Is CRE lurking in nursing homes?

Nursing home CRE

They say that things come in threes, so following hot on the heels of blogs about MRSA and other MDROs in nursing homes, I was struck by a recent outbreak report of CRE associated with nursing homes the Netherlands.

Following the admission of a patient from a Greek ICU, a nosocomial transmission of CRE (ST258 KPC K. pneumoniae) occurred. By the way, this occurred despite the hospital recognising the risk of CRE at the time of admission from the Greek ICU, perform an admission screening and implementing pre-emptive contact precautions. Then the index patient was transferred to a nursing home, where subsequent transmission occurred to four other patients.

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CRE winging its way around the world


CRE are known to be adept at hitchhiking around the world, hence the focus on cross-border transmission in Europe. A startling example of this comes in a report from Poland result from the terrorist shootings in Tunisia. Two Polish nationals seriously injured in the shootings were repatriated following a 10-day stay in a hospital in Tunis, Tunisia. A grand total of four CREs were identified from the two patients!

Three of these were identified at the time of admission, so almost certainly originated in Tunisia. The fourth CRE was identified 10 days after repatriation to Poland. The authors suggest that the most likely explanation for this is poor sensitivity of admission screening. I venture, however, that it’s more likely due to in-hospital transmission in Poland, since the two patients were treated by the same staff.

Nonetheless, the most troublesome finding here is that at least three separate CREs were imported into Poland by just two patients. Can anybody find me a paper on the prevalence and epidemiology of CRE in Tunisia? No? Thought not. The implication here is that CRE is already far more established than feared in Tunisia and many other parts of the world!

Image: Aeroplane.

CRE – too weak to spread!?



In the May issue of ICHE, Weber et al. published their findings of a study looking at the environmental contamination of rooms occupied  by patients colonized or infected with CRE. In addition to their observations they actively inoculated test surfaces with 102 CRE (which I find rather low). They found that the contamination in the patients’ room was infrequent (8.4%) and at low levels (5.1 CFU/120cm2). With the single exception of K. pneumoniae on formica, alle CRE had a less than 15% survival at 24 hours and a 0% survival after 72 hours.

Should we just conclude that the chance of CRE transmission from the environment is very low?

I believe that this conclusion would be too early and probably wrong. The survival of micro-organisms in the environment is clearly strain dependent and while the authors used clinical isolates they did not mention if they included a strain that has proven its ability to spread (eg. outbreak isolates). In general multi-resistant bacteria may loose some of their fitness – including the ability to survive in the environment – but survival studies like those of Kramer et al. show survival of multiple weeks for E. coli and Klebsiella spp.

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European approaches to MDR-GNR prevention and control


I was privileged to be asked to speak at the inaugural Healthcare Infection Society Middle East Summit in Dubai this week on ‘European approaches to MDR-GNR prevention and control’. You can download my slides here.

I began with a (probably too lengthy) preamble outlining some overall points:

  • CRE is a big deal in Europe, especially in the UK, and has prompted unprecedented action on a national level in the form of a Toolkit, a Patient Safety Alert and a letter to all CEOs requesting (demanding?) an action plan. The political picture is similar elsewhere in Europe and in the USA. Although this level of government scrutiny can be challenging, on the whole I think it’s beneficial, and is probably a sizeable factor in the successes achieved with MRSA and CDI.
  • Do we go universal or targeted? There’s been much discussion recently about abandoning traditional targeted (aka vertical) approaches in favour of universal (aka horizontal). Interesting, all guidelines that I could lay my hands on favoured a targeted approach for MDR-GNR, centred around screening and isolation of carriers.
  • Where is the evidence? We are hamstrung by the lack of high quality studies telling us with any certainty what works to control MDR-GNR. Pretty much all studies to date are either performed in an outbreak setting (regression to the mean…) or include multiple interventions (which worked?), or both. The few studies that evaluated a single intervention in an endemic setting are underpowered to deliver a meaningful conclusion. So, we need bigger and better studies!
  • How do you produce good guidelines – who is on the guideline writing dream team, and what are the key pitfalls to avoid. Plus, importantly, how to good guidelines translate through a good policy into good practice?

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Dispatches: Pan-drug-resistant doom – are we there yet?


Guest blogger and Acute Medicine trainee Dr Nicola Fawcett (bio below) writes…As the local Prophet of Antibiotic Resistance Doomsday to our population of hospital physicians, I’m always interested in finding out if the pan-drug-resistant superbug has emerged that is going to wipe us all out, for credibility purposes if nothing else. (Resistance Is Coming! Prepare thyself! Wash thy hands and document thy indication and duration or face Everlasting audits and perpetual personal protective equipment!). For the record – I’m actually a Registrar in Acute and General (Internal) Medicine. I’m doing some time in the world of ID/Micro/Genomics in the hope that it will help me work out whether it’s ok to just hand out co-amoxifrusiclavamide + nebs to everyone if not sure what’s going on. However  this question seems rather inextricably linked to antibiotic resistance, and having spent some time now with people who seem to know what they’re doing,  I’m increasingly flabbergasted at the massive divide between the views of microbiologists who see the latest data, and the views of the common garden hospital physician. Therefore my side-mission, if you like, has become to spread the good, or rather, spectacularly bad news that antimicrobial resistance is currently spreading around our biosphere at a scale and speed at which we simply cannot react fast enough.

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CRE: coming to a hospital near you


I thought for quite some time about whether the title to this post ought to be a statement or a question. I decided on a statement: pretty much wherever you are in the world, I am certain that CRE is now one (hospital) degree of separation from you.

I gave this talk yesterday at the imaginatively named “Darling Bugs of May” IPS conference, and you can download my slides here. I’ve given similar talks before, but the whole thing took on greater significance now I have had some first hand experience of making decisions around the management of CRE patients.

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Do you know your CRE from your CRAB?

I gave a talk today at a meeting on combating carbapenem-resistant organisms. My angle was to clearly differentiate the epidemiology of the Enterobacteriaceae (i.e. CRE) from the non-fermenters (most importantly carbapenem-resistant A. baumannii – CRAB), and you can download my slides here.

I’ve blogged before about how confusing the terminology surrounding multidrug-resistant Gram-negative rods has become. Non-expert healthcare workers have little chance in distinguishing CRE from CPE from CRO from CPO. So we need to help them by developing some clear terminology, given the gulf in epidemiology between CRE and CRAB (see below).

CRE and CRAB are like apples and pears: they share some basic microbiology but that’s about where the comparison ends!CRE CRAB

So, I think we should talk in terms of CRE (and CPE for confirmed carbapenemase carriers), and CRNF (or CRAB for A. baumannii and CRPA for P. aeruginosa). I don’t think that CRO is a useful term – in fact, I find it rather confusing. Carbapenem resistance in Enterobacteriaceae (CRE) and A. baumannii (CRAB) are both emerging problems, but they are not the same problem.