Carbapenemase-Producing Enterobacteriaceae ( CPE ) - The Early Detection, Management and Control of

Publication: 01/10/2014  --
Last review: 27/02/2019  
Next review: 01/02/2022  
Clinical Guideline
CURRENT 
ID: 3965 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The Early Detection, Management and Control of Carbapenemase-Producing Enterobacteriaceae (CPE)

Back to top

Summary of Guideline

This guideline provides advice on the management of colonisation or infection with carbapenemase-producing enterobacteriaceae (CPE).

CPE are members of a large family of bacteria, the Enterobacteriaceae, that usually colonise the gut. Species in this family include Escherichia coli and Klebsiella pneumoniae. CPE are strains of these organisms that produce enzymes which destroy carbapenem antibiotics, such as meropenem, ertapenem and imipenem. They are usually resistant to most other antibiotics too, making infections with CPE very difficult to treat.

Early detection of CPE can be achieved by risk assessing all patients on admission to hospital and some targeted areas in pre assessment.

For the purpose of this guideline once a patient has had a positive result, however long ago, they will be managed under the section ‘Patients with a confirmed CPE’.

Patients with confirmed CPE should be placed in source isolation and remain there for the duration of their stay.

Those identified through screening questions as being at high risk of being colonised with a CPE should be placed in source isolation and screened for carriage. This is done by taking three rectal swabs (or stool samples), each two days after the last one.

Strict standard precautions should be applied and specific PPE should be worn (see below). Scrupulous infection prevention and control (IPC) practices are essential when caring for invasive devices and associated equipment.

If a patient confirmed to be colonised or infected with CPE is nursed in an open bay their contacts should be identified, cohorted (where possible) and screened.

Back to top

Background

What are CPE?
CPE are members of a large family of bacteria, the Enterobacteriaceae, that usually live harmlessly in the gut of humans and animals. However, these organisms are also some of the most common causes of opportunistic infections, such as urinary tract, intra-abdominal and bloodstream infections. They include species such as Escherichia coli, Klebsiella pneumoniae and Enterobacter spp.  

Carbapenems are a valuable family of antibiotics normally reserved for serious infections caused by drug-resistant Gram negative bacteria like E. coli, K. pneumoniae and Pseudomonas aeruginosa. They include meropenem, ertapenem and imipenem. Carbapenemases are enzymes that destroy carbapenem antibiotics, conferring resistance. They are made by a small but growing number of Gram negative bacteria. These include members of the Enterobacteriaceae family and also species of Pseudomonas and Acinetobacter. There are different types of carbapenemases, of which KPC, OXA-48, NDM and VIM enzymes are currently the most common. Organisms that carry these enzymes are usually also resistant to most other antibiotics too.

Why does carbapenem resistance matter?
Carbapenem antibiotics are a group of β-lactam (penicillin-like) antibiotics used in hospitals. Until now, they have been the antibiotics that doctors often use (when other antibiotics failed) to treat infections caused by resistant Gram negative bacteria. Unless we act now, learning from experiences elsewhere across the globe, rapid spread of carbapenem-resistant bacteria has great potential to pose an increasing threat to public health and modern medicine.

Infections with CPE lead to worse outcomes for patients. They are associated with a higher mortality than infections caused by non-CPE strains of the same bacteria. They also cost more to treat and there are resource implications for managing CPE carriers, e.g. the use of side rooms. It is therefore vital that we identify CPE carriers and prevent onward transmission of these organisms.

How can CPE be detected early and any spread prevented?
Early detection can be achieved by risk assessing all patients on admission to hospital and some targeted areas in pre assessment.

Back to top

Who to risk assess for CPE and how to do it

  • All inpatient admissions to LTHT or transfers from other hospitals
  • All haemodialysis patients

A risk assessment for CPE shouldshould be undertaken at the earliest opportunity in the care pathway for all of these patients, either at pre-assessment or on admission, using the LTHT Risk assessment tool for adult (Appendix A) or paediatric (Appendix B) patients.

Using the appropriate risk assessment tool:

1. Firstly consider if the patient is already known to be colonised/infected with CPEs:  ask the patient and look on PAS (patient administration system).  PAS will be flagged with an infection alert for cases known to be positive to LTHT.

