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Vital Signs Telebriefing on Carbapenem-Resistant Enterobacteriaceae

Tuesday, March 5 at 1:30 pm ET

OPERATOR: Welcome.  And thank you for standing by.  You've been placed in a listen-only mode until the question-and-answer portion of today’s conference.  If you have any objections, you may disconnect at this time. I would now like to turn the meeting over to Mr. Thomas Skinner.  You may begin. 

TOM SKINNER: Thank you for joining us today for the release of another Vital Signs from the CDC.  This one on CRE.  Today, we're joined by the director of the Centers for Disease Control and Prevention, Dr. Tom Frieden, as well as a medical epidemiologist from our Division of Healthcare Quality Promotion, Dr. Arjun Srinivasan.  Dr. Frieden will provide some opening remarks and then we'll get right to your questions.  So I'd like to turn the call over to Dr. Frieden. 

TOM FRIEDEN: Thank you all for joining us today to discuss the Vital Signs report we're releasing this month, a special MMWR publication that highlights a critical public health issue facing our country.  It's not often that our scientists come to me to say that we have a very serious problem, and we need to sound an alarm.  But that's exactly what we're doing today.  CDC works 24/7 to save lives and protect people.  Part of our role is to let people know about health threats before they become widespread.  This Vital Signs is an early warning about a healthcare-associated infection that's happening in hospitals and other inpatient medical facilities.  The good news is that we now have an opportunity to prevent its further spread.  What I’m talking about today is CRE, carbapenem-resistant enterobacteriaceae.  CRE are nightmare bacteria.  They pose a triple threat. First, they're resistant to all or nearly all antibiotics.  Even some of our last-resort drugs.  Second, they have high mortality rates.  They kill up to half of people who get serious infections with them.  And third, they can spread their resistance to other bacteria.  So one form of bacteria, for example, carbapenem-resistant klebsiella, can spread the genes that destroy our last antibiotics to other bacteria, such as E. coli, and make E. coli resistant to those antibiotics also.  E. coli is the most common cause of urinary tract infections in healthy people.  So we only have a limited window of opportunity to stop this infection from spreading to the community and spreading to more organisms.  We're calling for a “detect and protect” strategy that we know can save patients' lives and stop the spread of CRE. 

To give you some background, the long word, carbapenem-resistant enterobacteriaceae, is a family of more than 70 different kinds of bacteria.  It includes some very common ones, like klebsiella and E. coli, that are normally present in our intestines.  Sometimes, however, these bacteria can get into the wrong places like the blood or the bladder.  When this happens, people can get severe infections called urinary tract infections.  Some types of enterobacteriaceae have become resistant to antibiotics, even high-powered, last resort, last line of defense of antibiotics, called carbapenems.  Antibiotic resistance is what turns normal enterobacteriaceae into drug resistant or CRE.  Now there are many different types of resistance that are carried by different plasmids that go by names like KPC or VIM or NDM, or CRKP.  These are all types of CRE.  Types of resistant bacteria.  They all result in the same end point, a highly drug-resistant infection that has a very high fatality rate for people who have serious infections with it. 

The risk of CRE infection is highest among patients who are getting complex or long-term medical care.  This mostly means patients in regular hospitals or long-term acute care hospitals, or nursing homes.  CRE spread among people, mostly patients in hospitals and long-term care facilities, usually from unclean hands.  Medical devices such as ventilators or catheters increase the risk of life-threatening infection because they allow new bacteria to get deeply into a patient's body.  Unfortunately, it appears that CRE bacteria are spreading.  We know that in the first half of 2012 alone, nearly 200 hospitals and long-term acute care facilities treated at least one patient who was infected with these bacteria.  We've tracked CRE from a single healthcare facility in one state in 2001 to healthcare facilities now in 42 states or more.  In some of those places, these bacteria are now a routine challenge for patients and clinicians. 

