Healthcare-associated infections (HAI) program

Carbapenem-resistant and Carbapenemase-producing Organisms for Public Health and Healthcare Providers

About

Carbapenem-resistant organisms (CRO) are Gram-negative bacteria that are resistant to the broad-spectrum, “last resort” carbapenem class of antibiotics. They include: bacteria from the Enterobacterales order (previously Enterobacteriaceae) (CRE), such as E. coli or Klebsiella pneumoniae; Pseudomonas aeruginosa (CRPA); and Acinetobacter baumannii (CRAB). Patients with CRO infections have significantly worse outcomes than patients with susceptible infections. Certain CRO are resistant because they produce carbapenemase enzymes (e.g., KPC, NDM, OXA, VIM, IMP) that make carbapenems ineffective. Carbapenemase genes can be transferred between different kinds of bacteria and lead to the spread of antibiotic resistance.

Carbapenemase-producing organisms (CPO) are increasingly more common throughout California healthcare settings. Public health and healthcare providers across the continuum of care are coordinating efforts to prevent the emergence and transmission of CRO, CPO and other highly drug-resistant infections in California.

Key Documents:

CPO Reporting FAQ (PDF) for guidance on reporting CPO to public health

Targeted Surveillance Program Flyer (PDF) for CRPA and CRAB Isolates

CRE, CRPA and CRAB information for patients and their families.

CRE Quicksheet (PDF) for guidance on investigating CRE cases and clusters.

CRPA/CRAB Quicksheet (PDF) for guidance on investigating CRPA/CRAB cases and clusters.

CPO Screening Decision Tree (PDF) for guiding colonization testing recommendations in healthcare facilities.

Algorithm for Prioritizing Carbapenemase Testing (PDF) of carbapenem-resistant organisms.

Prevention of Multidrug-resistant Organisms in Long-term Care Facilities. December 10, 2020

Slides (PDF)
Webinar Recording (opens in YouTube)

Antimicrobial Resistance Testing: Public Health Laboratory Testing Updates, and Recommendations for Isolate Submission and Reporting
October 6, 2021

Slides (PDF)
Webinar Recording (opens in YouTube)

Carbapenemase-producing Organisms: Guidance for Reporting and Containment. September 29, 2022

Slides (PDF)
Webinar Recording (opens in YouTube)

Testing for Carbapenemase Production Among Carbapenem-Resistant Organisms: When and How? October 27, 2022

Slides (PDF)
Webinar Recording (opens in YouTube)
Carbapenemase Testing for Carbapenem-Resistant Organisms: A Primer for Clinical and Public Health Laboratories (PDF)

The Role of Carbapenemase Testing in Clinical Practice December 6, 2022

Slides (PDF)
Webinar Recording (opens in YouTube)