If the patient already has previously laboratory-confirmed infection or colonisation with a CPE then:

  • Immediately place the patient into a single room, preferably with en suite facilities
  • Apply strict standard precautions (see page 4 and LTHT Standard Infection Prevention and Control Precautions Guideline ) to prevent possible spread
  • Ensure good hand hygiene
  • Use appropriate personal protective equipment (PPE) - gloves and a disposable gown with long sleeves and thumb loops
  • Advise the patient (and relatives if appropriate) of the previous positive result
  • Provide the patient with an information sheet (Appendix D)
  • Inform the Infection Prevention and Control (IPC) Team
  • Further screening is NOT required

2. If there is no previous history of colonisation/infection with CPE undertake the following risk assessment:
Assess the patient to determine the answers to these screening questions:
a) Within the last 12 months have they been hospitalised:

  • in any overseas healthcare facility
  • in London, Manchester and the North West (see the IPC intranet site for an up to date list of relevant hospitals)
  • in Sheffield spinal unit

or, were they hospitalised in LTHT ward J83 during 2013?
If the answer is yes check to see if the patient has already had 3 negative screens since the admission.
OR
b) Has the patient had haemodialysis overseas, in London or in Manchester in the last 12 months (and has not since had 3 negative CPE screens)?

If the answer is yes to either question the patient is considered to meet the criteria for being suspected of having a CPE and are considered ‘high risk’. They require source isolation and screening samples to be collected (see below).

If the answer is no to both questions the patient is considered to be ‘low risk’ and no further action is required.

Screening in Patients Transferred to Neonatal Unit
If a patient is transferred to the neonatal unit and meets the criteria for CPE screening, they will need source isolation until they have had three negative screens and these should ideally be undertaken in LTHT. Under circumstances whereby source isolation is problematic or needs to be limited due to capacity and CPE screening has been undertaken at the referring trust, up to two of these results can be considered towards the full screening process, but at least one further screen needs to be undertaken in LTHT. Neonates who fall into this category could be nursed in an incubator rather than formal source isolation provided criteria above are met, whilst awaiting the LTHT result. Please note Cepheid testing is now available in the Neonatal Unit to enable rapid screening results.  

Back to top

How to screen for CPE in patients identified as being at 'high risk'

What screening sample(s) to take from all ‘high risk’ patients:

A rectal swab is the sample of choice for CPE screening, except in the following situations:  neutropenic patients, children (see Appendix B) or if the patient refuses.

A rectal swab should be taken using a routine bacteriology swab 48 hours apart at the following time intervals:

  • On admission
  • Day 2 after admission
  • Day 4 after admission

DO NOT SPLIT MRSA SCREENING PACKS FOR ROUTINE USE.

To take a rectal swab insert the swab gently 3-4cm into the rectum, and rotate to ensure faecal material is sampled: there must be visible faecal material on the swab. Place the swab back into the transport medium and send to the Microbiology Laboratory, requesting “CPE Screen”. If using Order Comms request ‘Carbapenemase producing organism screen’. This can be found under the Infection Control Screening link on the Microbiology tab.

If a rectal swab cannot be taken collect a stool sample, in the same way as for routine culture, and send to Microbiology requesting “CPE screen”.

Take bacteriology swabs of any wounds and device-related sites.  If the patient is known to have been ventilated on a Critical Care unit, also send sputum if available, or throat swab if not. If the patient is catheterised a CSU (catheter specimen of urine) is also required.

Back to top

Treatment/Management

Treatment:

Colonisation should not be treated and there is currently no decolonisation available. If a patient has evidence of an infection with a CPE treatment should always be discussed with a Microbiologist, as there is no single antibiotic that is predictably effective against these organisms. Microbiology advice is available by contacting 23962 from 9am to 5pm Monday to Friday, or via switchboard out of hours (ask for the Microbiology StR on call).

Infection prevention and control management:

1. Patients with a confirmed CPE on screening

Patients with a confirmed CPE should be placed in source isolation and remain there for the duration of their admission. Information should be provided to patients and (if appropriate) their family (Appendix D).  Strict standard precautions should be applied and scrupulous IPC practices are particularly important when caring for devices/equipment as these are highly transmittable organisms.

