Carbapenemase-Producing Enterobacterales (CPE) - Framework of Actions to Contain

Publication: 01/10/2014  
Next review: 31/10/2025  
Clinical Guideline
CURRENT 
ID: 3965 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

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.

Framework of Actions to Contain Carbapenemase-Producing Enterobacterales (CPE)

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Summary of Guideline

This guideline focuses on carbapenemase-producing Enterobacterales (CPE); these organisms spread rapidly in healthcare settings and lead to poor clinical outcomes because of limited therapeutic options. The increased incidence of CPE has significant cost and operational implications for healthcare providers.

This guideline sets out a range of measures, that if implemented well, will help health and social care providers minimise the impact of CPE. These include:

  • active patient admission screening of risk groups
  • rapid detection of patients colonised or infected with CPE, with appropriate surveillance systems to enable ongoing monitoring
  • consistent implementation of infection prevention and control practices and contact precautions
  • minimisation of CPE reservoirs by effective environmental cleaning and decontamination
  • antimicrobial stewardship programmes to minimise inappropriate use of broad-spectrum antibiotics, including carbapenems
  • optimised laboratory methods to detect carbapenemase-producing Gram-negative bacteria, including Enterobacterales
  • prompt recognition of outbreaks to enable effective management
  • organisational ownership to support the implementation of this framework.

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Background

What are carbapenemase-producing Enterobacterales?

Recent taxonomy changes have included the family Enterobacteriaceae within the order Enterobacterales. Enterobacterales are a large family of bacteria that usually live harmlessly in the gut of humans and animals. They include species such as Escherichia coli, Klebsiella species. and Enterobacter species . However, these organisms are also some of the most common causes of infections, including urinary tract infections, intra-abdominal and bloodstream infections.

Carbapenems are a valuable family of β-lactam (penicillin-like) antibiotics normally reserved to treat serious life-threatening multidrug-resistant Gram-negative infections in hospitals. They include meropenem, ertapenem, imipenem and doripenem.

Resistance to some or all carbapenems is an intrinsic (natural) characteristic of some Gram-negative bacteria. Others can produce carbapenemases, which are enzymes that destroy carbapenem antibiotics, conferring resistance. This document focuses on acquired carbapenemases, a particular concern as these genes (usually located on mobile elements such as plasmids) can move vertically (within a strain) and horizontally (between strains, species and genera).

Enterobacterales producing acquired carbapenemases are referred to as CPE. KPC, OXA-48-like, NDM, VIM, and IMP enzymes are the most prevalent enzymes in the UK. Increasing gut colonisation with these resistant bacteria will inevitably lead to an increase in difficult-to-treat infections. Figure 1 illustrates the relationship between CPE and other carbapenem-resistant and carbapenemase-producing Gram-negative bacteria.

Why does carbapenem resistance matter?

Unless action is taken and lessons are learnt from experiences elsewhere in the world, rapid spread of CPE will pose an increasing threat to public health and medical treatment pathways in the UK. These resistant bacteria can spread rapidly in healthcare settings.

Invasive infections with CPE increase both patient length of stay, as a consequence of morbidity, and mortality, compared to bacteria not carrying resistance markers. Additionally, large outbreaks in the UK have led to substantial costs (healthcare, staffing and other resources) given the time taken to achieve control once the outbreak is established. In some health and social care organisations in England, CPE are now endemic. Early detection of CPE can be achieved by risk assessing all patients on admission to hospital.

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CPE risk assessment, screening and source isolation

Each patient admitted to LTHT should have a clinical risk assessment to determine those at higher risk of CPE colonisation on admission, readmission or transfer from another healthcare facility.

Patients must be risk assessed for CPE at the earliest opportunity in their care pathway, either at pre-assessment or on admission.

Active screening for CPE is recommended to:

  • minimise transmission from CPE positive patients
  • minimise the risk that colonised patients will develop clinical infections eg from invasive devices
  • ensure appropriate surgical prophylaxis and prescribing of effective antibiotic therapy if clinical infection develops
  • minimise environmental contamination and the development of potential reservoirs

See appendix A for the LTHT CPE risk assessment tool. This is for reference only - please use the PPM+ clinical document CPE risk assessment.

