- Multi-resistant organisms, including CRE, are a concern for all health services.
- A coordinated response is required to address the risk of CRE becoming established in healthcare facilities or in the community.
- All public health services and private hospitals are required to review their systems and implement in full the national guideline published in November 2013 by the Australian Commission on Safety and Quality in Health Care, Recommendations for the control of Multi-drug resistant Gram-negatives: carbapenem resistant Enterobacteriaceae.
- Evidence now strongly suggests transmission of a particular strain of KPC between patients in Victoria, affecting a small number of hospitals and aged care facilities since 2012.
- Most cases of colonisation and infection with KPC since 2012 have been associated with hospitalisation at St Vincent’s Hospital Melbourne or affiliated facilities in the 12 months prior to detection. Several other health services across Victoria have identified isolated cases.
- Enhanced control measures must be applied where there is evidence of local transmission of CRE within or across a health service.
- The Department has convened an Outbreak Control Team, with representation from infection control, microbiology, infectious diseases experts and laboratories.
- Designated risk areas will be identified by the Department and health services to eliminate further transmission.
- A detailed guideline for the control of KPC and other CRE in Victoria is being developed to supplement this interim advice and the national guideline on CRE.
All public health services and private hospitals must now:
- Develop management plans to prevent, detect and contain CRE;
Implement all recommendations in the existing national guideline for CRE;
- Follow the recommendations in this Circular, including screening requirements for patients who have been hospitalised overseas;
All laboratories in Victoria are requested to refer Enterobacteriaceae displaying reduced-susceptibility to carbapenems to the Microbiological Diagnostic Unit Public Health Laboratory (MDU PHL) for further characterisation.
- Multi-drug resistant Gram-negative bacteria are a significant global public health threat that can disrupt health systems and involves potentially untreatable infections
- Carbapenem resistant enterobacteriaceae (CRE) are Gram-negative bacteria that are resistant to most types of antibiotics, including a key ‘last resort’ class of antibiotic, the carbapenems (e.g. meropenem)
- Infections with CRE can carry a mortality rate of up to 50 per cent
- Since 2012 there has been an increase in detection of one type of CRE, Klebsiella pneumoniae carbapenemase-producing bacteria (KPC)
- Over 3 years (June 2012-June 2015), KPC infection or colonisation has been identified in 57 patients in Victoria. So far this year (Jan-June 2015), the Department is aware of five isolations of KPC in patients in Victoria.
Objectives for control of CRE
KPC and other CRE are highly significant multi-drug resistant organisms that can spread between patients. A “search and contain” strategy is recommended, with the intensity of active surveillance and control interventions stratified by the degree of transmission in each facility.
In all acute and sub-acute health service facilities, patients with CRE colonisation or infection should be placed on contact precautions. A single room, dedicated toilet, cohorted nursing staff, reinforcement of hand hygiene, use of gowns and the use of gloves (in accordance with local policy) should be implemented.
Recommendations for control of CRE
1. Prevention, detection and containment
A health service should ensure the following measures are in place:
- A management plan for CRE, implementing best practice antimicrobial stewardship;
- Surveillance for multi-drug resistant organisms - including screening for CRE where required according to national guidelines and interim recommendations below;
- Strict infection control precautions with alerts to any subsequent admission at any health service in Victoria;
- Education and training for staff on CRE and infection control measures.
The management plan should also take into account the following interim guidance:
Notification of Key Personnel
When a laboratory confirms the isolation of a CRE from a patient (causing infection or colonisation), it should notify the health service immediately. The health service should ensure the following personnel are informed:
- Medical practitioner(s) responsible for the care of the patient
- Infection Control personnel (for patients being treated in hospital)
- Nurse in charge of the ward or unit
- Other personnel as may be specified in the facility’s CRE plan
Confirmation of Diagnosis
The first culture of a suspected or confirmed CRE isolate from each patient, plus any new clinical isolate, should be sent to the Microbiological Diagnostic Unit Public Health Laboratory (MDU PHL), Peter Doherty Institute, for surveillance purposes and confirmatory testing if required.
As cases (infected or colonised) are identified, infection control personnel in conjunction with management need to ensure appropriate isolation and infection control measures are implemented for the affected patient, and guide screening and isolation of contacts as directed by infection control guidelines. Non-essential transfers or admissions should be reviewed carefully.