Overall, CRE has increased from one percent to four percent in the past decade and the most common type of CRE has increased from two percent to 10 percent during that time.  That's a very troubling increase.  It's a four or five-fold increase in the proportion of these serious infections that are from highly-resistant organisms.  The good news is that we still have time to stop CRE.  Many facilities can act now to prevent CRE from emerging, or if it has emerged, to control it.  We need healthcare leaders, clinicians, health departments, to act to prevent CRE, so it doesn't become widespread and spread to the community.  Last year, CDC released a tool kit with updated recommendations to tackle CRE, and we're very gratified to see that places that have implemented those tools have seen dramatic reductions in their CRE rates.  Similarly, in other countries we've seen a drastic reduction in CRE with this type of approach.  Today we're calling on health departments, chief executive officers, chief medical officers, other leaders in healthcare facilities to support internal and regional “detect and protect” programs to prevent CRE and other multi-drug resistant bacteria. 

There are six important steps that healthcare providers can take.  The first two are in the “detect” part of this equation.  The last four are in the “protect” part of it.  The first two are, first, know if your patients have CRE, and request immediate alerts from your laboratory every time they identify a patient with CRE.  Second, when either receiving or transferring patients, make sure to ask and find out if the patient you're receiving has CRE.  Third, in the “protect” area, protect your patients from CRE by following contact and other precautions whenever you're getting patients with CRE, so you don't inadvertently spread their organism to others.  Fourth, whenever possible, have specific rooms, equipment, and staff equipped for CRE patients.  That reduces the chance CRE will spread from one patient to others.  Fifth, take out temporary medical devices like catheters as soon as possible.  And finally, and very importantly, prescribe antibiotics carefully.  Unfortunately, half of all of the antibiotics prescribed in this country are either unnecessary or inappropriate.  Overuse and misuse increases drug resistant infections and that results in longer inpatient treatment, higher costs, and poorer patient outcomes.  Many antibiotics have been shown to increase the risk of getting CRE.  For example, in one study giving a patient one antibiotic, a carbapenem, increased their risk of getting CRE 15-fold.  On the flip side, individual hospitals have saved hundreds of thousands of dollars a year by improving antibiotic use, and of course, patients benefit when they get more targeted treatment. 

Patients and their loved ones also have a role to play.  They need to feel empowered to speak up, bring a family member or friend who can be your advocate, and insist that everyone who touches you during your medical care, doctors, nurses, technicians, visitors, wash their hands before touching you.  If you have a catheter, an intravenous line, or a urinary catheter in, ask how long you'll have it and request it be removed as soon as possible.  These are simple prevention measures, but they're critical and there use can significantly reduce the problem today.  But the work doesn't end there.  We need to continue to invest in research and tests to prevent CRE infection in the first place and more quickly identify it.  CDC and other federal agencies are actively engaged in this research. 

There are two promising approaches that I'll mention.  One is chlorhexidine bathing for patients and the other are advanced molecular detection approaches.  Chlorhexidine is an antimicrobial soap that was recently shown can reduce infection from multidrug-resistant organisms; and advanced molecular detection is an approach that allows us to study the genome of different infections and could help us detect them more quickly and improve our treatment and control.  Of course, we also need new antibiotics.  But we know from experience that bacteria are quick to develop ways to get past new antibiotics as well.  So preventing the spread of CRE and other bacteria will continue to be essential.  Everyone involved in medical care from CEOs to patient care staff to health departments needs to act rapidly in a coordinated fashion to stop CRE before our window to control these bacteria closes.  Thank you and we'll be happy to answer your questions at this time. 

TOM SKINNER: Okay.  Thank you.  I believe that we're ready for questions, please. 

OPERATOR: Thank you.  At this time, if you would like to ask a question, please press star 1 on your telephone keypad.  Record your name at the prompt.  Again, that is star 1 to ask a question.  Our first question comes from Denise Grady with the New York Times.  Your line is open. 

DENISE GRADY: Thank you very much.  How many cases are there actually in a given year?  How many deaths?  And how in severity or seriousness that we have to take this?  How does it compare to the other drug resistant things we hear about, like MRSA?  Just so we can put this in context.  Thanks. 

TOM SKINNER: Dr. Frieden, do you want Dr. Srinivasan to answer? 

