NUR 699: Evidence-Based Literature Review on CRE Management

This literature review systematically examines evidence-based practices for managing Carbapenem-resistant Enterobacteriaceae (CRE) infections in hospital settings. Following PRISMA guidelines, the review analyzes studies from Cochrane, Medline, and PubMed databases, focusing on cultural assessments, recurrent CRE, and treatment outcomes. Key findings highlight the importance of hand hygiene, environmental cleanliness, and colonization pressure in controlling CRE spread. Interventions such as on-site infection control assessments, national guidelines, and CRE surveillance policies are crucial for reducing carrier prevalence. Bundled interventions including patient screening, contact isolation, and healthcare education are also associated with reduced CRE colonization and infection rates. The review underscores the need for in-depth assessment of CRE infection factors and emphasizes the role of hospital cultural practices in effective CRE management, noting that delays in observation can lead to complications.

EVIDENCE- BASED PRACTICE PROPOSAL- SECTION C: LITERATURE
REVIEW
Evidence-Based Practice Proposal- Section C: Literature Review
Jennifer Enriquez
Grand Canyon University: NUR 699
Date

Search strategy
The systematic review was performed using PRISMA guidelines, (Moher, Liberati,
Tetzlaff, & Altman, 2009). It involves databases searchers in Cochrane, Medline and Pub
med databases. The review involves research articles done between the last five 10 years. The
keywords used in this research involved; patients and patients diagnosed with CRE, Cultural
assessment of CRE and recurrent CRE during the treatment phase. None of the studies found
had a well reliable validity assessment measures.
Inclusion and exclusion criteria
The studies were included if they evaluated outcomes of CRE assessment and their
outcomes, length of stay at the hospital, recurrent CRE and management of CRE in hospital
setups. The search excluded studies which were less than 5 months of duration, used
surveillance cultures obtained from nonsterile bodies and not obtained from original data.
Literature review
The study by Barnes et al, (2014), has pointed on how prevention of multidrug-resistant
organisms can be modeled through hand hygiene and environmental cleanliness. The study
developed an agent-based model of conducting patient to patient transfusion through hands.
The model involved both nurses and physicians on hand hygiene. Simulations were done for
one year based on various micro bacteria. From the simulated scenarios, hand hygiene
practice performance outperformed the overall cleanliness. Thus making hand hygiene to be a
priority practice for infection control coupled with adequate environmental hygiene. This
study reflects the level II evidence level.
In a prospective cohort interventional study on prevention of the spread of CRE in post-
acute hospitals designed in a setting of 13 post-acute care hospitals, the intervention was
undertaken between 2008-2011. The intervention methodology involved periodic on-site
assessments on infection control and policies and resources, assessment of risks factors,
developing national guidelines and cross-sectional surveys. The results of the study showed
that the infection control score rose from 6.8 to 14.0 at p<.001. The carrier prevalence
declined from 16.8% to 12.5% at p=0.013. Hand hygiene using alcohol-based washing;
gloves usage and CRE surveillance policy were crucial for lower carrier prevalence, (Ben
David et al., 2014).
Bonten, (2012), conducted a literature assessment on usage and utilization of
colonization pressures as a risk factor of antibiotic resistance in intensive care units. The key
benefit of colonization pressure underpins the function of cross-transmission in antibiotics
resistance at the ICU which has major consequences on infection control effectiveness. The

