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7 Jun 2018

#Carbapenem-resistant #Enterobacteriaceae–1rst #update. 4 June 2018 (@ECDC_EU, summary)



#Carbapenem-resistant #Enterobacteriaceae–1rst #update. 4 June 2018.


Antimicrobial Resistance, Enterobacteriaceae, risk assessment update.


European Centre for Disease Prevention and Control (ECDC), full PDF file: (LINK). Summary, edited.


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Carbapenem-resistant Enterobacteriaceae - first update. 4 June 2018


Suggested citation: European Centre for Disease Prevention and Control. Rapid risk assessment: Carbapenem-resistant Enterobacteriaceae - first update 4 June 2018. Stockholm: ECDC; 2018. 

© European Centre for Disease Prevention and Control, Stockholm, 2018

Conclusions and options for response

  • Carbapenem-resistant Enterobacteriaceae (CRE) pose a significant threat to patients and healthcare systems in all EU/EEA countries.
  • CRE infections are associated with high mortality, primarily due to delays in administration of effective treatment and the limited availability of treatment options.
  • New antibiotics capable of replacing carbapenems for their main indications are not likely to become available in the near future.
  • CRE are adapted to spread in healthcare settings as well as in the community, and measures should address both routes of transmission. 

Options for actions to reduce identified risks

  1. Actions related to limited treatment options and high mortality
    • Timely and appropriate laboratory investigation and reporting is essential in order to avoid a delay in appropriate treatment, which is associated with increased morbidity and mortality.
    • Patients with CRE infections will benefit from consultations with specialists in infectious diseases or clinical microbiology, which would ensure the best possible outcome, given the limited treatment options. 
  2. Actions to prevent transmission of CRE in hospitals and other healthcare settings
    • Implementation of and strict adherence to infection control measures - including hand hygiene, contact precautions, environmental cleaning, proper reprocessing of medical devices, adequate microbiological laboratory capacity and sufficient capacity for contact isolation - are the basis for preventing transmission of multidrug-resistant bacteria such as CRE for both infected and colonised patients.
      • Prompt notification of the clinical team and of the infection prevention and control/hospital hygiene team is essential in order to implement timely infection control precautions.
      • For healthcare settings other than acute care, the control measures implemented should be proportionate to the risk of CRE transmission to other patients.
    • Targeting patients at high risk o f CRE carriage
      • Patients who have recently been hospitalised in a country or region known as having a high CRE prevalence – or who have been transferred from an individual hospital with a high CRE prevalence – should be considered at high risk of CRE carriage in their digestive tract.
      • Screening these patients for digestive tract CRE carriage and implementing pre-emptive contact precautions and pre-emptive isolation should be considered.
      • Hospitals could also consider pre-emptive isolation and screening for digestive tract CRE carriage in accordance with national guidance for patients who may recently have travelled to countries/regions known for high CRE prevalence, even if they were not in contact with a healthcare institution/service. 
      • Risk factors that could be helpful in identifying patients at increased risk of CRE carriage are history of an overnight stay in a healthcare setting within the last 12 months, dependency on dialysis or having received cancer chemotherapy in the last 12 months, known previous carriage of CRE in the last 12 months, and epidemiological linkage to a known carrier of CRE.
      • Based on the local epidemiology, additional at-risk populations could be defined.
    • Preventing transmission from CRE - positive patients
      • Enhanced control measures, such as contact precautions, isolation or cohorting, and dedicated nursing staff can be considered for hospitalised patients with confirmed digestive tract CRE carriage or confirmed CRE infection.
      • In addition, screening of contacts will enable early identification of carriers and implementation of control measures.
    • Preventing spread of CRE in specific wards/units
      • In units/wards where patients are at high risk of infection (e.g. intensive care units and onco-haematology units), pre-emptive isolation and active surveillance (screening) for CRE by rectal swab on admission should be considered, depending on the risk of digestive tract CRE carriage and the local prevalence of CRE.
      • Regular review of appropriate device use is an important infection prevention measure in high-risk settings.
      • The role of the environmental reservoir of epidemic CRE strains and/or carbapenemase-encoding plasmids should be investigated and relevant control measures implemented accordingly.