TOM FRIEDEN: Thank you. I'll make the initial comments and then Dr. Srinivasan can add to that.  We're working to figure out exactly how many CRE infections occur in the country each year.  We know that it's widespread, in that 42 states have had at least a single case.  When we compare it with other drug resistant bacteria, such as MRSA, it has not yet spread to the community.  And we think that's really a message of hope.  We still have a window of opportunity to stop it before it becomes as prevalent as other serious resistant organisms.  The other thing that's different about CRE is that while we have treatment options for MRSA, that’s Methicillin -resistant Staphylococcus aureus, we really have very limited or no treatment options for CRE.  Furthermore, CRE can spread its resistance among many different types of bacteria, and that's not something we've seen with something like MRSA.  In summary, I would say that it is not nearly as widespread as MRSA is, and it's important we keep it that way because it's so dangerous in terms of both the high fatality rate among patients who have it, the limited treatment options, and its ease of spreading among patients and among bacteria.  Dr. Srinivasan? 

ARJUN SRINIVASAN: I don't have anything to add to that. 

TOM SKINNER: Next question, Calvin, please? 

OPERATOR: Next question comes from Mike Stobbe with the Associated Press.  Your line is open. 

MIKE STOBBE: Hi.  Thanks.  Just a couple of questions actually.  First of all, Dr. Frieden, you said it's not yet spread to the community.  How do you know that?  Has there been a lot of testing in the community for this?  And how long is this window of opportunity will be open?  Do you have any feel for that?  Not to be greedy, but I had a third question.  Of the 200 hospitals who had CRE, I was wondering, is it just bad luck that these hospitals get it, or have you observed that these are hospitals that have a lot of hospital-acquired infections in general? 

TOM FRIEDEN: I will let Dr. Srinivasan answer the bulk of those questions.  I will comment that the window of opportunity, basically the sooner we act, the quickly we can get it under control, the less likely it will be to get out into the community.  As noted in the report, about hospitals that are having a particularly high rate of infections are the long-term acute care hospitals, which may have patients who are on a ventilator for a long period of time.  Dr. Srinivasan? 

ARJUN SRINIVASAN: Absolutely.  Mike, your first question about do we know that the CRE organisms are not present in the community.  The answer to that is, yes, we do have some good evidence that they're not.  And that comes from some work that we do in collaboration with a number of different health departments around the country, through a program called the Emerging Infections Program, which is a collaboration between CDC and these health departments.  And they've been looking at CRE for the past few years.  And working to better understand the characteristics of the people who get these infections.  What they've found is this is something that's basically almost exclusively limited to patients who have extensive exposure to healthcare.  We feel like we have information through these collaborations with the health department that makes us confident in saying this is a problem for our healthcare facilities, but it's not yet an issue that we face out in the community. 

TOM SKINNER: Mike, did that answer all your questions? 

MIKE STOBBE: I was hoping for a little more on whether the 200 or so hospitals that in general had recurring problems with high hospital healthcare-acquired infection rates? 

ARJUN SRINIVASAN: That's a good question, mike.  We don't know the answer to that. 

MIKE STOBBE: Okay.  Thank you. 

TOM FRIEDEN: What we do know is that some hospitals have been the site of outbreaks simply because they've received a patient in transfer from another facility, and that patient already had CRE.  And then started a cluster, or outbreak in that hospital.  So it can be really a result of exposure to a patient who developed it somewhere else. 

MIKE STOBBE: Thank you. 

TOM SKINNER: Next question, Calvin, please? 

OPERATOR: The next question comes from Peter Eisler from USA Today.

PETER EISLER: Hi.  I’m just wondering, two questions.  One, have you considered recommending active surveillance for this?  And why aren't you recommending that?  And what about -- any thoughts about mandatory reporting, or trying to get a better reporting handle on this? 

TOM FRIEDEN: Dr. Srinivasan? 

ARJUN SRINIVASAN: Peter, that's a good point.  We do recommend active surveillance testing for this.  We believe that “detect” is obviously the first part of the “detect and protect” strategy.  We don't recommend a one size fits all approach to active surveillance testing because the presence of these organisms varies from place to place.  In our CRE tool kit, we have some very specific recommendations for the types of active testing that healthcare facilities should perform based on the frequency with which CRE is being recovered in their facility, in the area around them.  So we do certainly recommend active surveillance to help prevent the spread of CRE.  There are a number of states that have implemented mandatory reporting for CRE.  It's a strategy that CDC recommends and encourages states to consider as a way to get critical data for action in combating CRE.  We know at least six states have already made this a reportable condition.  And we know of a number of other states that are considering doing so. 

TOM SKINNER: Next question, please? 

OPERATOR: Next question comes from Lena Sun with the Washington Post. 