Standard precautions include:

  1. Good hand hygiene (see Hand Hygiene Policy)
  2. Use of appropriate PPE - gloves and a disposable gown with long sleeves and thumb loops.
  3. Environmental cleaning (using a solution of 1000ppm chlorine) including an enhanced focus on frequent cleaning of hand contact areas
  4. Single patient use equipment where possible or, where not possible, decontamination of shared equipment with a solution containing 1000ppm available chlorine after use
  5. Safe use of sharps
  6. Safe management of laundry, of body fluid spillages and waste disposal - all linen should be treated as infectious and placed in a red alginate bag before removal from the room. All waste from the room should be treated as infectious patient waste. Full waste and linen bags should be disposed of promptly from the ward
  7. Aseptic technique when handling invasive devices (e.g. IV lines)
  8. Appropriate decontamination of the room on discharge (see below)

Scrupulous IPC practices when caring for the following devices/equipment:

  • Intravenous lines( both peripheral and central)
  • Urinary catheter
  • Colostomy/ileostomy
  • Urostomy
  • Ventilators
  • Renal dialysis equipment
  • Enteral feeding equipment
  • Any re-usable diagnostic equipment.

For more information see the LTHT Isolation Guideline.

For the purpose of this guideline once a patient has had a positive result (infection or colonisation), however long ago, they will be managed under the section ‘Patients with a confirmed CPE on screening’. No further screening is required during their admission.

2. Patients identified as high risk of colonisation/infection with CPE

Patients identified to be at high risk of colonisation/infection with CPE by the screening questions in the risk assessment should be placed in source isolation and the same strict standard precautions applied as for colonised patients (see above). The only difference is that the appropriate PPE when entering these patients' rooms is gloves and a standard disposable apron. These measures must continue until three negative screens have been obtained taken 48hrs apart (i.e. on admission, day 2 after admission and day 4 after admission). Once this has been achieved the patient can be removed from source isolation with no further screening required during their admission. Patients (and if appropriate their family) should be provided with an information sheet (see Appendix C) during the screening process.

3. Patients identified as positive for CPE from a clinical sample during admission

If during their stay a patient is subsequently identified as CPE positive from a clinical sample this patient must be managed as per the guidance in the section ‘Patients with a confirmed CPE on screening’ (see section 1 above).

In addition;

  • Contact the IPC team
  • Inform the patient and (if appropriate) their family of the result and provide an information sheet (Appendix D)
  • PAS will be flagged with an infection alert (this is initiated by the IPC team)
  • Information about the positive result must be included on all transfer/discharge documents
  • If the patient has previously screened negative within LTHT, or has never been screened, the positive result represents a potential acquisition. It must be recorded on the incident reporting system (Datix web) and a level 1 investigation should be undertaken.
  • Contacts will need to be identified (use the form in Appendix E) and screened (see below).

Additional measures over and above these guidelines may be in place for certain groups of patients, agreed by local CSU management teams along with the infection prevention and control team.

Screening of contacts

  • Screening should be undertaken with input from the IPC team
  • Screening of patient contacts of a positive case SHOULD be undertaken if the case has spent time (regardless of the length of time) in an open ward or bay with other patients before (or despite) having a positive result for a CPE
  • Contacts do not need to be in source isolation but should be placed together in a cohort, if possible
  • Strict standard precautions should be used when caring for contacts, especially hand hygiene, until they have screened negative
  • PPE when caring for contacts is gloves and standard aprons (long-sleeved gowns do not need to be used)
  • Take a rectal swab/stool sample screen from all the contacts on a once weekly basis for a period of 4 weeks following the date of last contact with the case. Should any contact screen positive, manage as confirmed positive case (see above)
  • If all of the screens are negative no further action is required
  • Screening of household contacts and healthcare staff is NOT required; there is no compelling evidence to suggest that screening the household or healthcare staff to check for colonisation will provide additional benefit in controlling spread in the healthcare setting

Patient transfer and discharge:

If a patient who is colonised with CPE, has an infection, or is undergoing screening for CPE carriage or as a contact requires a diagnostic test, or procedure that cannot be undertaken in the patient’s room, the procedure should be planned at the end of the day’s list and the room and equipment terminally cleaned after use. Similarly, known positive outpatients should be planned at the end of the day’s list and known positive renal dialysis patients should be isolated during dialysis.

If infected/colonised patients or those currently being screened for CPE carriage or as a contact are moved, receiving wards or institutions must be informed of the patient’s CPE carrier status. This includes long-term care facilities (i.e. residential and nursing homes). The patient’s GP must also be informed on the eDAN.

