Carbapanem-Resistant Enterobacteriaceae (CRE)

By Nick Deuz

Student Nurse Hunter-Bellevue School of Nursing, Class 2016

         Protocols for the prevention of the transmission of multi-drug resistant organisms (MDROs) have been implemented throughout many, if not all, healthcare systems. The most common protocol is the Centers for Disease Control and Prevention ‘s (CDC) Standard Precautions (Siegal et al., 2007). With such practices implemented, however, there are still multi-drug resistant organisms (MDRO) that play a major threat to the patient’s safety. In an acute long-term inpatient facility, the transmission of CRE is on the rise (CDC, 2013). According to the CDC (2013), CRE is an incurable MDRO. It is also considered an urgent level type of threat that requires intensive observation and prevention. CRE is considered the most dangerous MDRO because of its resistance to basically all types of antibiotics (CDC, 2013). In order to prevent the spread of the pathogen in the healthcare setting, preventative measures needs to be established. Such measures include surveillance, health care compliance to the Standard Precautions, and other guidelines for the prevention of CRE (CDC, 2012).

Carbapemens: Antibiotics of Last Resort

            CRE has the ability to fight off the Carbapanem and the Cephalosporin class of antibiotic (Rapp & Martin, 2008). The CDC (2013) considers the Carbapanems the antibiotic of last resort. This type of antibiotic is broad-spectrum and has the ability to treat infections caused by Gram-negative bacteria. It is considered more stable than the penicillins, cephalosporins and monobactams (Rapp & Martin, 2008). Yet, inappropriate use of these broad-spectrum antibiotics can lead to the development of CRE. Starting off with a carbapanem antibiotic as the initial drug for infection treatment can result in a greater chance of developing CRE (Rapp & Martin, 2008). If CRE infection arises in a person after the initial antibiotic treatment, then the person is limited to treatment. This is because drug treatment options for CRE are very limited as only three medications; Colistin, Tigecycline and Amikacin have been reported to have some activity against CRE (Zurawski, 2014). Therefore, carbapenems should be the last medication used for treatment of infections in order to prevent CRE (Rapp & Martin, 2008).

            The limited treatment options for CRE make it a very dangerous MDRO that can be fatal for patients who contract it (CDC, 2013). In order to stop the spread, the public, especially healthcare workers, should be more aware of its transmission. Nurses especially should be more mindful of the spread of infection since they are the person who provides the most direct care to the patient. This is especially true in an acute inpatient facility where the patients are sicker and are seen more frequently by the nurses. In the case of a busy schedule, the nurse may not feel the need or may forget to follow CDC protocol and perform proper hand hygiene due to the hectic nature of working in an acute care. Hand Hygiene and the education of the nurses in regards to infection prevention are part of the core guidelines for CRE prevention (CDC, 2012).

All employees must wash hands before… and after …

            Effective interventions on controlling the spread of CRE needs to be done before incidences of the pathogen rises and infects more people. Research has to be mobilized to test not only new antibiotics but also to look into the barriers in infection control compliance. According to Schwaber and Carmeli (2008), there should be more research that helps better understand the trends and treatments of these malicious organisms. MDRO is a public health threat and therefore, a concerted effort should be invested in educating the public, the primary care providers, the informal caregivers in the community and the patients. Community-based organizations can start public health education based on the unique characteristics of the populations at risk (i.e. education materials in a language other than English). More effort should be placed in helping develop new evidenced-based guidelines that ensure appropriate prevention control strategies for facilities are implemented. Education of pre-licensure health care providers  (nursing and medical students) should focus on measurable competencies. It might also be beneficial for government to provide financial incentives to test new medication for CRE using current knowledge in bimolecular science and targeted therapies. A strong political will is needed to allow congress to enact laws that pro-active in infection control. There is so much more research and more opportunity to expand on the development of prevention strategies against CRE.


            In spite of advances in medical technology, the march of MDROs remains a challenge, both in institutional settings and public health spheres. Compliance with Standard and Transmission-Based precautions remains at the heart of infection control and cannot be over-emphasized. The implementation of the eight core measures for CRE prevention suggested by the CDC must be taken seriously by all health care providers and patients. The education of staff and future nurses must take into account hardwiring infection and control competencies that are translated to bedside practice. Now, more than ever, prevention is more important in the advent of emerging incurable infections.


Centers for Disease Control and Prevention. (2012). Guidance for Control of          Carbapenem-Resistant Enterobacteriaceae (CRE): 2012 CRE Toolkit [Data File]. Retrieved from

Centers for Disease Control and Prevention. (2013a). Antibiotic Resistance Threats in the United States [Data File]. Retrieved from

Centers for Disease Control and Prevention. (2013b). Vital Signs [Data File]. Retrieved from

Rapp, R.P., & Martin, C. (2008). Carbapenem Antibiotics: Maximizing Response and Minimizing Resistance. Pharmacy Practice News, Special Edition, 43-50.

Schwaber, M. J., & Carmeli, Y. (2008). Carbapenem-Resistant Enterobactericeae: A Potential Threat. The Journal of the American Medical Association, 300(24), 2911-2913.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Health Care Infection Control    Practices Advisory Committee. (2007). 2007 Guideline For Isolation Precautions:         Preventing Transmission of Infectious Agents in Health Care Settings. American     Journal of Infection control35(10), S65-S164.

Zurawski, R. M. (2014). Carbapenm-Resistant Enterobacteriaceae: Occult Threat in the     Intensive Care Unit. American Association of Critical-Care Nurses, 34(5), 44-52.