A - Any history of previous CPE colonisation or infection? - CPE positive likely
Patients should be managed in a single room with en-suite facilities, where possible. If the single room does not have en-suite facilities, a commode or dedicated toilet should be assigned to the patient.
Gloves and a disposable gown with long sleeves and thumb loops should be worn by all staff.
Screen required day 0 (if negative repeat day 2 & day 4)
Contact IPC once results obtained for review/risk assessment.
Do not remove from source isolation until the above actions have been completed.

B - G - At risk of CPE

B - Been an inpatient in a UK hospital with high CPE risk (link) within the past 12 months
C - Been an inpatient in an LTHT ward with high CPE risk (link) within the past 12 months
D - Been directly transferred from a hospital abroad
E - Had multiple regular treatments in the last 12 months (e.g. haemodialysis or chemotherapy)?
F - Been a contact of a known CPE case (carrier or infection)
G - Been prescribed any broad-spectrum antibiotics within the past 28 days (see appendix A for list)

Isolate at the bedside (providing there are no other infections that require source isolation) with strict emphasis on maintaining compliance with contact precautions and optimal environmental cleaning until screening results available. NB: CPE is commonly transmitted via the faecal-oral route.

The following factors increases the risk of CPE transmission and should be considered when risk assessing the patient, isolate in a side-room

  • Incontinence (urine or faeces)
  • Discharging wounds
  • Medical devices in situ (eg long-term catheter or central vascular access device)
  • Ventilatory support requirements
  • Walks with purpose

**For outpatients and day cases – provide appointment timed for end of clinic or list; consider caring for day case in single room dependent on degree of contact with body fluids e.g. endoscopic procedures would pose greater risk of transmission than an ophthalmology patient. Maintain compliance with standard precautions and optimal environmental cleaning. In an outpatient setting, contact precautions should be instigated based on a risk assessment and in discussion with IPC team.

H – Is patient being admitted to an augmented care/high-risk unit or a direct inpatient transfer (see appendix A for the list of areas in LTHT).

Admission CPE screening indicated. Source isolation not required unless other criteria (A-G) met.

If none of the above criteria apply (A-H) source isolation not required for CPE and CPE screen not indicated. Please review for other indications for source isolation.

Risk assessment for source isolation:

See appendix D for risk prioritisation tool for source isolation. This should be used in conjunction with the CPE risk assessment tool to assess the need for source isolation, with consideration to the location/ward of admission.

Staff screening:
Staff screening in general or outbreak situations is not recommended . There is no evidence of effectiveness and it is not recommended in international guidelines or by UK experts.

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How to screen for CPE

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

A rectal swab should be taken using a routine bacteriology swab.

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 Prevention Screening link on the Microbiology tab.

If a rectal swab cannot be taken (the patient is neutropenic or refuses) 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.

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Treatment/Management

Management of patients found to be positive for CPE (colonisation or infection) on current admission:

  • Immediately place the patient in to a single room, preferably with en-suite facilities for the duration of the admission
  • Apply strict standard IPC and contact precautions (see appendices B & C) to prevent possible spread
  • Use appropriate PPE - gloves and disposable gown with long sleeves and thumb loops
  • Advise the patient (and relatives if appropriate) of the positive result
  • Provide the patient with a CPE information leaflet.

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).

Antimicrobial stewardship (AMS) with particular attention to reducing the use of broad-spectrum antibiotic use is critical in the prevention of antimicrobial resistance.

Standard infection control precautions and contact precautions:
Standard infection control precautions (SICP) (See appendix B) and contact (transmission based) precautions (See appendix C) should be used for patients suspected or known to be CPE positive. Staff should apply contact (transmission based) precautions for patients infected or colonised with CPE, particularly where there is a presence of wound drainage, diarrhoea or faecal incontinence.

Visitors:
Visitors who are not providing any patient care and who are not visiting other patients in the hospital do not need to wear gloves or an apron/gown. However, they should clean their hands on leaving the room. If visitors are taking an active part in the patient’s care, SICP should be used. Visitors should not use patient toilet facilities.

Patient transfer and discharge:
Should the patient require a diagnostic test or procedure, this should be undertaken in the patient’s room if possible. If not, the procedure should be planned at a time when decontamination of equipment and the environment can be undertaken after the patient has vacated the area. It is recommended to remove any equipment not needed for the procedure from the room to aid cleaning.

