As part of World Antibiotic Awareness Week, the World Health Organization (WHO) yesterday unveiled the first-ever global guidelines for preventing and controlling three types of carbapenem-resistant gram-negative bacteria in health settings that are highly transmissible, difficult to treat, and can cause severe illness and death.
The organisms include carbapenem-resistant Enterobacteriaceae (CRE), Acintobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA). Besides the link to severe and fatal infections, the three organisms have mobile elements that can pass resistance genes to other bacteria.
Global health experts have documented an alarming increase in the incidence and prevalence of carbapenem-resistant gram-negative bacteria, which have caused outbreaks in different regions of the world involving hospitals and long-term care facilities.
Targeting a growing threat
In the introduction to the guidelines, the WHO said the idea for developing them came out of deliberations during the crafting of updated guidelines released in 2016 on infection prevention and control programs for nations and hospitals. "It became clear that the specific threat posed by infections due to CRE-CRAB-CRPsA required specific attention, including having clear, practical IPC [infection prevention and control] guidelines on how best to manage this rapidly emerging problem," the group said.
Not only are the infections linked to severe illnesses and deaths, they have the potential to trigger outbreaks and fuel the spread of resistance. The threat stands out, because colonization with the organisms almost always precedes or coexists with other infections, making early recognition key to identifying patients most at risk.
Also, flagging colonized patients allows medical staff to more quickly implement IPC steps to prevent transmission to other patients and to avoid environmental contamination.
Eight key recommendations
The guidelines development group emphasized that the 2016 guidelines in core components of IPC programs are the foundation of preventing and controlling CRE, CRAB, and CRPsA infections, and they made eight key recommendations to help facilities better target the three organisms.
For each recommendation, the group discusses the quality of supporting evidence as it related to each of the bacteria, factors they considered, resource implications, acceptability, and research gaps. Most of the recommendations are strong, but the quality of evidence was assessed to be very low to low.
The eight recommendations are:
- Adopt multipart strategies to prevent and control CRE, CRAB, or CRPsA infection or colonization that includes at least hand hygiene, surveillance (especially for CRE), contact precautions, patient isolation (single room or cohorting), and environmental cleaning
- Implement hand hygiene best practices spelled out in earlier WHO guidance
- Conduct surveillance for CRE-CRAB-CRPsA infection and colonization, especially targeting those with previous CRE colonization, contacts of CRE patients, or those with a history of recent hospitalization in CRE-endemic settings
- Implement contact precautions when caring for infected or colonized patients
- Isolate infected or colonized patients, either in a single room or with others who have the same pathogen
- Comply with environmental cleaning protocols in the "patient zone" of infected or colonized patients, though the optimal cleaning agent was not identified
- Take surveillance cultures of the environment to detect contamination
- Monitor the impact of the interventions
The WHO posted the 76-page report that details the recommendations on its website, along with an audio "teleclass" on the new recommendations that includes accompanying slides.
Nov 14 WHO statement
Nov 14 guidelines
WHO guidelines teleclass audio
WHO guidelines slides