The following is an announcement from the State Epidemiologist for Communicable Diseases.
On July 1, 2018, changes to Chapter 145 of the Department of Health Services (DHS) Administrative Code became effective, including the addition of Carbapenem-resistant Enterobacteriaceae (CRE) as a Category I reportable condition. Category I conditions are of urgent public health importance, and require immediate notification by speaking with a local health officer or their designee, followed by a fax, mail, or electronic report within 24 hours, as outlined below under Reporting CP-CRE.
The following provides clarification and guidance for reporting Carbapenem-resistant Enterobacteriaceae (CRE) in accordance with Chapter 145 of the DHS Administrative Code. This memo serves as clarification that at this time carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) is the only type of CRE considered a category I condition requiring immediate notification. In addition, Infection Preventionists should continue to report CRE into the National Healthcare Safety Network (NHSN) in accordance to the NHSN CRE surveillance definition. Additional detail about reporting and follow-up for CRE is included below.
CRE Case Definition for reporting under Chapter 145 of the DHS Administrative Code: Carbapenemase- producing carbapenem-resistant Enterobacteriaceae (CP-CRE)
- Confirmed: An isolate of Enterobacteriaceae that is positive for a carbapenemase resistance mechanism (e.g., KPC, NDM, VIM, IMP, OXA-48) by an FDA approved or validated laboratory-developed test (e.g., PCR, Xpert® Carba-R), or sequencing method.
- Probable: An isolate of Enterobacteriaceae for which the phenotypic test is positive or indeterminate (e.g., metallo-β-lactamase test, Carba NP, Carbapenem Inactivation Method [CIM], or modified CIM), but the molecular testing is negative or not performed.
CRE Case Definition for NHSN: Carbapenem resistant Enterobacteriaceae (CP or non CP) of the following species: Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Enterobacter spp.
This definition includes the following laboratory criteria:
- Any Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Enterobacter spp. testing resistant to imipenem, meropenem, doripenem, or ertapenem by standard susceptibility testing methods (specifically, minimum inhibitory concentrations of ≥4 mcg/mL for doripenem, imipenem and meropenem or ≥2 mcg/mL for ertapenem) OR
- Any organism producing a carbapenemase (specifically, KPC, NDM, VIM, IMP, OXA-48) demonstrated using a recognized test (examples: PCR, metallo-β-lactamase test, Carba-NP, Xpert® Carba-R ).
This disease shall be reported IMMEDIATELY BY TELEPHONE to the patient’s local health officer or to the local health officer’s designee upon identification of a case or suspected case, per Wis. Admin. Code § DHS 145.04 (3) (a). In addition to the immediate report, complete and fax, mail or electronically report an Acute and Communicable Disease Case Report (DHS F-44151) to the address on the form, or enter the data into the Wisconsin Electronic Disease Surveillance System (WEDSS), within 24 hours.
Local Health Department Follow-up for Reported CP-CRE
When a facility identifies a new CP-CRE case, the next public health step is to contact the local health department. Per Chapter 145 of the DHS Administrative Code, the facility must call and speak to a health officer or their designee. Voicemails are not sufficient. Upon taking the initial report, the local health officer/designee will ask for the following information from the reporter:
- Name of patient
- Date of birth (DOB)
- Address of patient
- Date of specimen collection
- Type of specimen
- Species identified
- Date of admission to facility (if applicable)
- Where was the patient admitted from
- Date of discharge (if applicable)
- Where was patient discharged to (if applicable)
- Was the receiving facility notified of patient
- Multi-Drug-Resistant Organism status (if applicable)
For information regarding CRE patient/resident management, please use the following Division of Public Health (DPH) CRE toolkits which are available online for acute care/long-term acute care facilities and skilled nursing facilities. The toolkits provide background on CRE, frequently asked questions, patient scripts, and other useful CRE response information for the facilities. Once the initial notification from the facility is received, local health departments should create a WEDSS case, and contact the Wisconsin DPH Healthcare-Associated Infections (HAI) Prevention Program to discuss CRE case investigation.
- For questions related to infection prevention, contact Heather Kloth, Infection Preventionist with the Wisconsin DPH HAI Prevention Program: 608-266-0365 or Kloth@wi.gov.
- For reporting or lab-related questions, contact Megan Lasure, Antibiotic Resistance Laboratory Network Epidemiologist with the Wisconsin DPH HAI Prevention Program: 608-266-0915 or Lasure@wi.gov.
- Wisconsin HAI Prevention Program: 608-267-7711 or DHSWIHAIPreventionProgram@wi.gov
- Wisconsin Local Health Departments: https://www.dhs.wisconsin.gov/lh-depts/counties.htm Resources
- CDC Facility Guidance for Control of CRE: http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
- CP-CRE Case Reporting and Investigation Protocol (EpiNet): https://www.dhs.wisconsin.gov/disease/cre.htm
- NHSN MDRO protocol: https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
- Wisconsin Division of Public Health. Guidance for Preventing Transmission of Carbapenem-resistant Enterobacteriaceae (CRE) in Acute Care and Long Term Care Hospitals. Available at: https://www.dhs.wisconsin.gov/library/P-00532A.htm
- Wisconsin Division of Public Health. Guidance for Preventing Transmission of Carbapenem-resistant Enterobacteriaceae (CRE) in Skilled Nursing Facilities. Available at: https://www.dhs.wisconsin.gov/library/p-00532.htm