Areas where patients undergo diagnostics and/or procedures, including operating theatres, should aim to place CPE positive patients at the end of the day’s list to allow for thorough cleaning. However, patient care should not be compromised. Where possible, CPE positive patients should have separate waiting and recovery areas to reduce any possible environmental contamination and subsequent transmission

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.

Cleaning and decontamination:

  • transmission to other patients is reduced through appropriate ward and equipment cleaning and disinfection, appropriate waste disposal, education of staff, audit of processes and feedback
  • effective cleaning of high-touch surfaces and management of environmental reservoirs will minimise spread of gut flora and transmission to subsequent room residents
  • environmental reservoirs can be difficult to eradicate; such reservoirs include sinks, drains, and other water sources
  • use dedicated single-patient or single-use equipment, for example blood pressure cuffs, pulse oximeters, stethoscopes or thermometers
  • implement and audit high standards of cleaning and disinfection
  • decontaminate equipment after use by a colonised or infected patient, especially when the equipment may be shared with other patients
  • enhance cleaning and disinfection (eg increase frequency) in response to an outbreak or cluster of CPE positive patients
  • physical removal of biofilm from a sink or shower waste trap by cleaning is not recommended
  • all basins, sinks and showers should be maintained so they drain efficiently
  • hand wash basins should only be used for hand hygiene

Sinks, basins, showers and drains:
Many surfaces within drainage systems will be colonised by micro-organisms in a slime layer; this is known as a “biofilm”. Antibiotic-resistant bacteria can be long-term residents within these biofilms and studies have demonstrated that hospital sinks and associated drainage systems can harbour antimicrobial resistant bacteria, including CPE.

Sink and shower waste can harbour high numbers of bacteria. Whilst most of these bacteria are firmly fixed within the biofilm matrix, bacteria can also be released into the water covering the biofilm. There is some evidence that CPE in waste traps and/or drainage biofilm can transmit to patients. Strains recovered from sinks have also been isolated from patients, but the route and/or direction of transmission is difficult to determine and is often unclear.

This could occur in several ways:

  • if the stream of water from the spout of a tap flows directly into the drain hole of the sink below, it could cause dispersal of drain water by splashing - this could contaminate surrounding surfaces and the person using that sink
  • if drainage is partially blocked and water builds up in the sink bowl, there is likely to be a pooling of water and reflux from the drain - water flow from the tap will cause splashing and dispersal of contaminated water droplets
  • if showers do not drain efficiently, there can be reflux of water from the drain and contact between the shower user’s feet and that contaminated water.

Nutrients such as food waste may both increase bacterial numbers in a biofilm and impede drainage and should not be disposed of via sinks. Hand wash basins should only be used for hand hygiene and not for:

  • disposal of body fluids
  • disposal of tea, coffee or other nutrient containing beverages
  • disposal of IV fluids
  • washing any patient equipment
  • storage of used equipment awaiting decontamination

It is important to ensure that cleaning of hand wash basins and taps is undertaken in a way that does not allow cross-contamination from a bacterial source to the tap.

Decontamination of the room following patient transfer or discharge:
Environmental decontamination is critical following the transfer, discharge or death of a colonised or infected patient and requires coordination between cleaning services, ward/unit staff and the IPC Team. The room requires hydrogen peroxide vapour cleaning RED CLEAN (HPV or ‘fogging’).

The following points are examples of particular importance:

  • mattresses are especially important as sheets are not an effective barrier to passage of contamination patient-to-mattress or mattress-to-patient
  • bedframes, handrails and mattress covers should be cleaned then disinfected, and the integrity of the cover assessed; if the mattress cover is damaged, the mattress should be condemned. Pillows should be disposed of if the integrity of the cover is damaged or the pillow itself is soiled
  • dynamic mattresses should be disassembled, cleaned and disinfected – usually by specialist external contractors or in specialist facilities within the hospital
  • privacy curtains should be removed and laundered or be single-patient use only
  • all used or unused single-use items or consumables in the patient’s immediate vicinity (that may have become contaminated by hand contact) should be discarded – keeping limited stocks near the patient reduces the need for this
  • avoid having extraneous equipment in the individual’s room
  • tubes of ointment and lubricant should be discarded
  • lavatory brushes and their holder should be disposed of as part of the discharge/terminal clean

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.

Close contacts should be risk assessed to determine patient placement whilst awaiting screening results e.g. faecal incontinence.