LENA SUN: Hi, Dr. Frieden and Arjun.  Could you -- one of my questions was already asked, but could you elaborate on the last point?  What are the six states that mandate reporting for CRE, and which are the states that are considering doing so? 

TOM FRIEDEN: This is Dr. Frieden.  We know that Tennessee, Oregon, Minnesota, Colorado, Wisconsin and North Dakota have already mandated reporting.  Others are considering it.  There are various ways to track infections through hospital laboratories, through outreach work.  So reporting is a good way to find out about all the cases in a community.  But there are other ways as well.  Dr. Srinivasan? 

ARJUN SRINIVASAN: I have nothing to add to that. 

LENA SUN: Hello, can I just ask a follow-up? 


LENA SUN: You know, some states mandate reporting.  My impression is that not all hospitals are equipped to test for CRE. I mean, it's not like a routine test.  And so, you know, hospitals say, well, we don't have CRE, but the better question is, do you have the mechanisms to test for it, to say that you don't?  Is that an issue for you folks? 

TOM FRIEDEN: Dr. Srinivasan? 

ARJUN SRINIVASAN: We don't believe that it is.  There are standard recommendations, there are tests that are -- can be performed by really any hospital microbiology lab. They are put forth by a number of different organizations that provide these recommendations and procedures to hospital microbiology labs.  So we really feel confident that hospital microbiology labs in this country do have the capability to detect CRE.  There are some special tests that have to be done.  But there are tests that use routine equipment that's available in any hospital microbiology lab.  It's not an issue where you need special equipment to detect these organisms.  These are tests that the labs do have access to, and there are protocols and procedures for how to do that available from a number of different organizations, including, of course, on the CDC website. 

LENA SUN: I’m sorry, can I ask just one more follow-up question?  I was giving my name and organization so I didn't hear the first question.  I don't know if somebody already asked this.  Dr. Frieden, you sort of hinted at this, but have you guys done something on CRE in the past, or was there such a pool of evidence from the scientists who were seeing spread of this infection that you decided to put this one out, that you haven't put something out previously on CRE? 

TOM FRIEDEN: We have done work on CRE up until now.  This is the monthly Vital Signs and we're pulling together and releasing for the first time, data from the first half of 2012 from the National Healthcare Safety Network.  That information really does show that we've got a four or five-fold increase in the proportion of CRE among the most common enterobacteriaceae or enteric bacteria.  So that's the genesis of this.  We also have the positive news that places that have implemented our recommendations have been able to drastically reduce their number of cases.  We know it's a serious problem, but we also know it’s a problem that we can stop. 

TOM SKINNER: Next question, Calvin, please? 

OPERATOR: Next question comes from Dan Childs, with ABC News.  Your line is open. 

DAN CHILDS: Thank you very much for taking my question.  I actually had sort of a two-fold question.  Number one, you know, obviously those in the community in general have heard a lot about super bugs, and it is something that is quite frightening to them.  What, if anything, can people just in the community as a whole do to protect themselves, if anything, maybe even if they happen to be visiting loved ones in the hospital, are there any special measures that they can take?  And the follow-up question to that is, what are the warning signs if this super bug does enter the community?  And if it were to get into the community, how quickly would we know that it was there? 

TOM FRIEDEN: Thank you.  I'll start.  Then Dr. Srinivasan may want to continue.  The first thing is to recognize that not all fevers require antibiotics.  The more we use antibiotics unnecessarily, the more we promote the spread of drug resistance.  So understanding that for most routine infections, they're viral and antibiotics won't help.  In the hospital, ensuring that you, your visitors and your caretakers wash their hands before touching you is also very important.  Because that's the main way these organisms spread.  Dr. Srinivasan? 

