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. Carbapenems 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.



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.


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


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.


Currently, there is no immunity for CRE infections.

Risk in Hawaii

CRE infections are most commonly seen in people with exposure to healthcare settings like hospitals and long-term care facilities, such as skilled nursing facilities, and long term acute care hospitals. Patients who are taking long courses of certain antibiotics, and whose care requires invasive devices such as ventilators or urinary catheters are among those at highest risk for CRE infection. Hawaii is still a relatively low incidence state, and most cases of CRE in Hawaii have occurred in people who had been hospitalized in another state or country. For more information about the different types of CRE in the United States, visit the CDC website “Tracking CRE”. More information on antibiotic resistance patterns in Hawaii can be found on the Hawaii State Antibiogram page.


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.


Last reviewed May 2019