Coordinated CRO/CPO Prevention Strategies

	HEALTHCARE PROVIDERS	PUBLIC HEALTH DEPARTMENTS
Laboratory Identification	Know your laboratory’s capabilities for CRO identification and resources for carbapenemase testing to identify CPO. Implement updated laboratory breakpoints for carbapenems and Enterobacterales. Learn more by viewing Implementing Current Breakpoints for Carbapenems and Enterobacterales on Your AST System: Step by Step Instructions (PDF). Access the Testing for Carbapenemase Production Among Carbapenem-Resistant Organisms: When and How? webinar recording (opens in YouTube) and webinar slides (PDF). View the Antimicrobial Resistance Testing: Public Health Laboratory Testing Updates, and Recommendations for Isolate Submission and Reporting webinar recording (opens in YouTube) and webinar slides (PDF).	Know local, state and regional laboratory resources for CPO identification. CDPH offers carbapenemase testing for CRE and CRPA. Learn more about extended carbapenemase testing services at the CDPH Microbial Disease Laboratory (PDF). Carbapenemase testing for CRAB is available through the Centers for Disease Control and Prevention (CDC) Antibiotic Resistance Laboratory Network (AR Lab Network). Contact HAIProgram@cdph.ca.gov for more information. Use the CDPH Algorithm for Prioritizing Carbapenemase Testing (PDF) to guide isolate submission to public health.
Surveillance	Ensure the laboratory rapidly notifies infection prevention and clinical staff when a patient or resident with CRO/CPO is identified. Consider tracking CRE LabID events using the NHSN MDRO module (PDF). Participate in the AR Lab Network Targeted Surveillance Program (PDF) to access confirmatory identification, antibiotic susceptibility and carbapenemase testing for CRPA and CRAB at no cost. Contact HAIProgram@cdph.ca.gov for more information.	Know the local epidemiology and prevalence of CRO/CPO in your region. Understand patient risk factors and high-risk facilities for CRO/CPO in your jurisdiction, such as long-term acute care hospitals (LTACH) and ventilator-equipped skilled nursing facilities (vSNF). Work with local healthcare facilities to ensure awareness of CRO/CPO.
Colonization Testing	Perform CPO colonization testing of patients and residents who are epidemiologically-linked to a patient newly identified with a CPO. Epi-linked patients include roommates, patients residing on the same unit, or patients exposed to the same medical device. Consider performing CPO colonization testing upon admission of high-risk patients. High-risk patients include those admitted from LTACH or vSNF, or have received healthcare outside the United States during the prior 12 months.	Access CPO colonization testing services free of charge using the AR Lab Network. To learn more, contact the HAI Program to initiate a request. Use the CPO Screening Decision Tree (PDF) to guide colonization testing recommendations in healthcare facilities.
Infection Control Measures	Place patients infected or colonized with CPO in a single room whenever possible, and implement Standard and Contact precautions; in skilled nursing facilities, if there is no evidence of transmission, place residents with risk factors for MDRO transmission on Enhanced Standard precautions.	Use the CRE Quicksheet (PDF) or CRPA/CRAB Quicksheet (PDF) for guidance on investigating CRO/CPO cases and clusters. Access the CP-CRE: Guidance for Local Public Health webinar recording (opens in YouTube) and webinar slides (PDF). Be prepared to conduct a site visit when necessary and assess implementation of infection control strategies. Use the CRE self-assessment tool (PDF) or the Core Infection Prevention assessment tool (PDF) and MDRO module PDF); use the Ventilator module (PDF) as needed.
Adherence Monitoring	Use infection control assessment and adherence monitoring tools, for example, hand hygiene, environmental cleaning and disinfection. Monitoring adherence and providing feedback to staff are critical to successful implementation of infection prevention measures.	During an outbreak, consider requesting the facility provide documentation of their own adherence monitoring.
Environmental Cleaning	Ensure thorough daily and terminal environmental cleaning. Focus on high-touch surfaces or any shared reusable medical equipment. Review environmental cleaning checklists available on the CDPH HAI Program website.	Be prepared to assess appropriateness and adequacy of environmental cleaning measures. Use the CDPH tools for monitoring adherence to environmental cleaning and disinfection.
Interfacility Communication	Communicate CRO/CPO status to the receiving facility ahead of time to ensure appropriate care is maintained when transferring a patient/resident. Use the HAI Program interfacility transfer form during all patient transfers available via the Interfacility Transfer Communications Guide webpage.	Set expectations for facilities to communicate CRO/CPO status when transferring patients/residents to another healthcare facility. During an outbreak, consider requesting facilities notify public health of all discharges and transfers involving individuals with CRO/CPO.
Antimicrobial Stewardship	Implement strategies to limit use of broad spectrum antimicrobial agents and an antimicrobial stewardship program (ASP) to promote and measure appropriate antimicrobial use by optimizing the selection, dosing, route, and duration of therapy. Apply to be recognized as a top-performing ASP through the CDPH Antimicrobial Stewardship Honor Roll.	Understand and promote local stewardship resources, including CDPH’s Antimicrobial Stewardship Honor Roll.
Regional Prevention	Participate in regional efforts to prevent the spread of drug-resistant infections. Participate with laboratory partners in the California Antimicrobial Resistance Lab-Epi Alliance.
Reporting	Report CPO cases through CalREDIE electronic laboratory reporting (see CPO Reporting FAQ (PDF)) Report CRO and CPO outbreaks to public health and your local CDPH Licensing and Certification District Office Access the CPO: Guidance for Reporting and Containment webinar recording (opens in YouTube) and webinar slides (PDF).	Contact the HAI Program for any suspected and confirmed CRO/CPO outbreaks. Complete relevant investigation information in CalREDIE Lab and Epi Info tabs for CP-CRE and CPO (excluding CRE) conditions.