ARJUN SRINIVASAN: I agree.  I think that taking antibiotics carefully, not demanding antibiotics when your healthcare provider tells you that you don't need them, those are all things that people can do.  Careful attention to washing hands is also absolutely critical when you're in the hospital, when you're out of the hospital.  That's something that we know is a simple thing that every one of us can do to prevent the risk of infection spreading.  And also, asking your healthcare team.  When you or a loved one is in the hospital, ask your healthcare team, what are you doing to keep me safe from getting a healthcare-associated infection.  What are you doing to keep me safe from CRE.  Asking those types of questions helps healthcare facilities know that patients and patients' loved ones are interested and want hospitals to take these steps that we're recommending.  Your other question about warning signs for -- will we know when this gets into the community.  There are a couple of ways we're keeping obviously a close eye on that.  One is in collaboration with all of the healthcare providers who work with us, who will share information with us, and tell us, this was a person who was admitted to the hospital after being in the community, and having an infection that was treated unsuccessfully.  And of course, the other is the surveillance that we do in collaboration with the state health departments that I mentioned previously, the Emerging Infections Program.  This project we have working with them, looking at CRE, one of the goals of that project is to make sure that we have a good understanding of where we're seeing these organisms, so we'll have an early warning if we ever see them occurring more commonly outside of healthcare facilities. 

DAN CHILDS: Excellent.  So what we're seeing then is that this wouldn't necessarily be something where it would be on the same sort of pace as the Vital Signs report which is now talking about the first half of 2012, this is something that we'd be able to see right away in terms of the community surveillance that’s being done by these community health departments? 

ARJUN SRINIVASAN: Yes, that's right. 

DAN CHILDS: Okay.  Thank you very much. 

TOM SKINNER: Next question, please? 

OPERATOR: Our next question comes from BJ Austin with KERA Radio in Dallas.  Your line is open. 

BJ AUSTIN: Yes, thank you very much.  How do you know if institutions in your area have had CRE cases?  How do people find out? 

ARJUN SRINIVASAN:  This is something that if you are concerned, if you have concerns, we encourage you to ask when you're admitted to the hospital.  Ask your healthcare team, have you heard about CRE?  Have you heard about the CDC recommendations?  Do you follow those recommendations?  Ask them if they know what the status is in that local area.  We are encouraging health departments to bring healthcare facilities together to work collaboratively so that healthcare facilities can have an awareness of what's going on with CRE in their community, and we're encouraged to see that health departments are beginning to take that action of bringing healthcare facilities together to talk about what's going on at the regional level.  Because we know that we're all in this together.  Patients move between our healthcare facilities.  So it's not something that one hospital, or one long-term acute care hospital can do on its own, it really takes the coordination of all of the facilities in an area, working together with public health to address this problem. 

BJ AUSTIN: Thank you. 

TOM SKINNER: Next question, Calvin? 

OPERATOR: Our next question comes from Maryn McKenna with “Wired.” Your line is open. 

MARYN MCKENNA: Thanks so much for doing this.  So I guess this is a two-part question, but that seems to be the trend.  My question is, when I talk to healthcare teams that are dealing with these bacteria already in their institutions, of course, they want to take care of their patients, but they almost universally express how daunted they are at the granularity and cost of combating them, of upping their environmental cleaning, of improving their surveillance, of improving their diagnostics, and this is part two, they're particularly concerned about what they see coming in from the other types of institutions that you mentioned, the long-term care and nursing homes that don't have highly paid preventionists, or don't have testing schemes.  So I’m just wondering if there's anything you can say to those healthcare workers about how to cope with the economic burden and the logistical burden of actually getting these programs started? 

TOM FRIEDEN: It’s not cost-free to start these programs, but it will cost a lot more if hospitals don't.  Because if the resistant bacteria become more prevalent, then the costs will increase exponentially.  The existence of infections in long-term acute care hospitals and in nursing homes is one reason we work closely with state governments, which oversee all of the healthcare facilities in their state, and can take action to improve care, and improve infection control in each of these.  Dr. Srinivasan, anything you'd like to add? 

ARJUN SRINIVASAN:  No, I have nothing to add to that. 

TOM SKINNER: Okay.  Next question, Calvin? 

OPERATOR: Our next question comes from Tony Pugh from McClatchy Newspaper.   

TONY PUGH: Thank you.  I saw in the report that a lot of these infections are to be found in the urine of patients.  And I’m wondering, are these bacteria only lethal when they're in the blood stream or are they lethal when they're in the urine as well?  And I’m wondering have you been working with some of these umbrella organizations, hospital associations, Alliance for Quality Nursing Home Care, on getting their member facilities to adapt your recommendations for improving this?  I guess I want to know what the take-up rate is for facilities in actually doing this, doing these recommendations that you have? 

