Carbapenemase-Producing Enterobacterales Transfer From Long-Term Care

Place the patient in a single room with contact precautions; if no single room is available, cohort only with another patient with confirmed carbapenemase-producing Enterobacterales, not with a catheterized patient who has a healing fracture. The current roommate is at increased risk because of the indwelling urinary catheter and recent hospitalization, so move him to another room and perform a risk assessment for CRE colonization. Obtain a rectal or perirectal surveillance swab, or a stool sample if the swab is not feasible, and send it for carbapenemase-producing organism screening. Also culture the sacral wound and urine as clinically indicated. Notify the laboratory that the patient has a history of KPC-producing Klebsiella so that appropriate identification and susceptibility testing are performed. Do not start decolonization; there is no established regimen for CRE decolonization. Review hand hygiene and environmental cleaning, especially shared bathroom and equipment use.

The patient is septic with hypotension, so empiric therapy must cover likely pathogens, but meropenem alone may be inadequate if the organism is a KPC producer. The history of KPC-producing Klebsiella makes carbapenem resistance likely, and the severity of illness justifies broad initial coverage. Obtain blood and urine cultures and wound cultures before changing therapy if this does not delay treatment. Consider ceftazidime-avibactam, which covers KPC-producing Enterobacterales, or another regimen active against carbapenemase producers based on local susceptibility and expert consultation. Do not use meropenem as definitive therapy for a confirmed KPC producer unless susceptibility testing supports it. The stewardship pharmacist should document the indication, planned duration, and criteria for de-escalation. Review the source: a sacral pressure injury and urinary tract may both be infected, but asymptomatic bacteriuria should not be treated. Reassess at 48 to 72 hours with culture results and clinical response.

A point prevalence survey is reasonable because the unit has had two other CRE patients in the same room in the past 6 months, suggesting possible undetected transmission. Survey patients who shared the room, patients with indwelling devices, and those with recent transfers from the same long-term care facility. Use rectal or perirectal swabs and screen for carbapenemase production. Communicate with the long-term care facility to obtain the prior microbiology, including the KPC isolate's susceptibility profile, and to determine whether the facility has other colonized patients. On the unit, reinforce contact precautions, dedicated equipment, hand hygiene, and cleaning with a disinfectant effective against CRE. Do not disclose identifiers unnecessarily; share only what is needed for care and infection control. Document the investigation and results in the facility's quality and safety system, and repeat the survey if a new case is identified.