Microbiological Surveillance/ Screening of contacts
A rectal, peri-anal or faecal swab for culture (as appropriate for the patient) is the sample of choice for screening.
2. Screening for CRE
Prior to transfer between hospitals, or aged and residential care facilities, any past or current colonisation or infection with CRE should be documented as an alert and communicated to the receiving hospital.
The following patients should be screened on admission to a health service with pre-emptive contact precautions until results are known:
- All patients directly transferred from any overseas hospital;
- Any patient who has been admitted overnight to any overseas hospital or overseas residential aged care facility within the last 12 months;
- Any patient who is identified as a CRE contact* during any hospitalisation in the past AND where there is no evidence of post-contact negative cultures.
*In this circular, the term CRE contact means:
a patient who has shared the same room for more than 24 hours with a patient colonised or infected with CRE, OR
a patient who stayed overnight in an area designated by the department as a risk area for transmission of CRE.
3. Designated risk areas for transmission
These areas may be a room, bay, ward or larger area. Such areas will be identified through laboratory and epidemiological investigations and communicated by the Department to health services. Based on a local risk assessment, a health service can also designate an area of its service as a risk area for transmission of CRE.
At the time of this circular, the Department has identified Ellerslie Transitional Care, Kew Campus, St Vincent’s Hospital Melbourne as a risk area for transmission of CRE. Other areas are still being assessed and further investigation may result in designation of additional risk areas for transmission of CRE.
It is the responsibility of the sending hospital to inform a receiving health service if a CRE contact is being transferred and has not had a negative screen result from a screening sample taken in the seven days prior to transfer. This is a communication standard which should apply for all multi-resistant organisms of concern.
Isolation and screening on admission for all transferred patients from an affected health service is not required. For CRE contacts use of the Department’s quick guide to patient-centred risk assessment for management of MRO may also be useful in decision-making.
4. Laboratories actions for suspected CRE
Laboratory methods for screening non-sterile specimens for CRE have been developed and validated. Chromogenic agar for early detection of CRE is available at Laboratory and Clinical Evaluation of Screening Agar Plates for Detection of Carbapenem-Resistant Enterobacteriaceae from Surveillance Rectal Swabs.
To capture isolates of CRE in Vitoria, and to allow molecular confirmation and genomic characterisation of strains, all Enterobacteriaceae with the following criteria should be referred to the Microbiological Diagnostic Unit Public Health Laboratory at the Peter Doherty Institute:
- Positive colorimetric test for carbapenemase (CarbaNP or BlueCarba) OR
- Other positive phenotypic test for carbapenemase e.g. modified Hodge test, carbapenem double disc synergy testing, OR
- Positive molecular assay for carbapenemase, OR
- Meropenem MIC ≥ 0.5mg/L, or disc diffusion zone ≤ 24mm (CLSI or EUCAST) or CDS disc diffusion zone ≤ 6mm. The result should be communicated to the health service or treating clinician as appropriate.
What is being done to control this problem?
The Victorian Department of Health and Human Services has established an Outbreak Control Team and has sought advice from experts including members of the Department’s Hospital Acquired Infections Advisory Committee. More detailed guidelines for the control of CRE in Victoria are being developed and will be available in July.
How can CRE be treated?
Expert advice is recommended. CRE strains are universally resistant to penicillins (including beta-lactam/beta-lactamase inhibitor combinations), cephalosporins and carbapenems. The majority of Victorian KPC isolates where data is available have been susceptible to gentamicin and colistin. Other susceptibilities that should be tested include tigecycline and fosfomycin. Ceftazidime-avibactam, available on SAS, may also be a treatment option for KPC-producing Enterobacteriaceae.
Where can I find more information?
Communicable Disease Prevention and Control
Department of Health & Human Services.
Telephone: 1300 651 160
Quality and Safety Unit,
Sector Performance, Quality and Rural Health,
Health Service, Performance and Programs,
Department of Health & Human Services
Telephone: (03) 9096 7553
Quick guide to patient centred risk assessment for management of MRO
Key facts and the Victorian situation regarding CRE
Acting Chief Health Officer and
Health Service Performance and Programs