Carbapenem-Resistant Organisms (CROs) For Providers

Carbapenem-Resistant Organisms (CROs) For Providers

Carbapenem-resistant organisms, or CROs, are a type of multidrug-resistant (MDRO) organism that can cause both infection and colonization in healthcare settings. CROs include carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) both of which have been identified in Alameda County. When Enterobacterales, a group of Gram-negative, non-spore forming bacteria, develop resistance to carbapenems, they are referred to as carbapenem-resistant Enterobacterales (CRE). In 2017 there were an estimated 13,100 hospitalizations and 1,100 deaths due to CREs in the U.S.

The 2019 CDC Antibiotic Resistance Threats Report lists CROs as Urgent Threats, which is the highest level of concern. Since the COVID-19 pandemic, the threat of antimicrobial resistance has only become more dire, with hospital-acquired antibiotic-resistant infections increasing by at least 15% in the first year of the pandemic. There are many reasons for this increase in antibiotic resistance including changed healthcare-seeking behaviors allowing undiagnosed and untreated infections to spread, increasing chances of developing resistance; from March to October of 2020, more than 80% of patients hospitalized with COVID-19 received unnecessary antibiotic therapy due to difficulty of distinguishing COVID-19 pneumonia from community-acquired pneumonia, increasing ability of bacteria to develop resistance.

CROs can be classified by their mechanism of resistance, non-carbapenemase producing organisms (non-CP), and carbapenemase-producing organisms (CPO). Carbapenemases are enzymes that break down antibiotics and render them ineffective. These enzymes are categorized into Class A, B, and D. Some common carbapenemases are Klebsiella pneumoniae carbapenemase (KPC), imipenamase (IMP), Verona integron-encoded metallo-β-lactamase (VIM), New Delhi metallo-β-lactamase (NDM), and oxacillinase (OXA). CPOs are of special public health concern because of their ability to easily spread resistance between many species of bacteria in healthcare settings.

Risk factors for CRO colonization or infection include prolonged inpatient stays, severe illness and/or comorbid conditions, invasive medical devices (such as catheters, endotracheal tubes, and feeding tubes), and treatment with certain antibiotics. Because patient populations in long-term care facilities (LTCF) and skilled nursing facilities (SNF) tend to have many of these risk factors, healthcare teams in these facilities should be especially cognizant of CROs.

The spread of CROs is mediated by patient transfer between facilities and inconsistently applied infection control measures. This highlights the importance of using the Infection Control Transfer Form and ensuring your facility is prepared for a patient with CRO, such as implementing appropriate infection control practices and environmental cleaning. In addition, California Department of Public Health (CDPH) advocates that all residents of SNFs be on Enhanced Standard Precautions which is a resident-centered activity-based approach to help limit the spread of resistant organisms.

In 2017, the Alameda County Public Health Department (ACPHD) issued a Health Officer Order for reporting CRE and submitting CRE isolates to the Alameda County Public Health Laboratory. CDPH began to require laboratory reporting of CPOs as of September 2022. Of note, the CDPH requirement does not supercede the local Health Officer Order. Cases and outbreaks of CPOs have been increasingly recognized in California including Alameda County. From mid-2019 to mid-2021 there were 452 CRO cases reported to Alameda County;107 (24%) were identified as CPOs. In 2022, there were 380 cases of CROs in Alameda County and 122 (32%) of those cases were confirmed as CPOs. In 2022 the most commonly isolated organism was Pseudomonas aeruginosa, and the most commonly identified carbapenemase gene was KPC.

ACPHD takes CRO infection control and prevention very seriously. We have provided links to resources below. Further questions can be directed to acutecd@acgov.org

If you have a CRO outbreak

Important documents

Resources

New Infection Preventionist Guidance

For Acute Care Hospitals and Long-Term Care Facilities

The Acute Communicable Diseases Team from the Division of Communicable Disease and Prevention works closely with Alameda healthcare facilities to prevent the transmission of communicable diseases.

We encourage you to join the following two monthly Microsoft Teams calls:

1) Public Health and Provider Calls

Held monthly on the third Thursday of the month from 12:15pm – 1pm. Email to Shani Sims (shani.sims@acgov.org) for an invitation.

The objectives of these calls are to:

  • Inform clinicians regarding infectious diseases topics that public health staff are working on
  • Promote collaboration between clinicians and public health staff; and
  • Increase awareness among public health staff regarding initiatives clinical colleagues are implementing regarding diagnosis, treatment, or prevention of infectious diseases

2) Multidrug Resistant Organism (MDRO) Collaborative Calls

Held on the last Thursday of the month from 12pm – 1pm. Email acutecd@acgov.org for an invitation.

The objectives of these calls are to:

  • Foster open dialogue among the Alameda County healthcare continuum
  • Share experiences around infection control
  • Foster peer-to-peer learning and partnerships
  • Build partnership with Alameda County Public Health Department beyond outbreak management
  • Highlight successes and challenges on infection control and prevention efforts
  • Share data and resources to support efforts as available

Resource List

As a resource list for new Infection Preventionists, we recommend reviewing the following:

Additional Training Resources

 

Please reach out to acutecd@acgov.org to introduce yourself and ensure we have your contact information in the event that we need to reach you and your healthcare facility.

We look forward to working with you to limit the development and transmission of all communicable diseases in Alameda County.