Carbapenem-Resistant Enterobacteriaceae (CRE)

About This Disease

Carbapenem-resistant Enterobacteriaceae or CRE, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics, in particular carbapenems. Some examples of Enterobacteriaceae are Escherichia coli (E. coli), Enterobacter species and Klebsiella species. Enterobacteriaceae are one of the most common causes of bacterial infections in both healthcare and community settings. Carbapenem are a type of antibiotic frequently used to treat severe infections. Some Enterobacteriaceae can no longer be treated with carbapenems because they have developed resistance to these antibiotics (i.e., CRE); resistance makes the antibiotics ineffective in killing the resistant germ. Resistance to carbapenems can be due to a few different mechanisms. One of the more common ways that Enterobacteriaceae become resistant to carbapenems is due to production of Klebsiella pneumoniae carbapenemase (KPC). KPC is an enzyme that is produced by some CRE that was first identified in the United States around 2001. KPC breaks down carbapenems making them ineffective. Other enzymes, in addition to KPC, can breakdown carbapenems and lead to the development of CRE, but they are uncommon in the United States.

Signs and Symptoms

Enterobacteriaceae are commonly found in normal human intestines (gut). Sometimes these bacteria can spread outside the gut and cause serious infections such as pneumonia, bloodstream infections, urinary tract infections, and wound infections.

 

Transmission

To get a CRE infection, a person must be exposed to CRE bacteria. CRE bacteria are most often spread person-to-person in healthcare settings through contact with infected or colonized people, particularly contact with wounds or stool. CRE can cause infections when they enter the body, often through medical devices like intravenous catheters, urinary catheters, or through wounds caused by injury or surgery.

Diagnosis

If you have an infection associated with an Enterobacteriaceae, your healthcare provider may order additional tests to determine if it is resistant to antibiotics.

Treatment

CRE are often resistant to many commonly prescribed antibiotics but may remain susceptible to one or more antibiotics. Decisions on treatment of infections with CRE should be made on a case-by-case basis by a healthcare provider. Some people might be colonized rather than infected with CRE and may not require any treatment.

Immunity

Currently, there is no immunity for CRE infections.

Risk in Hawaii

Healthy people usually don’t get CRE infections. CRE primarily affect patients in acute and long-term healthcare settings, who are being treated for another condition. CRE are more likely to affect those patients who have compromised immune systems or have invasive devices like tubes going into their body. Use of certain types of antibiotics might also make it more likely for patients to get CRE. CRE have been spread during ERCP (endoscopic retrograde cholangiopancreatography), a medical procedure that involves inserting a specialized endoscope commonly called a duodenoscope into the mouth and down to the intestine where the bile duct attaches.

A variety of enzymes produced by Enterobacteriaceae make them resistant to carbapenems. Several of these enzymes appear to be more common in other countries than they are in the United States. As with medical care in the United States, medical care abroad can be associated with healthcare–associated infections and/or resistant bacteria.

Prevention

To prevent CRE Patients should:

  • Tell your doctor if you have been hospitalized in another facility or country.
  • Take antibiotics only as prescribed.
  • Expect all doctors, nurses, and other healthcare providers wash their hands with soap and water or an alcohol-based hand rub before and after touching your body or tubes going into your body.  If they do not, ask them to do so.
  • Clean your own hands often, especially:
    – Before preparing or eating food
    – Before and after changing wound dressings or bandages
    – After using the bathroom
    – After blowing your nose, coughing, or sneezing
  • Ask questions. Understand what is being done to you, the risks and benefits.

Additional Resources

Information for Clinicians

Clinicians play a critical role in slowing the spread of CRE. Rapidly identifying patients colonized or infected with these organisms and placing them in Contact Precautions when appropriate, using antibiotics wisely, and minimizing device use are all important parts of preventing CRE transmission.

CDC has developed a CRE toolkit for facilities to control CRE.