Carbapenem-resistant Enterobacteriaceae (CRE) Infection: Patient FAQs

What are CRE?

CRE, which stands for Carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. CRE are an important emerging threat to public health.

Common Enterobacteriaceae include Klebsiella species and Escherichia coli (E. coli). These germs are found in normal human intestines (gut). Sometimes these bacteria can spread outside the gut and cause serious infections, such as urinary tract infections, bloodstream infections, wound infections, and pneumonia. Enterobacteriaceae can cause infections in people in both healthcare and community settings.

Carbapenems are a group of antibiotics that are usually reserved to treat serious infections, particularly when these infections are caused by germs that are highly resistant to antibiotics. Sometimes carbapenems are considered antibiotics of last resort for some 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.

How are CRE spread?

To get a CRE infection, a person must be exposed to CRE germs. CRE germs are usually spread person to person 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 ventilators, intravenous catheters, urinary catheters, or wounds caused by injury or surgery.

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Who is most likely to get an infection with CRE?

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.

Can CRE be treated?

Many people with CRE will have the germ in or on their body without it producing an infection. These people are said to be colonized with CRE, and they do not need antibiotics for the CRE. If the CRE are causing an infection, the antibiotics that will work against it are limited but some options are often available. In addition, some infections might be able to be treated with other therapies, like draining the infection. Strains that have been resistant to all antibiotics are very rare but have been reported.

What are some things hospitals are doing to prevent CRE infections?

To prevent the spread of CRE, healthcare personnel and facilities can follow infection-control precautions provided by CDC. These include:

• Washing hands with soap and water or an alcohol-based hand sanitizer before and after caring for a patient
• Carefully cleaning and disinfecting rooms and medical equipment
• Wearing gloves and a gown before entering the room of a CRE patient
• Keeping patients with CRE infections in a single room or sharing a room with someone else who has a CRE infection
• Whenever possible, dedicating equipment and staff to CRE patients
• Removing gloves and gown and washing hands before leaving the room of a CRE patient
• Only prescribing antibiotics when necessary
• Removing temporary medical devices as soon as possible
• Sometimes, hospitals will test patients for these bacteria to identify them early to help prevent them from being passed on to other patients

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What can patients do to prevent CRE infections?

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.

What if I have CRE?

Follow your healthcare provider’s instructions. If your provider prescribes you antibiotics, take them exactly as instructed and finish the full course, even if you feel better. Wash your hands, especially after you have contact with the infected area and after using the bathroom. Follow any other hygiene advice your provider gives you.

I am caring for someone with CRE at home; do I need to take special precautions?

CRE have primarily been a problem among people with underlying medical problems, especially those with medical devices like urinary catheters or those with chronic wounds. Otherwise healthy people are probably at relatively low risk for problems with CRE. People providing care at home for patients with CRE should be careful about washing their hands, especially after contact with wounds or helping the CRE patient to use the bathroom or after cleaning up stool. Caregivers should also make sure to wash their hands before and after handling the patient’s medical device (e.g., urinary catheters). This is particularly important if the caregiver is caring for more than one ill person at home. In addition, gloves should be used when anticipating contact with body fluids or blood.

Is CRE infection related to medical care abroad?

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. Learn about those risks and how to minimize them.

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