Decontamination of the room following patient transfer or discharge:

When patients known to have a CPE infection or colonisation are transferred or discharged the room must be cleaned as per guidance in the Source Isolation Guideline . In addition, the IPC team must be contacted for advice on whether the room also requires hydrogen peroxide vapour cleaning (HPV or ‘fogging’). The decision to deploy HPV will be based on a risk assessment, which requires the following information:

  • Sample(s) from which the CPE has been identified (e.g. rectal screen, CSU, blood culture)
  • Whether the patient has a CPE infection or is just colonised
  • Whether the patient has diarrhoea, faecal or urinary incontinence
  • Whether the patient has any medical devices in place (e.g. urinary catheter, IV lines, stoma) or chronic wounds

Please have this information available when contacting the IPC team. HPV fogging will be used to clean all rooms vacated by patients with a CPE infection. It will also be used in those who are colonised at sites other than, or in addition to, the rectal screen, and in those with diarrhoea or faecal incontinence.

Rooms vacated by patients who are undergoing screening for CPE, either having been identified as high risk of colonisation or as a contact of a known carrier, do not require discussion with the IPC team as HPV cleaning is not indicated. The room will still require cleaning in accordance withthe Source Isolation Guideline.

Some areas will have procedures in place over and above this guideline, agreed locally by the CSU
and Infection Prevention and Control Team.

Back to top

Appendix A - Screening and source isolation requirements for Carbapenemase Producing Enterobacteriaceae (CPE) in adult patients

* For advice where there is inability to isolate a patient contact the Infection Prevention and Control team

COLLECTING AND SENDING SCREENING SAMPLES:

  • Rectal swab :
    • Take a rectal swab unless the patient is neutropenic or refuses
    • Gently insert a routine charcol swab 3-4cm into the rectum and rotate it
    • There must be visible faecal material on the swab to ensure CPE can be detected
  • Stool sample:
    • If the patient cannot or will not have a rectal swab
  • Also, if the patient was hospitalised or had haemodialysis in the last 12 months…
    • Take swabs from any wounds and device-related sites (e.g. PEG site)
    • Take a CSU sample if the patient has a catheter
    • Take a sputum sample or throat swab if the patient was ventilated whilst in hospital
  • For all samples:
    • Send them to Microbiology requesting “CPE screen” on the form
    • If using Order Comms request ‘Carbapenemase producing organism screen’ which can be found under the Infection Control Screening link on the Microbiology tab
  • Record results in the source isolation care plan
  • If the screen is negative repeat it on days 2 and 4 of admission

Back to top

Appendix B - Screening and source isolation requirements for Carbapenemase Producing Enterobacteriaceae (CPE) in Paediatric Patients

Back to top

Appendix C - I have been assessed as at risk of carrying a carbapenemase-producing organism – what does this mean?

What does ‘carbapenemase-producing enterobacteriaceae (CPE)’ mean?
Carbapenemase-producing enterobacteriaceae (sometimes called CPE), are bacteria that usually live harmlessly in the gut of humans. This is called ‘colonisation’ (a person is said to be a ‘carrier’). However, if the bacteria get into the wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems are one of the most powerful types of antibiotics. Carbapenemases are enzymes (chemicals), made by some strains of these bacteria, which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics.

Why does carbapenem resistance matter?
Carbapenem antibiotics can only be given in hospital directly into the bloodstream. Until now, doctors have relied on them to successfully treat certain ‘difficult’ infections when other antibiotics have failed to do so. Therefore, in a hospital, where there are many vulnerable patients, spread of these resistant bacteria can cause problems.

Does carriage of a carbapenemase-producing enterobacteriaceae need to be treated?
If a person is a carrier of a CPE they do not need to be treated. As mentioned, these bacteria can live harmlessly in the gut. However, if the bacteria have caused an infection then antibiotics will be required.

How will I know if I am at risk of being a carrier or having an infection?
Your doctor or nurse may suspect that you are a carrier if you have been in a hospital abroad, or in a UK hospital that has had patients carrying these bacteria, or if you have been in contact with a carrier elsewhere. If any of these reasons apply to you, screening will be arranged for you and you will be accommodated in a single room with your own toilet facilities whilst you are in hospital, until the results are known.

How will I be screened for CPE?
Screening usually entails taking a rectal swab by inserting it just inside your rectum (bottom). Alternatively, you may be asked to provide a sample of faeces. The swab/sample will be sent to the laboratory and you will normally be informed of the result within two to three days. If the result is negative, the doctors or nurses may wish to check that a further two samples are negative. These measures will not hinder your care in any way. If all results are negative no further actions are required.

