An evaluation of a toolkit for the early detection, management, and control of carbapenemase-producing Enterobacteriaceae: a survey of acute hospital trusts in England

Published:March 09, 2018DOI:



      Following hospital outbreaks of carbapenemase-producing Enterobacteriaceae (CPE), Public Health England published a toolkit in December 2013 to promote the early detection, management, and control of CPE colonization and infection in acute hospital settings.


      To examine awareness, uptake, implementation and usefulness of the CPE toolkit and identify potential barriers and facilitators to its adoption in order to inform future guidance.


      A cross-sectional survey of National Health Service (NHS) acute trusts was conducted in May 2016. Descriptive analysis and multivariable regression models were conducted, and narrative responses were analysed thematically and informed using behaviour change theory.


      Most (92%) acute trusts had a written CPE plan. Fewer (75%) reported consistent compliance with screening and isolation of CPE risk patients. Lower prioritization and weaker senior management support for CPE prevention were associated with poorer compliance. Awareness of the CPE toolkit was high and all trusts with patients infected or colonized with CPE had used the toolkit either as provided (32%), or to inform (65%) their own local CPE plan. Despite this, many respondents (80%) did not believe that the CPE toolkit guidance offered an effective means to prevent CPE or was practical to follow.


      CPE prevention and control requires robust IPC measures. Successful implementation can be hindered by a complex set of factors related to their practical execution, insufficient resources and a lack of confidence in the effectiveness of the guidance. Future CPE guidance would benefit from substantive user involvement, processes for ongoing feedback, and regular guidance updates.


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        • Munoz-Price L.S.
        • Poirel L.
        • Bonomo R.A.
        • Schwaber M.J.
        • Daikos G.L.
        • Cormican M.
        • et al.
        Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases.
        Lancet Infect Dis. 2013; 13: 785-796
        • Nordmann P.
        • Naas T.
        • Poirel L.
        Global spread of carbapenemase-producing Enterobacteriaceae.
        Emerg Infect Dis. 2011; 17: 8
        • Cantón R.
        • Akóva M.
        • Carmeli Y.
        • Giske C.G.
        • Glupczynski Y.
        • Gniadkowski M.
        • et al.
        Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe.
        Clin Microbiol Infect. 2012; 18: 413-431
        • Public Health England
        English surveillance programme for antimicrobial utilisation and resitance (ESPAUR).
        PHE, London2014
        • Dautzenberg M.J.
        • Ossewaarde J.M.
        • de Kraker M.E.
        • van der Zee A.
        • van Burgh S.
        • de Greeff S.C.
        • et al.
        Successful control of a hospital-wide outbreak of OXA-48 producing Enterobacteriaceae in the Netherlands, 2009 to 2011.
        Euro Surveill. 2014; 19
        • Enfield K.B.
        • Huq N.N.
        • Gosseling M.F.
        • Low D.J.
        • Hazen K.C.
        • Toney D.M.
        • et al.
        Control of simultaneous outbreaks of carbapenemase-producing Enterobacteriaceae and extensively drug-resistant Acinetobacter baumannii infection in an intensive care unit using interventions promoted in the Centers for Disease Control and Prevention 2012 carbapenemase-resistant Enterobacteriaceae toolkit.
        Infect Control Hosp Epidemiol. 2014; 35: 810-817
        • Fournier S.
        Maitrise des bacteries hautement resistantes aux antibiotiques emergentes (BHRe).
        J Anti-Infect. 2014; 16: 80-88
        • Nordmann P.
        • Dortet L.
        • Poirel L.
        Carbapenem resistance in Enterobacteriaceae: here is the storm!.
        Trends Mol Med. 2012; 18: 263-272
        • Public Health England
        Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae.
        PHE, London2013
        • England N.H.S.
        Patient Safety Alert: Stage Two: Resources – Addressing rising trends and outbreaks in carbapenemase-producing Enterobacteriaceae.
        NHS England, London2014
        • Cane J.
        • O’Connor D.
        • Michie S.
        Validation of the theoretical domains framework for use in behaviour change and implementation research.
        Implement Sci. 2012; 7: 37
        • Cabana M.D.
        • Rand C.S.
        • Powe N.R.
        • Wu A.
        • Wilson M.H.
        • Abboud P.A.C.
        • et al.
        Why don’t physicians follow clinical practice guidelines? A framework for improvement.
        JAMA. 1999; 282: 1458-1465
        • NHS Digital
        ERIC – Estates Return information collection – trust level.
        HSCIC on behalf of the Department of Health, 2015
        • Ritchie J.
        • Spencer L.
        Qualitative data analysis for applied policy research.
        in: Bryman A. Burgess R. The qualitative researcher's companion. Sage Publications, USA2002
        • Ferguson K.J.
        • Waitzkin H.
        • Beekmann S.E.
        • Doebbeling B.N.
        Critical incidents of nonadherence with standard precautions guidelines among community hospital-based health care workers.
        J Gen Int Med. 2004; 19: 726-731
        • Doran D.
        • McCutcheon A.S.
        • Evans M.G.
        • MacMillan M.G.
        • McGillis H.L.
        • Pringle D.
        • et al.
        Impact of the manager's span of control on leadership and performance.
        Canadian Health Services Research Foundation, Ottawa2004
        • Magiorakos A.P.
        • Burns K.
        • Rodríguez Baño J.
        • Borg M.
        • Daikos G.
        • Dumpis U.
        • et al.
        Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control.
        Antimicrob Resist Infect Control. 2017; 6: 113
        • French C.E.
        • Coope C.
        • Conway L.
        • Higgins J.P.T.
        • McCulloch J.
        • Okoli G.
        • et al.
        Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: an evidence review.
        J Hosp Infect. 2017; 95: 3-45
        • Tacconelli E.
        • Cataldo M.A.
        • Dancer S.J.
        • De Angelis G.
        • Falcone M.
        • Frank U.
        • et al.
        ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients.
        Clin Microbiol Infect. 2014; 20: 1-55
        • Parker V.A.
        • Logan C.K.
        • Currie B.
        Carbapenem-resistant Enterobacteriaceae (CRE) control and prevention toolkit.
        (Prepared by Boston University School of Public Health and Montefiore Medical Center under Contract No. 290-2006-0012-l.) Agency for Healthcare Research and Quality, Rockville, MD2014 (Publication No. 14–0028)
        • Madan A.K.
        • Raafat A.
        • Hunt J.P.
        • Rentz D.
        • Wahle M.J.
        • Flint L.M.
        Barrier precautions in trauma: is knowledge enough?.
        J Trau Acute Care Surg. 2002; 52: 540-543
        • Centers for Disease Control and Prevention
        Facility guidance for control of carbapenem-resistant Enterobacteriaceae (CRE): November 2015 update – CRE Toolkit.
        CDC, Atlanta, GA2015