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Outbreaks of CPE

Large-scale, costly CPE outbreaks often arise from transmission from patients whose colonisation status are not recognised or swiftly contained. It is vital that any CPE detection is appropriately managed to prevent onward transmission. A robust, multidisciplinary approach is required to investigate and manage such incidents.

While some CPE incidents are just one organism strain (clonal), others may not be organism specific – multiple different organisms may be found, harbouring the same resistance mechanism and therefore still be linked. Microbiological expertise will be required to consider if plasmids carrying resistance mechanisms have transmitted between genera eg from E. coli to Klebsiella spp.

Bay or unit contacts of patients newly identified as CPE positive need to be screened to detect possible transmission as further carriers may be detected. The number of contacts to be screened will be determined by the hospital infection prevention and control team on a case-by-case basis based on proximity to the index case, duration of exposure, and shared staff. In high-risk units, hospitals should strongly consider screening all patients on these wards.

An Outbreak is a situation in which there are 2 or more cases of the same organism in a patient group or clinical area within LTHT in a defined time frame. The level of outbreak management required is determined by the Infection Prevention Leadership Team (IPLT), +/- other members of the IPCT, taking into account the number of cases and severity of disease. For further information on outbreak management please refer to the LTHT ‘Control of an Outbreak of Infection in Hospital’ guidelines.

When CPE positive patients are found among screened contacts, the strategy for further screening of patients needs to be expanded.

An enhanced period of screening is recommended during the outbreak period. As an example, the patients in the affected unit/bay/ward should be screened twice a week for two weeks, and weekly for a further two weeks.

Once no new cases are detected the frequency of screening may be reduced and stopped at an appropriate point in time after no further cases have been detected. While there is no evidence to suggest how long this should be, experience with other resistant bacteria would suggest a pragmatic period of between 4 and 8 weeks.

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Appendix A - LTHT CPE risk assessment tool (adults)

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Appendix B - Standard infection control precautions

Used by all staff, in all care settings, at all times, for all patients whether infection is known to be present or not to ensure the safety of those being cared for, staff and visitors in the care environment

  • Hand hygiene
  • Respiratory and cough hygiene
  • Personal protective equipment which includes:
    • Gloves
    • Aprons
    • Long sleeved gowns to be worn where any part of the uniform (work wear) is not adequately protected by an apron eg turning patient, or where there is a risk of extensive splashing of blood and/or other body fluids eg excessive wound exudate, diarrhea, faecal incontinence
  • Safe management of care equipment
  • Safe management of the care environment
  • Safe management of linen
  • Safe management of blood and body fluid spillages
  • Safe disposal of waste (including sharps)
  • Occupational safety: prevention and exposure management (including sharps)

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Appendix C - Contact precautions

Used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment).

  • Patient placement/assessment for infection risk
  • Safe management of patient care equipment in an isolation room/cohort area
  • Safe management of the care environment
  • Personal protective equipment: respiratory protective equipment [not routine for CPE patient care]
  • Infection prevention and control during care of the deceased

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Appendix D - Risk prioritisation for source isolation

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Appendix E - Monitoring and Surveillance

New evidence since publication of previous guidance

  • horizonal transfer of carbapenemases means that surveillance systems need to monitor patients colonised and/or infected with different bacteria.

Key recommendations

All healthcare providers:

  • real-time surveillance systems should be in operation to rapidly detect patients either colonised or infected with CPE
  • surveillance definitions should be clear and based on acquired carbapenemases
  • analyse data regularly (at least monthly) to improve case finding within the organisation
  • maintain a database of known cases and their contacts, that is accessible to those who need to make decisions on isolation and screening within the organisation

Hospital settings:

  • flag patients with history of or exposure to CPE so that they can be isolated and/or screened as appropriate on readmission.
  • track colonised patients and contact movements within organisations to identify common epidemiological links and potential transmission routes.
  • employ laboratories that report phenotypically-resistant Gram-negative bacteria AND those identified as acquired carbapenemase producers.
  • report acquired carbapenemase producers to PHE’s national microbiological surveillance system

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Provenance

Record: 3965
Objective:

Aims
To advise on the diagnosis and 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, 2020. Framework of actions to contain carbapenemase-producing Enterobacterales. PHE publications gateway number: GW-1625.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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