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REVIEW

Using a toolkit to prevent the spread of CPE

  • Comment

Public Health England has published a toolkit to help acute trusts halt the spread of carbapenemase-producing enterobacteriaceae (CPE), a growing public health threat

Abstract

Carbapenem antibiotics are usually reserved for the most serious drug-resistant infections. However outbreaks of infection with carbapenem-resistant gut bacteria, known as carbapenemase-producing enterobacteriaceae (CPE), are rising in the NHS. Public Health England says CPE pose a serious threat to public health and has produced a toolkit to help trusts prevent spread. Every patient should be screened on admission and those with proven or suspected CPE colonisation or infection must be isolated, with appropriate infection prevention and control measures in place.

Citation: Anderson P (2014) Using a toolkit to prevent the spread of CPE. Nursing Times; 110: 39, 16-17.

Author: Pat Anderson is freelance editor and writer.

Introduction

Enterobacteriaceae are gut bacteria, including species such as E coli, Klebsiella and Enterobacter. Usually they live harmlessly in the gut but also cause urinary tract, intra-abdominal and bloodstream infections. Some strains have developed enzymes (carbapenemases) that destroy carbapenem antibiotics, thereby causing resistance. Clusters and outbreaks of carbapenemase-producing enterobacteriaceae (CPE) have occurred in some trusts in the last five years.

Public Health England says carbapenem antibiotics are usually reserved for serious infections caused by drug-resistant bacteria, so resistance to them poses a threat to public health (PHE, 2014). There were 600 cases of CPE last year in England (NHS Choices, 2014) and in some countries prevalence is high (Box 1). Public Health England says acute trusts must take immediate action to prevent CPE spread. Its new toolkit outlines the steps nursing and other healthcare staff must take; these are outlined below.

Box 1. CPE region

Countries with high prevalence of healthcare-associated CPE

Bangladesh, Balkans, China, Cyprus, Greece, India, Ireland, Israel, Italy, Japan, Malta, Middle East (all countries), North Africa (all countries), Pakistan, South East Asia, Latin America, Turkey, Taiwan, US

UK regions where some hospitals have had clusters or outbreaks

North West (especially Manchester), London

Routine risk assessment

The toolkit is designed to help acute trusts improve CPE detection, management and control. It states a risk assessment for CPE must be part of the routine admission procedure. The only exception is if a patient has laboratory confirmation of CPE colonisation or infection during the current admission episode, or this has been confirmed by a UK facility transferring the patient. In this case, the patient should be treated as CPE-positive and isolated immediately. In all other cases, staff must find out at admission whether the patient has:

  • Previously been colonised or infected with CPE or had close contact with a person who has;
  • Been an inpatient in a hospital abroad in the last 12 months;
  • Been an inpatient in a UK hospital known to have problems with the spread of CPE in the last 12 months.

Patients with one or more of the above meet the criteria for a “suspected case”. They should be isolated immediately (in a room with en-suite toilet facilities) and the trust should implement strict standard precautions to prevent possible spread. A rectal swab with visible faecal matter or a stool sample should be taken to ascertain whether the patient is colonised or infected with CPE.

Positive test results

Patients who test positive or are laboratory-confirmed cases on admission should remain in isolation. Weekly tests should confirm their current CPE status. All relevant staff should be made aware that a suspected or confirmed case of CPE has been identified, and should adhere to the trust’s CPE management plan. A risk assessment should be done to identify the likely cause of the colonisation/infection.

Alert, well-trained staff are key to preventing spread. They should ensure they understand isolation procedures and practise strict standard precautions, including:

  • Hand hygiene;
  • Use of personal protective equipment;
  • Aseptic technique;
  • Laundry management;
  • Safe use of sharps;
  • Waste disposal, especially faeces.

Staff should also practise “scrupulous” infection prevention and control measures when using and caring for devices such as:

  • Intravenous infusions;
  • Central venous catheters;
  • Urinary catheters;
  • Ventilators;
  • Renal dialysis equipment;
  • Enteral feeding equipment;
  • Colostomies or ileostomies;
  • Any reusable diagnostic equipment.

Loose stools or diarrhoea increase the risk of spread of the bacteria from the gut, so staff should observe strict infection prevention and control measures, and help patients with hand hygiene.

