Managing transmission of carbapenem-resistant enterobacteriaceae in healthcare settings: a view from the trenches

Clin Infect Dis. 2013 Dec;57(11):1593-9. doi: 10.1093/cid/cit531. Epub 2013 Aug 9.


In 2011, the National Institutes of Health Clinical Center experienced a cluster of infection and colonization caused by carbapenem-resistant Klebsiella pneumoniae among profoundly immunocompromised inpatients. This manuscript describes the approach and interventions that were implemented in an attempt to curtail the cluster. Interventions employed included engagement of all stakeholders involved in care of at-risk patients; detailed and frequent communication with hospital staff about issues relating to the outbreak; aggressive microbial surveillance; use of techniques that facilitate rapid identification of resistant organisms; rapid characterization of resistance mechanisms; whole-genome sequencing of outbreak isolates to characterize the spread and to investigate mechanisms of healthcare-associated spread; implementation of enhanced contact precautions for all infected or colonized patients; geographic and personnel cohorting; daily chlorhexidine gluconate baths; dedicating equipment to be used solely for cohorted patients and aggressive decontamination of equipment that had to be reused on uncohorted patients; monitoring adherence to infection control precautions, including unwavering attention to adherence to appropriate hand hygiene procedures; and attention to the details of environmental decontamination. In addition, the manuscript discusses some of the challenges associated with managing such an event, as well as a few of the unanticipated consequences associated with the aftermath of the case cluster.

Keywords: carbapenem-resistant enterobacteriaceae; isolation; multi-drug resistance; transmission; whole genome sequencing.

MeSH terms

  • Anti-Bacterial Agents / pharmacology
  • Carbapenems / pharmacology*
  • Cross Infection / drug therapy
  • Cross Infection / microbiology
  • Cross Infection / prevention & control*
  • Cross Infection / transmission
  • Disease Outbreaks
  • Disease Transmission, Infectious / prevention & control*
  • Drug Resistance, Multiple, Bacterial
  • Enterobacteriaceae / drug effects*
  • Enterobacteriaceae / genetics
  • Enterobacteriaceae / isolation & purification
  • Enterobacteriaceae Infections / drug therapy
  • Enterobacteriaceae Infections / microbiology
  • Enterobacteriaceae Infections / prevention & control*
  • Enterobacteriaceae Infections / transmission
  • Genome, Bacterial
  • Humans
  • Infection Control
  • beta-Lactam Resistance*


  • Anti-Bacterial Agents
  • Carbapenems