TOM FRIEDEN: We work very closely with hospital associations and a wide variety of organizations, and we've seen a lot of eagerness to implement the recommendations.  The most serious infections are those that are what we call invasive, meaning they're invading a part of the body that is usually sterile, like the blood stream.  And what we find is that for things like urinary tract infections which can become invasive, it's very important to remove urinary catheters quickly, as quickly as possible, because having the catheter in place makes it virtually impossible to get rid of the infection.  Dr. Srinivasan, anything you'd like to add? 

ARJUN SRINIVASAN:  No, there isn't, not to that.  Thank you. 

TOM SKINNER: Next question, Calvin? 

OPERATOR: Our next question comes from Delthia Ricks with Newsday.  Your line is open. 

DELTHIA RICKS: Hello there.  I'd like to know if you can give me a sense of where some of the clusters occurred?  I understand there were some here in New York, particularly in New York City.  And if you know where the clusters were, how large were they?  Did they involve multiple hospitals, one hospital, two hospitals?  Can you give a sense of that?  And then I want to ask another question about plasmas. 

TOM FRIEDEN: Okay.  Dr. Srinivasan, why don't you take the first one? 

ARJUN SRINIVASAN:  Sure.  We know from hospitals that have reported some of these outbreaks, we don't know all of the places where these clusters have occurred.  Some of them have been in individual facilities, some of them have been in multiple facilities in an area.  Most of these have been fairly small.  And that's good.  Because that means the facilities took prompt action to halt the spread. 

DELTHIA RICKS:  But can I stop you for a second?  The one that was at NIH in 2011 was not small.  That involved 17 people.  And I understand that the person who transferred the bacteria, the CRE, had come from New York.  Where there had been a large outbreak.  There had been an outbreak here.  And I’m trying to get a sense of, is that one of the clusters you know about? 

ARJUN SRINIVASAN:   The cluster at NIH? 

DELTHIA RICKS:  The cluster in New York. 

ARJUN SRINIVASAN:  Well, yes, the CRE is actually --

DELTHIA RICKS: Who took it to NIH. 

ARJUN SRINIVASAN:   …and so clinicians in New York are very familiar with CRE.  It's prevalent in a number of hospitals in the New York area.  So it's been an issue that they have been combating and dealing with for many years now.  And in fact, a lot of the information that we have about how CRE spreads, how lethal the infections are, comes from reports that have been published by people, by clinicians in New York.  Because they've been dealing with this for so long. 

DELTHIA RICKS:  Okay.  But you don't know how large the cluster -- if the cluster we're both talking about or thinking about was of any size and whether it was here in New York? 

 ARJUN SRINIVASAN:   Well, there’s not a specific cluster that I’m referring to.  I’m referring to the fact that broadly in the New York area, we know that clinicians frequently encounter CRE. 

DELTHIA RICKS:  Okay.  And we mean New York City, right? 

ARJUN SRINIVASAN:   That’s correct. 

DELTHIA RICKS:  Okay.  And the second question I want to ask about plasmas, I know that plasmas are jumping genes.  How are these genes jumping from one bacteria to the other in a facility?  Are healthcare workers getting the bacteria, and therefore, the plasmas on their hands and the plasmas they're invading other bacteria and it’s being transferred that way?  Or am I misunderstanding it? 

TOM FRIEDEN: In a single -- this is Dr.  Frieden -- in a single patient's intestine, you'll have billions of bacteria, different types of bacteria.  If one of them has -- is a CRE with one of the plasmids that encode for genes that destroy our last resort antibiotics, that plasmid can jump to other organisms like E.coli in that patient’s intestines.  And then, if there isn't good hand washing, those newly resistant E.coli can be spread to the healthcare workers themselves and to other patients. 

DELTHIA RICKS: Okay, thank you.  I’m sorry for asking so many questions.  But I just wanted a few things clarified. 

TOM SKINNER: Okay, Calvin we’ll take a few more questions please.

OPERATOR: Our next question comes from Bridget Kuehn from JAMA Medical News.   

BRIDGET KUEHN: Hi thanks for taking my call.  A lot of the things in the tool kit are pretty similar to some of the prevention techniques you've been promoting for a while for MRSA and others.  You know, how are they different from them just sort of regular precautions to prevent the spread of the bacteria?  And what's special about CRE compared to dealing with other organisms such as MRSA? 