Screening contacts

Staff should provide a contact leaflet (included in the toolkit) and screen for contacts of positive cases based on the likelihood of exposure. Screening of patients in the same ward is not normally required if the case has been identified on admission and isolated immediately. Screening the contacts of a patient with CPE is needed if the patient has spent time in an open ward or bay with other patients. Contacts need not be isolated while awaiting the results of screening, but should be placed in a cohort, if possible, with strict hand hygiene enforced. Patients in the bay or ward where the patient with CPE spent time should be screened every week for four weeks after the last case was detected. Screening should be restricted to patient contacts still in hospital; any who screen positive should be managed as positive cases.

Screening household contacts or healthcare staff for CPE colonisation is not recommended; no compelling evidence indicates this will control spread in the healthcare setting. Keep the focus on strict standard precautions, especially hand hygiene.

Treatment

Treatment with antibiotics is not advised for patients colonised with CPE. Skin decolonisation is also not advised - the bacteria generally colonise the gut, not the skin, and there is concern that using antibiotics for gut decolonisation would help increase resistance in the longer term. Patients who are infected can be treated under the microbiologist’s advice with monotherapy (polymyxins, tigecycline, fosfomycin or aminoglycoside) or combination therapy (polymyxin with carbapenem, tigecycline or aminoglycoside).

Cleaning and decontamination

Cleaning need not be done more often than usual (unless there is evidence of transmission) but scrupulous routine cleaning is required. High cleaning standards should be promoted and audited, and equipment routinely and stringently decontaminated after use with an affected patient.

Terminal decontamination is crucial after a patient leaves a specific area such as an isolation room. If they need a diagnostic test it should be done in their room, if feasible; if not, it should be planned at the end of the day’s list, and the equipment and room used terminally cleaned.

Conventional mattress covers should be cleaned and disinfected; dynamic mattresses should be disassembled, cleaned and disinfected by specialist contractors or within the hospital. Box 2 outlines how to deal with other close-contact equipment.

Box 2. Dealing with close contact equipment

  • Pulse oximeters: single-patient use, or clean and disinfect
  • Blood pressure cuffs, stethoscopes and thermometers: single-patient use only
  • Privacy curtains: remove and launder, or single use
  • Unused single-use items in patient’s vicinity that may have been contaminated by hand contact: discard
  • Tubes of ointment and lubricant: dispose of

Negative test results

Patients who test negative must stay isolated until another two consecutive samples, which should be taken 48 hours apart, test negative. Even if all samples are negative, those with a previous positive CPE status can revert to being positive so careful risk assessment is needed before they are moved from isolation.

Telling patients, families and carers

Patients should be advised to practise good hand hygiene, particularly after using the toilet, and especially if they develop loose stools or diarrhoea. If they test positive for CPE, they and their family should be told and given a factsheet. The toolkit includes various factsheets for patients and contacts.Patient notes should be flagged with the positive result, as should any transfer/admission documents if the patient is moved or referred for community care. Robust communication within and between healthcare organisations and professionals before patient transfer or discharge and throughout the care pathway is crucial to prevent and control CPE spread.

On discharge, patients need to understand their current status - for example, that their infection is cleared but they may still be a carrier - and the need for good hand hygiene. They should also be aware that if a close contact is admitted to hospital or another healthcare setting, they must tell healthcare staff of their exposure.

Guidance for trusts

The PHE toolkit sets out a CPE management plan template that can be adapted locally. It also includes: a checklist of actions for trusts to prevent and minimise CPE spread; a checklist to help them manage an outbreak, suspected outbreak or cluster of colonised or infected cases; and a transfer form for notifying other organisations about a patient who is colonised or infected.

Key points

  • Some gut bacteria, known as entero-bacteriaceae, have developed resistance to “last-resort” carbapenem antibiotics
  • Last year, there were 600 cases where enterobacterial infections did not respond to carbapenem antibiotics; there, were five in 2006
  • All patients admitted to hospital should be screened for carbapenemase-producing entero-bacteriaceae
  • Positive or suspected cases should be put in isolation and swabs taken
  • Nurses should know, and implement, suitable infection prevention and control measures 
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