AHE Member Communication Regarding Ongoing CRE and Shigella sonnei Outbreak Investigations
We have two very important updates for you regarding two different outbreak investigations.
**This information is current as of publication date of April 9,2015**
Communication Regarding Ongoing CRE Outbreak
Background on CRE:
CRE, stands for carbapenem-resistant Enterobacteriaceae, a family of germs that are difficult to treat because they have high levels of resistance to most antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria, which can become carbapenem-resistant. Types of CRE organisms are sometimes known as KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase). KPC and NDM are enzymes that break down carbapenem antibiotics and render them ineffective.
- CRE is not a single microorganism, but rather several microorganisms such as the ones identified above that fall into a family of dangerous pathogens.
- Carbapenem is an antibiotic used to treat severe infections.
- Currently the US Centers for Disease Control and Prevention (CDC) is investigating an outbreak of Carbapenem-resistant Enterobacteriaceae (CRE) associated with inadequate cleaning and disinfection of duodenoscopes
- Duodenoscopes are medical devices that are inserted down the patient’s throat and used in a variety of procedures, and in the case of this outbreak for a specific type of procedure called an endoscopic retrograde cholangiopancreatography (ERCP).
- CRE organisms are resistant to multiple and in some cases all known antibiotic therapies, and therefore pose a risk to both the patient and the health care team including the environmental services technician.
Environmental Impact of CRE in Health Care Settings:
- CRE can be spread via the hands of the patient and health care personnel
- CRE organisms are transmitted in the same manner as many other Multi-Drug Resistant Microorganisms (MDRO’s), and core infection prevention and control measures such as hand hygiene, environmental cleaning and disinfection with an EPA registered, hospital-grade disinfectant for environmental surfaces, patient and staff cohorting and appropriate use of isolation precautions will mitigate risk for transmission of CRE organisms and most MDRO’s.
- When not used correctly and according to manufacturer’s instructions, hospital-grade disinfectants may not have full efficacy against CRE organisms. It is important to completely follow all manufacturer’s instructions for use including dilution, contact time, etc. in accordance with the EPA Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA).
Recommended Actions for Mitigation of CRE in Health Care Settings:
Process duodenoscopes according to manufacturer's instructions for use with a minimum of a high-level disinfection process.
For Environmental Services Professionals:
- Collaboration between infection preventionists, infectious disease/epidemiology staff, biomedical engineering and facilities teams to understand CRE organisms, how to manage the environmental impact
- Diligent hand hygiene, proper glove and PPE use
- Collaborate with the medical laboratory to monitor any environmental cultures collected from the patient care environment for potential identification of CRE organisms
- Employ an EPA-registered, hospital-grade disinfectant for environmental cleaning and disinfection with clinically relevant claims for MDRO’s.
- Infection prevention measures for MDRO’s such as CRE microorganisms should be treated in the same manner as other pathogens such as MRSA
- Collaborate with your facility’s infection disease, epidemiology, and infection prevention departments and conduct a risk analysis to evaluate potential action items necessary to respond to and/or mitigate risk for transmission of CRE organisms.
The CDC recommends several core measures for health care settings to follow to mitigate risk for transmission of CRE. These recommendations are the same as those for many other pathogens and include:
- Hand Hygiene for the Health Care Team and Patient: Hand hygiene is the single most important infection prevention intervention to reduce the risk for transmission of Health Care Associated Infections (HAI’s) including CRE.
- Contact Precautions: Health care professionals and Technicians should receive adequate training on the proper use of contact precautions and personal protective equipment (PPE).
- Provide Health Care Personnel Education: Health care personnel should be educated about the modes of transmission of CRE organisms and evidence-based mitigation recommendations. Use the CDC Vitals Signs Report (see webpage link below) to educate health care personnel on the risk of CRE and basic prevention strategies.
- Cohort Health Care Staff with Suspected or Confirmed CRE Infections: This will reduce the risk for potential transmission between staff members and also other patients and environmental surfaces.