    • Antimicrobial stewardship
      • The implementation of comprehensive antimicrobial stewardship programmes is recommended to prevent and control the emergence and spread of CRE and other multidrug-resistant bacteria.
      • Nevertheless, targeted and appropriate use of antibiotics is not likely to fully reverse the current CRE trends, and antimicrobial resistance trends in general, and there is an urgent public health need for new antibacterial agents (antibiotics) active against prevalent multidrug-resistant bacteria such as CRE.
  3. Actions to prevent spread of CRE into the community
    • It is important to avoid the potential transmission of CRE via the food chain.
      • The harmonised monitoring programme for antimicrobial resistance in ‘food-producing animals and food thereof’ requests the monitoring of CRE in broilers, turkeys, pigs and veal calves, and meat derived thereof every second year on a routine basis [1].
      • Continued prohibition of the use of carbapenems in food‐producing animals would be a simple and effective option for intervention.
      • As genes encoding carbapenemase production are mostly plasmid‐mediated, and coresistance may be an important issue in the spread of such resistance mechanisms, decreasing the frequency of antimicrobial usage in animal production within the EU in accordance with prudent use guidelines is also of high priority [2].
      • In addition, improving the conditions of animal husbandry (e.g. biosecurity, hygienic conditions) and implementing alternative measures to antimicrobials would reduce both the need to use antimicrobials and the development of resistant bacteria in food-producing animals.
      • A multifaceted integrated approach to minimising antimicrobial use is recommended and further options related to this are outlined in the ‘EMA and EFSA Joint Scientific Opinion on measures to reduce the need to use antimicrobial agents in animal husbandry in the European Union, and the resulting impacts on food safety' [3]. 
      • In households and shared public environments, standard personal hygiene rules should be applied to prevent person-to-person transmission, as well as good food handling practices to prevent food contamination from colonised handlers.
  4. Actions to prevent cross-border spread
    • Measures related to enhanced CRE surveillance and pre-emptive isolation and screening of patients transferred from hospitals and other healthcare settings in high-CRE-prevalence countries represent an immediate means of reducing transmission in healthcare and preventing outbreaks of imported CRE.
      • Documentation and inter-facility communication of known CRE carriage or infection during cross-border patient transfer would optimise the early and effective implementation of measures to prevent the spread of CRE.
      • Moreover, gathering reliable epidemiological data by notifying cases to public health authorities and exchanging information are important activities to enable informed and coordinated action by public health authorities across the EU/EEA.
      • Public health authorities shall issue notifications on the Early Warning and Response System (EWRS) where relevant, as per Article 9 of Decision 1082/2013/EU on serious cross-border threats to health.
      • Use of the Epidemic Intelligence System (EPIS) is encouraged to ensure transparent and timely information sharing among the participating public health authorities in order to detect public health threats at an early stage.
      • Only concerted worldwide measures, such as regulating antimicrobial use, improving infection control in hospitals, and improving water and sanitation infrastructure, can offer a long-term solution.
      • As a first step towards control, the capacity for resistance detection and surveillance in low-resource countries needs to be improved in order to collect more reliable data on the worldwide distribution of CRE.
      • Patients should be tested for faecal carriage of CRE upon hospital admission, in accordance with the relevant national guidelines for testing persons at risk of carrying CRE and other multidrug-resistant gram-negative bacteria.
      • However, the presence of such infection or colonisation should not preclude the transfer or inhibit the care of patients.
  5. Actions to reduce risks for healthcare systems
    • Appropriate levels of healthcare staffing and infection control staffing as well as adequate funding for hospitals should be ensured to enable compliance with infection control measures.
      • CRE prevalence is currently still low in many European countries, and it is likely that the spread of CRE could be controlled through proportionate investment in control measures in most countries.
      • However, once the situation becomes endemic, control efforts will be more costly and less likely to be effective.


Keywords: ECDC; Updates; European Region; Antibiotics; Drugs Resistance; Carbapenem; Enterobacteriaceae.


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