study relays the importance of colonization pressure on the clinical epidemiology in ICU
settings. Colonization effects are beneficial in that they are a reliable and simple indicator for
hand hygiene failure which further complicates control measures. This study depicts level II
evidence thus cannot solely be reliable for practice but offers insightful concepts on
colonization pressure which is often experienced in hospital settings.
Investigation on Klebsiella pneumonia carbapenemase which produces
Enterobacteriaceae in health care settings especially long term acute care indicates a high
prevalence of the microorganisms. Using a stepped wedge design, various interventions were
assessed. With a total of an estimate of 3894 patients enrolled in pre-intervention periods and
2951 were enrolled during the intervention period. Results show that bacteria colonization
was stable during intervention with an average of 45.8% at 95% CI. At the intervention
phase, the bacteria load were high during the intervention. The study assessment on the
bundled intervention which included patients screening, contact isolation, single rooms
admissions, bathing, health care education and close monitoring were clinically associated
with reduction of CRE colonization, infection, all-cause bacteraemia and contamination of
blood culture in high risk long term acute care facilities, (Hyden et al., 2014).
A study by Patel et al., (2008), assessed the outcomes of infection of carbapenem-
resistant Klebsiella pneumonia and the impact caused by antimicrobial and adjunctive
therapies. The setting of the study was undertaken in a hospital set up with a capacity of
1,171-bed capacity care hospital. The study matched two case-control studies, making a
comparison of controls and case-patients, while the second case study patient survivors of
CRE pneumonia resistance were compared with those who were not survivors in order to
identify risk linked to mortality among patients with CRE resistant pneumonia. The results of
the study showed that CRE pneumonia was associated independently with recent organ
transplant, mechanical ventilation reception, and longer length of hospital stay and limited
treatment options of antimicrobial agents.
In a systematic review on the efficacy of empiric antibiotic therapy for sepsis care,
prospective studies were reporting on the appropriate antibiotic management on all-cause
mortality among adult patients. The studies obtained yielded calculation of odds ratios with
adjustments of variants, methods and covariates were done on the studies found. Random
effects were applied on OR. The review yielded 70 studies which 48 of them yielded
inappropriate empirical antibiotic treatment, which is associated with a high incidence of
mortality. The study designs, mortality period and reporting periods were affected by size.
Further septic shock was highly associated with high Ors. Studies which assessed background

conditions and severity of sepsis showed pooled adjusted OR of 1.60 (CI=95%, 1.37-1.86).
The associated empirical antibiotic was highly linked to reduced all-cause mortality, (Paul, et
al., 2010).
Generally, the literature search shows the in-depth assessment of how CRE infection
arises and factors which are highly linked to its occurrence in hospital settings. The studies
lay the foundation on how hospitals setting cultural practices are essential in managing the
spread and management of CRE. Any associated delay with onset observation I of danger
signs often leads to CRE complications which further affects and complicates the patient
health status.

References
Barnes, S. L., Morgan, D. J., Harris, A. D., Carling, P. C., & Thom, K. A. (2014). Preventing
the transmission of multidrug-resistant organisms: modeling the relative importance
of hand hygiene and environmental cleaning interventions. Infection Control &
Hospital Epidemiology, 35(9), 1156-1162.
Ben-David, D., Masarwa, S., Adler, A., Mishali, H., Carmeli, Y., & Schwaber, M. J. (2014).
A national intervention to prevent the spread of carbapenem-resistant
Enterobacteriaceae in Israeli post-acute care hospitals. Infection Control & Hospital
Epidemiology, 35(7), 802-809.
Bonten, M. J. (2012). Colonization pressure: a critical parameter in the epidemiology of
antibiotic-resistant bacteria. Critical Care, 16(4), 142.
Hayden, M. K., Lin, M. Y., Lolans, K., Weiner, S., Blom, D., Moore, N. M., ... & Sikka, M.
(2014). Prevention of colonization and infection by Klebsiella pneumoniae
Carbapenemase-producing Enterobacteriaceae in long-term acute-care hospitals.
Clinical Infectious Diseases, 60(8), 1153-1161.
Patel, G., Huprikar, S., Factor, S. H., Jenkins, S. G., & Calfee, D. P. (2008). Outcomes of
carbapenem-resistant Klebsiella pneumonia infection and the impact of antimicrobial
and adjunctive therapies. Infection Control & Hospital Epidemiology, 29(12), 1099-
1106.
Paul, M., Shani, V., Muchtar, E., Kariv, G., Robenshtok, E., & Leibovici, L. (2010).
Systematic review and meta-analysis of the efficacy of appropriate empiric antibiotic
therapy for sepsis. Antimicrobial agents and chemotherapy, 54(11), 4851-4863.
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. Annals of internal
medicine, 151(4), 264-269.