CRE usually spreads from one person to another in healthcare facilities. This could happen when someone comes in contact with an infected person or a carrier of the bacteria. This is common through wounds or feces. CRE can cause infections when they enter the body. It can happen through medical equipment such as urinary catheters, intravenous catheters, or wounds caused by surgery or injury.

Enterobacterales cause many types of infections. Some examples are pneumonia, urinary tract infections, and bloodstream infections. Infections caused by CRE are harder to treat because the bacteria are very resistant to antibiotics.

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.

As a patient, you 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 to 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 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.

CRE infections are not common in children. If a student has a CRE wound infection, they should not go to school until the drainage from the wound or skin infection is controlled. It should also be covered with a clean and dry bandage. The student should avoid activities that might cause the wound to touch others or get wet, dirty, or damaged. Only a doctor can give permission to return to school.

Carbapenem-resistant Enterobacterales has been found in Texas.

When found in a clinical culture, CRE can represent an infection or colonization. There is no set clinical case definition for a CRE as it can cause many types of symptoms.

CRE Investigation Guidance

A Klebsiella species or E. coli from any body site that is laboratory confirmed:

• Klebsiella species or E. coli resistant to any carbapenem, including meropenem, imipenem, doripenem, or ertapenem, OR
• Production of a carbapenemase (i.e. KPC, NDM, VIM, IMP, OXA-48) demonstrated by a recognized test (i.e. polymerase chain reaction, Metallo-β-lactamase test (e.g., E-test) positive, modified Hodge test, Carba NP), OR
• Modified Carbapenem Inactivation Method (mCIM) positive or indeterminate, OR
• Carbapenem Inactivation Method (CIM) positive, OR
• Modified Hodge Test (MHT) positive

Confirmed: Carbapenem-resistant Enterobacterales (CRE):

• Klebsiella species, or E. coli from any body site that is laboratory confirmed.

Note: It is not possible to determine which organism the carbapenemase gene belongs to if a culture-independent diagnostic test (CIDT) reports multiple pathogens detected AND a carbapenemase gene detected is received. In this case, the recommendation is to collect a culture from the same site.

CRE Investigation Form

When reporting CRE, please include (if available):

• A copy of the lab report
• Carbapenems tested
• Susceptibility to antibiotics
• Minimum inhibitory concentration (MIC)
• Positive phenotypic or PCR test, if applicable.

*A DSHS or local health department epidemiologist may contact you for follow-up after receiving your report.