CRE rates creeping up

Here's what hospitalists can do to protect patients from carbapenem-resistant Enterobacteriaceae.

In 2001, only 1.2% of Enterobacteriaceae identified in U.S. hospitals were resistant to carbapenems. Over the next decade, that proportion increased to 4.2%, according to data collected by the National Healthcare Safety Network in 2011.

Admittedly, it's still a small percentage, but the increase in these difficult-to-treat, dangerous infections (about 40% mortality among patients who develop bloodstream infections from these bugs) is enough to worry officials at the Centers for Disease Control and Prevention (CDC). In March, the agency released a Vital Signs report on carbapenem-resistant Enterobacteriaceae (CRE) calling for aggressive action by clinicians, facility administrators, and public health officials to prevent further emergence.

To find out how hospitalists can contribute to this effort and protect their own patients from CRE's effects, ACP Hospitalist recently spoke with Arjun Srinivasan, MD, associate director for healthcare-associated infection prevention programs in the Division of Healthcare Quality Promotion at the CDC.

Q: Why is the CDC sounding the alert about CRE now?

A: We've been following CRE for a while now at CDC, and we've been concerned about it for quite some time, because these are infections that are very difficult to treat. They are very transmissible in health care settings and they are bacteria that can share those resistance genes with other bacteria. We think CRE poses this triple threat to patients. We think that there is an important opportunity to act now to prevent CRE from becoming a bigger problem. Action against CRE is vital because we don't have good treatment options for CRE and we're not likely to get new treatment options for CRE any time soon.

Q: Do you know what caused the observed increase?

A: We don't definitively know the answer, and there's probably not one answer to that question. Certainly, though, the use of antibiotics and our overuse of antibiotics in health care settings is one of several important driving factors that are leading to this growing problem of CRE. Most importantly, the issue of antibiotic use is one factor that is well within our power to control. We can't control how fast bacteria are going to evolve and develop resistance, but we certainly can control how well we use antibiotics.

Q: CDC reports have shown significant geographic variation in the prevalence of CRE. Is this a concern mainly for certain areas of the country?

A: There's definitely geographic variation in terms of how frequently people are encountering CRE. But we also know that facilities in at least 42 states have had at least one case of CRE. Action is warranted across the spectrum. We certainly need facilities where there is more CRE to take aggressive action to try to bring that down, but we also want to see facilities that are rarely or even never encountering CRE to take steps now to ensure that they are well protected and protecting their patients from CRE.

Q: What would you like hospitalists to do?

A: We think that hospitalists are an absolutely key group that we need to partner with. We know that they are probably some of the biggest prescribers of antibiotics in inpatient health care settings. And we know that hospitalists are really skilled at quality improvement work. What we would love to see from the hospitalist community is opportunity to engage with them, to learn from them what ways we at CDC can partner with them to help them protect their patients. A big area where we've already begun doing that work is related to antibiotic use in hospitals. The CDC, in partnership with the Institute for Healthcare Improvement, is doing a project looking at hospitalist-led efforts to improve antibiotic use. There's a growing awareness among the hospitalist community that they are well positioned and well armed to help us lead this fight against antibiotic resistance.

Q: Any advice to hospitalists individually on how to identify and deal with CRE?

A: Certainly, knowing what CRE is, knowing to be on the lookout for CRE—those are both important steps. Work closely with infection control if a CRE case is ever discovered.

Q: What's going on nationally to deal with this problem?

A: A lot of what's going on right now revolves around raising awareness, getting people to take action, helping people understand the actions that they can take. We refer people to our CRE toolkit, which has the steps that we want health care facilities to take to combat CRE, and it's broken down into [steps for] facilities where they see a lot of it, facilities where they don't see much or facilities that haven't seen any of it.

Q: Is there anything else you'd ask of hospitalists on this issue?

A: My request for hospitalists is to think about, and help us at CDC understand better, how we can work more with hospitalists on issues related to antibiotic resistance and health care-associated infections, be that CRE or Clostridium difficile or catheter-associated urinary tract infections. These are all common infections that hospitalists encounter day in and day out. As such, they are also common infections that hospitalists can play a lead role in helping us prevent.