I recently posted on the WHO CPE guidelines. A couple of people have alerted me to two other recently published guidelines, one from ECDC, and the other from Australian Commission on Safety and Quality in Healthcare. So, we now have a wealth of guidelines to prevent and control CPE. But how to they compare?
I’ve updated my summary table of the various guidelines below, to give a top-line summary of the key recommendations.
A few quick reflections:
- I like the ECDC approach to specify and clarify basic IPC core measures that should be applied to everybody all the time (aka universal precautions). They then recommend a smaller set of supplemental measures for CPE carriers (aka contact precautions plus some other bits).
- ECDC recommend screening anybody who has had an overnight stay in healthcare contact a healthcare setting in the past 12 months for CPE, and implementing pre-emptive isolation of these patients. This will be completely unworkable in most healthcare settings: we did some simple modelling to show that pre-emptive isolation as part of a screening programme would over-utilise our limited isolation facilities many times over!
- ECDC made a recommendation for antiseptic bathing for known carriers in outbreak settings, which was not a common recommendation in other guidelines.
- ECDC include an interesting approach to screening for patients with foreign travel: ‘If a patient has a history of foreign travel, the decision of whether or not to screen for CRE carriage, will lie with the admitting physician in consultation with the IPC team.’ Since 30% of admissions are likely to have overseas travel in the past 12 months, does that mean IPC get a call during 30% of admissions? We’d need to set up a call centre for that!
- It’s good to see the ACSQH guidelines making specific reference to appropriate decontamination of endoscopes and bronchoscopes.
- It’s also good to see both guidelines with a strong section on the importance of antibiotic stewardship.
- There’s an interesting ACSQH recommendation to screening known CPE contacts prior to transfer to another healthcare facility or care home – this makes sense (but implementation challenging)!
- ACSQH recommend a very aggressive management of any CPE contact, with pre-emptive isolation and screening CPE contacts weekly for the duration of their stay; these will be very difficult indeed to implement in practice.
- ACSQH quite bravely I think include structured criteria for declaring a patient cleared of CPE colonisation: there’s not a lot of evidence behind these recommendations, so need to be seen as pragmatic.
- I like the way that the ACSQH guidelines are stratified by local prevalence: what you do with a single case in isolation is different when compared with an endemic setting.
- ACSQH also include some helpful lab recommendations.
So, I think it’s fair to say we have a good range of CPE guidelines to choose from now. All make sensible recommendations, but are challenged by a limited evidence base. The most controversial areas seem to be around environmental screening, staff and patient cohorting, and patient decolonisation. Perhaps the most important take-home from all of this is that we all need to have a local CPE plan guided by local prevalence.