TOM FRIEDEN: CRE is special, because although it's widespread, it's not yet highly prevalent.  So we have the chance to stop it before it spreads into the community and widely to other organisms.  There are some important differences, including testing for CRE, and finding out if CRE is present and alerting facilities that you transfer patients to, that they have CRE, and asking when you receive a patient whether they have CRE.  There are other things that are generally good to reduce the risk of drug resistance, like using antibiotics rationally, having contact precautions, and removing devices as quickly as possible.  One other difference from some other resistant infections is that if at all possible, we recommend dedicating rooms, equipment and staff to CRE patients, and that we've seen has greatly reduced the risk that CRE will spread from one patient to others. 

BRIDGET KUEHN:  Is the bacteria --

TOM FRIEDEN: Dr. Srinivasan? 

ARJUN SRINIVASAN:  I don't have anything to add. 

BRIDGET KUEHN:  Is the bacteria then harder to clean off equipment, and rooms, than other types of bacteria? 

TOM FRIEDEN: Dr. Srinivasan? 

ARJUN SRINIVASAN:  It is not.  Standard hospital cleaners will do a perfect job of killing CRE on surfaces.  The key is not that we need to use different chemicals; the key is that the chemicals need to be applied.  And this is a challenge for healthcare facilities, where environmental services staff are not maybe given enough time to clean those rooms properly, or aren't trained properly in how to clean those rooms.  So we don't need new chemicals to clean the rooms, what we need is to make sure the rooms and environments in our hospitals are being cleaned adequately. 

TOM SKINNER: Calvin, we'll make this our last question and then we'll ask Dr. Frieden to close our call with a brief summary. So last question, please? 

OPERATOR: Our last question comes from Michelle Marill with the Hospital Employee Health Newsletter.  Your line is open. 

MICHELLE MARILL: Hi.  Thank you very much for taking my question.  My question is about -- I have a couple of parts -- three parts to this.  About healthcare workers, are they at risk, and can they be colonized as they can be with MRSA, or some other organisms?  I’m also wondering, you know, there's been a lot of studies showing that healthcare workers don't use personal protective equipment as they should.  And whether or not that is an issue.  And then lastly, I know there's been some use of ultra violet light to kill organisms, and I’m wondering if that could be an effective tool in this circumstance? 

TOM FRIDEN: Dr. Srinivasan? 

ARJUN SRINIVASAN:   The healthcare workers themselves are not at risk for infections with CRE, because most of the people who get infections of CRE are people who are receiving fairly aggressive medical care, whose immune systems are weakened in other ways.  So this is not something we worry about as a cause of infections in healthcare workers.  Certainly compliance with hand washing, with using gowns and hand gloves properly remains a challenge and something that we call on healthcare facilities to work with their providers to see how we can help them do a better job with compliance.  Because ultimately we know that it's compliance with these recommendations that's the key to making them successful.  Issues like UV light, we're always in favor of innovative approaches to room cleaning, innovative approaches for infection prevention, new technologies should be developed.  They should be studied carefully.  But the important thing to remember is that we have the steps, we have the actions now.  We don't need to wait for new technologies to help us prevent CRE.  We have the things, the weapons at our disposal right now to stop this from becoming a bigger problem. 

MICHELLE MARILL: And can they be colonized if they're not, you know, symptomatic? 

ARJUN SRINIVASAN:   Healthcare workers? 


ARJUN SRINIVASAN:   We don't have any data to suggest that colonization of healthcare workers is something that occurs frequently.  But there's not been any investigations that I know of that have looked at that issue. 

MICHELLE MARILL:  Okay.  Thank you. 

TOM FRIEDEN: So thank you all for joining us.  I'd like to just summarize very briefly with three key points.  First, that untreatable infections with CRE are on the rise.  Second, that there is now a critical window of opportunity to control lethal bacteria.  And that window is open, but not for long.  And third, that hospitals and other healthcare facilities need to act now to stop the spread of highly drug resistant bacteria.  I want to thank you all for joining us today, and look forward to joining you next month for Vital Signs as well, and look forward to answering any questions as needed through our press office. 

TOM SKINNER: Thank you all. This concludes our call.  If reporters have follow-up questions or need additional information, please call the CDC press office at 404-639-3286.  Thank you. 

OPERATOR: This concludes the conference.  You may disconnect at this time.  



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