 48% has contributed to documented outbreaks) 2
- Use water and soap when hands are visibly soiled rather than alcohol-based solutions 2
Critical Surveillance and Detection
- Immediately notify infection control and epidemiology teams upon identification of any patient with carbapenemase-producing organisms 2
- Establish alert codes in the electronic medical record to rapidly identify previously colonized patients during future admissions 2
- Perform rectal/perirectal swab surveillance cultures on all patients with epidemiological links to the index case (same unit, same healthcare personnel), as these have the highest yield compared to other body sites 2
Facility-Level Response Algorithm
For Non-Endemic Areas
When CRE is detected in a facility where it is not endemic, implement the following three-step approach: 1
Review microbiology records for the preceding 6-12 months to determine whether previously unrecognized CRE cases have occurred at the facility 1, 3, 2
If the review identifies previously unrecognized CRE, perform point prevalence culture surveys in high-risk units (ICU, units with previous cases, units with high broad-spectrum antimicrobial exposure) to detect additional colonized patients 1, 3, 2
Conduct active surveillance cultures (rectal swabs) of all patients with epidemiologic links to persons from whom CRE have been recovered 1, 2
For Endemic Areas
- Consider enhanced surveillance strategies beyond standard contact precautions, as there is increased likelihood of CRE importation 1
- Implement routine point prevalence surveys in intensive care units and high-risk areas 3
Laboratory Detection Requirements
Facilities must implement CLSI guidelines for carbapenemase detection using the modified Hodge test (MHT), which has sensitivity and specificity exceeding 90% for identifying carbapenemase-producing organisms, even in strains with MICs in the susceptible range 1, 2
- Test carbapenem-susceptible Enterobacteriaceae with elevated MICs or reduced disk diffusion zone sizes for carbapenemase presence 1
- Perform rapid molecular testing to identify specific carbapenemase types (KPC, NDM, OXA-48, VIM, IMP) to guide appropriate therapy if infection develops 2
Environmental Control Measures
- Implement regular environmental cleaning with appropriate detergents or disinfectants of all surfaces in contact with colonized/infected patients 2
- Consider environmental sampling of patient-contact surfaces during outbreak investigations 2
Critical Pitfalls to Avoid
- Never underestimate asymptomatic colonization: colonized patients without clinical symptoms serve as important reservoirs of transmission and have been documented as sources in outbreaks with 39 cases 2
- Never delay implementation of contact precautions: delayed recognition has directly contributed to documented outbreaks 2
- Never discontinue contact precautions during hospitalization: CDC and HICPAC recommend maintaining precautions throughout the entire hospital stay 1, 2
Duration of Precautions
Contact precautions should be maintained throughout the patient's hospitalization. The provided guidelines do not specify criteria for discontinuing precautions or declaring a patient "cleared" of colonization, as carbapenemase-producing organisms can persist for extended periods and asymptomatic carriers remain transmission risks 1, 2, 4