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Effective Date: 09/2017 Published Date: 02/22/2019 Current Version: 02/2019 Last Updated: 02/21/2019
Disease Investigation Guideline:
Carbapenem-resistant Enterobacteriaceae (CRE)
Contents Case Definition ................................................................................................................................ 3
Note: KDHE will classify CP-CRE as any bacteria that is positive by a phenotypic method or positive for
known carbapenemase resistance mechanism. National reporting to CDC will only occur for cases that
meet CDC’s CP-CRE definition.
Probable CP-CRE Cases (KDHE Use Only)
Any carbapenem-resistant bacteria that is tested positive by a phenotypic test and/or a
molecular test for carbapenemase production that has been more than 30 days but no more
than 12 months since prior positive CP-CRE. Must be same organism, species, and
carbapenemase. Used for data management purposes.
Suspect CP-CRE Cases (KDHE Use Only) Any carbapenem-resistant bacteria that is not available for testing at KHEL for carbapenemase
production. Used for data management purposes.
Not a Case (KDHE Use Only) Any carbapenem-resistant bacteria tested negative on a phenotypic test (e.g. mCIM) performed at KHEL
or through CDC’s Antimicrobial Resistance Laboratory Network (ARLN).
Criteria to Distinguish a New CP-CRE Case from an Existing CP-CRE Case • Different organisms/species/carbapenemases are counted as separate events from other
organisms/species/carbapenemases and each such event will separate CMR events
• There is at least a 12-month interval from previous CMR event for clinical cases
• Person with a clinical case should NOT be counted as a screening/surveillance case thereafter
(e.g., patient with known infection who later has colonization of GI tract is not counted as more
than one case)
• Person with a screening case that develops infection (e.g., patient with positive peri-rectal
screening swab who later develops blood stream infection)
Version: 02/2019 CRE, Page 5 of 13
Case Classification Comments 1. Cases involving isolates that are phenotypically positive for carbapenemase production (e.g.,
mCIM), but negative for KPC, NDM, OXA-48, VIM, and IMP should be counted as confirmed CP-
CRE. Isolates should be submitted to the regional laboratories of the ARLN for further
characterization (potential novel carbapenemase).
2. A positive Modified Hodge Test (MHT) can be used to confirm CP-CRE for Klebsiella spp. and E.
coli but not Enterobacter spp. An isolate that tests positive on MHT but negative PCR for KPC,
NDM, OXA-48, VIM and IMP should have additional characterization performed with another
phenotypic test for carbapenemase such as mCIM. CLSI updated guidelines for carbapenemase
testing recommend mCIM as the preferred method and removed the recommendation for MHT.
3. If isolate is indeterminate on mCIM and negative by PCR for KPC, NDM, OXA-48, VIM and IMP,
isolate should be tested using CarbaNP (at state public health laboratory or regional ARLN lab).
4. CP-CRE should be stratified by the 3 subtypes (genera): Klebsiella spp., Enterobacter spp. and
E.coli. Each subtype/ genus should be stratified by whether the cultures were clinical (i.e.,
collected for the purpose of diagnosing or treating disease in the course of normal care) versus
for screening/surveillance (i.e., collected for the detection of colonization and not for the
purpose of diagnosing or treating disease). Because it can be difficult to differentiate screening
cultures from clinical cultures based on microbiology records, screening tests should generally
be limited to rectal, peri-rectal or stool cultures. Cultures from such sites can be assumed to be
for screening unless specifically noted otherwise. Laboratory may also note screening culture for
other sites (e.g., wounds, tracheostomy or central line sites). Laboratories do not need to
change their practice; public health wants to identify all CP-CRE whether they come from
screening or clinical cultures.
5. For bacteria that have intrinsic imipenem nonsusceptibility (i.e., Morganella morganii, Proteus
spp., Providencia spp.), resistance to a carbapenem other than imipenem is required.
Version: 02/2019 CRE, Page 6 of 13
Laboratory Analysis
The Kansas Health and Environmental Laboratories (KHEL) performs carbapenemase testing on
carbapenem-resistant bacteria. Isolates submitted for carbapenemase testing is used for
epidemiological and infection control purposes only. KHEL performs the below testing on any isolate
that meets testing criteria (Figure 2). No change in the interpretation of carbapenem susceptibility test
results is necessary for mCIM positive specimens (CLSI, M100-S28).
Description of Carbapenemase Testing for Enterobacteriaceae and Pseudomonas
aeruginosa (CRE, CRPA): All carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-resistant Pseudomonas aeruginosa
(CRPA) isolates will be characterized using the following testing workflow:
1. Species identification by mass spectrometry (MALDI-ToF)
2. Phenotypic detection of carbapenemase enzymes by mCIM (modified Carbapenem Inactivation
Method)
3. mCIM positive isolates will be tested for the five most common carbapenemase (KPC, NDM,
IMP, VIM, OXA-48; Xpert Carba-R)
4. mCIM positive, PCR negative isolates are submitted to the Minnesota Department of Health –
Public Health Laboratory for further characterization (with some exceptions)
Description of Carbapenemase Testing for Acinetobacter baumannii: All carbapenem-resistant Acinetobacter baumannii (CRAB) isolates received at KHEL will be forwarded to
the Minnesota Department of Health – Public Health Laboratory for carbapenemase testing. CRAB
isolates will be characterized using the following testing workflow:
• Species identification by mass spectrometry (MALDI-TOF)
• Carbapenemase PCR for five most common carbapenemases (KPC, NDM, IMP, VIM, OXA-48;
available online at www.kdheks.gov/epi/disease_reporting.html.
1. Reporting to KDHE Bureau of Epidemiology and Public Health Informatics: a. Laboratorians must submit culture results and non-suppressed susceptibility report with
numerical values along with isolate submission (unless this information is submitted by Electronic Laboratory Reporting [ELR]). Isolates submitted without susceptibility report may be rejected.
b. Infection Preventionists/Mandatory Reporters should submit the Multi-Drug Resistant
Organism (MDRO) Reporting Form and laboratory results for any carbapenem-resistant
bacteria eligible for carbapenemase testing. The MDRO form is available at
www.kdheks.gov/epi/disease_reporting.html
2. Submitting isolates to KHEL:
a. Specimens needs to be isolated (raw material not accepted)
b. Submitted on typical slant media (blood, chocolate, TSA, etc.)
c. Shipped in Category B shipper at room temperature with Universal Submission Form
d. For additional information, call KHEL Customer Service 785-296-1620