- Create a System for CRE Screening: Proactive screening for potential CRE infections at the time of admission should be conducted in collaboration with Infection Prevention, the Emergency Department, and Medical Laboratory teams to facilitate rapid identification and isolation of potential cases, and timely communication to the health care team about necessary isolation precautions.
What actions is AHE taking to keep environmental services professionals informed about developments associated with this outbreak:
- AHE is closly monitoring the situation in collaboration with our partners at both the FDA and CDC.
- AHE has provided resource documents on its website that are available for environmental services professionals to download for reference at their facilities, and to facilitate conversations with internal partners such as the biomedical engineering and infection prevention departments
- AHE will provide input on environmental disinfection and the potential environment of care impact of CRE as requested by the FDA
Additional Information and Resources
- US Food and Drug Administration Resource Center on CRE:
- US Centers for Disease Control and Prevention Resource Center on CRE:
- US Centers for Disease Control and Prevention CRE Vital Signs Report
- US Food and Drug Administration (FDA)
- US Centers for Disease Control and Prevention (CDC)
- The Joint Commission
- US Centers for Medicare and Medicaid Services (CMS)
Communication Regarding Ongoing Shigella sonnei Outbreak
Background of Shigella sonnei and Current Outbreak:
Currently the US Centers for Disease Control and Prevention (CDC) is investigating an outbreak of Shigella sonnei bacteria in 32 states and Puerto Rico with a total of 157 cases from May 2014-February 2015. Half of these cases were associated with international travel.
- This microorganism causes an estimated 500,000 cases of diarrhea in the United States annually according to CDC estimates.
- The bacteria is transmitted easily from person to person and through contaminated food and recreational water sources.
- The bacteria can become resistant to commonly used antibiotic therapies for the infection.
- The bacteria can cause severe and in some cases fatal infections in immunocompromised people.
- Shigellosis is the infection caused by the bacteria, and the infection will typically resolve on its own within 5-7 days.
Environmental Impact of Shigella sonnei in Health Care Settings:
- Shigella sonnei can be spread via the hands of the health care providers, environmental services professionals and technicians, or the patients themselves, as well as thru contaminated environmental surfaces.
- When not used correctly and according to manufacturer’s instructions, hospital-grade disinfectants may not have full efficacy against Shigella sonnei organisms. It is important to completely follow all manufacturers’ instructions for use including dilution, contact time, etc. in accordance with the EPA Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA).
Recommended Actions for Prevention of Shigella sonnei in Health Care Settings:
- Regularly practice hand hygiene as indicated using a soap and water or an alcohol-based hand rub according to facility protocol. When the hands are visibly soiled, the CDC recommends the use of soap and water for hand hygiene purposes.
- For environmental cleaning and disinfection, use an EPA-registered, hospital-grade disinfectant with clinically relevant claims for organisms such as Shigella sonnei and other MDRO’s.
- Promptly clean and disinfect any patient bathrooms contaminated with diarrhea using an EPA-registered, hospital-grade disinfectant as previously noted.
- It is important for the Environmental services technician to wear appropriate PPE per facility protocol to safely dispose of soiled diapers as significant amounts of the microorganism can be found in the fecal material and lead to transmission.
- The CDC recommends several core measures for health care settings to follow to mitigate risk for transmission of Shigella sonnei. These recommendations include:
- Hand Hygiene for the Health Care Team and Patient: Hand Hygiene is the single most important infection prevention intervention to reduce the risk for transmission of Health Care Associated Infections (HAI’s).
- Contact Precautions: Health care personnel should receive proper training on the correct use of contact precautions and personal protective equipment (PPE).
Additional Information and Resources:
- US Centers for Disease Control and Prevention MMWR-Importation and Domestic Transmission of Shigella sonnei Resistant to Ciprofloxacin-United States, May 2014-February 2015
- US Centers for Disease Control and Prevention Resources for Shigella infection
- US Centers for Disease Control and Prevention Drug Resistant Threat Report
- US Centers for Disease Control and Prevention (CDC)