What happens if the result is positive?
If the result is positive your doctor or nurse will explain this to you in more detail. You will continue to be accommodated in a single room if you are in hospital. If you have an infection, you will need to have antibiotics. However, if there are no signs of infection and you are simply ‘carrying’ the bacteria, no treatment is required.

Back to top

Appendix D - I am colonised/have an infection with carbapenemase-producing enterobacteriaceae - what does that mean?

What does ‘carbapenemase-producing enterobacteriaceae (CPE)’ mean?
Carbapenemase-producing enterobacteriaceae (sometimes called CPE), are bacteria that usually live harmlessly in the gut of humans. This is called ‘colonisation’ (a person is said to be a ‘carrier’). However, if the bacteria get into the wrong place, such as the bladder or bloodstream they can cause infection. Carbapenems are one of the most powerful types of antibiotics. Carbapenemases are enzymes (chemicals), made by some strains of these bacteria, which allow them to destroy carbapenem antibiotics and so the bacteria are said to be resistant to the antibiotics.

Does carriage of a CPE need to be treated?
If a person is a carrier of CPE they do not need to be treated. As mentioned, these bacteria can live harmlessly in the gut. However, if the bacteria have caused an infection then antibiotics will be required.

How did I ‘pick up’ CPE?
Do ask your doctor or nurse to explain this to you in more detail. As mentioned above, sometimes this bacterium can be found, living harmlessly, in the gut of humans and so it can be difficult to say when or where you picked it up. However, there is an increased chance of picking up these bacteria if you have been a patient in a hospital abroad or in a UK hospital that has had patients carrying the bacteria, or if you have been in contact with a carrier elsewhere.

How will I be cared for whilst in hospital?
You will be accommodated in a single room with toilet facilities whilst in hospital. You may be asked to provide a number of samples, depending on your length of stay, to check if you are still carrying the bacteria. The samples might include a number of swabs from certain areas, such as where the tube for your drip (if you have one) enters the skin, a rectal swab i.e. a sample taken by inserting a swab briefly just inside your rectum (bottom), and / or a faecal sample. You will normally be informed of the results within two to three days.

How can the spread of CPEs be prevented?
Accommodating you in a single room helps to prevent spread of the bacteria. Healthcare workers should wash their hands regularly. They will use gloves and aprons when caring for you. The most important measure for you to take is to wash your hands well with soap and water, especially after going to the toilet. You should avoid touching medical devices (if you have any) such as your urinary catheter tube and your intravenous drip, particularly at the point where it is inserted into the body or skin. Visitors will be asked to wash their hands on entering and leaving the room.

What about when I go home?
Whilst there is a chance that you may still be a carrier when you go home quite often this will go away with time. No special measures or treatment are required; any infection will have been treated prior to your discharge. You should carry on as normal, maintaining good hand hygiene. If you have any concerns you may wish to contact your GP for advice.

Where can I find more information?
If you would like any further information please speak to a member of your care staff, who may also contact the Infection Prevention and Control Team for you.

The Public Health England website is another source of information:
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/CarbapenemResistance/

Back to top

Appendix E - Patient contact tracing form

Patients who have been in contact with suspected or confirmed case of carbapenemase-producing enterobacteriaceae (CPE)
Index patient identifier (NHS/PAS no.):                                                      Dates of contact:
Ward:                                                                                                  Member of staff responsible for compiling information:

Contact with suspected case - patients who have been in the same bay/room as the index case, at the same time or at any time up to and including the time the bay was closed

Please carefully print all information to enable contact of these patients if necessary

Bed no.

Patients Name

Patient identifying number

Date of birth

Date and time of admission

Date and time of discharge

Patient address and telephone number

GP address

 

 

 

           

 

 

 

           

 

 

 

           
   

 

 

 

 

 

 

 

 

 

 

           

 

 

 

           

 

 

 

           
   

 

           

Back to top

Provenance

Record: 3965
Objective:

Aims
To advise on the management of colonisation or infection with CPE and to minimise onward transmission.

Objectives
To provide evidence-based recommendations for appropriate infection prevention and control measures in the diagnosis, investigation and management of CPE.

Clinical condition:

Colonisation/infection with CPEs

Target patient group: All inpatients and haemodialysis patients
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Public Health England (2013); Acute trust toolkit for the early detection, management and control of carbapenemase-producing enterobacteriaceae.  PHE publications gateway number: 2013314

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.