Control of carbapenemase-producing Enterobacteriaceae outbreaks in acute settings: An evidence review

Abstract Background In recent years infections with carbapenemase-producing Enterobacteriaceae (CPE) have been increasing globally and present a major public health challenge. Aim To review the international literature to: i) describe CPE outbreaks in acute hospital settings globally, and ii) identify the control measures used during these outbreaks and report on their effectiveness. Methods We systematically searched MEDLINE and EMBASE databases, abstract lists for key conferences, reference lists of key reviews, and sought information on unpublished outbreaks, for 2000-2015. Where relevant, risk of bias was assessed using the Newcastle-Ottawa scale. We conducted a narrative synthesis of the evidence. Findings Ninety-eight outbreaks were eligible. These occurred worldwide, with 53 reports from Europe. The number of cases (CPE infection or colonization) involved in outbreaks varied widely, from 2-803. In the vast majority of outbreaks multi-component infection control measures were used, commonly including: patient screening, contact precautions (e.g. gowns, gloves), handwashing interventions, staff education or monitoring, enhanced environmental cleaning/decontamination, cohorting of patients and/or staff, and patient isolation. Seven studies were identified as providing the best available evidence on the effectiveness of control measures. These demonstrated that CPE outbreaks can be successfully controlled using a range of appropriate, commonly used, infection control measures. However, risk of bias was considered relatively high for these studies. Conclusion Our findings indicate that CPE outbreaks can be controlled using combinations of existing measures. However, the quality of the evidence-base is weak and further high-quality research is needed, particularly on the effectiveness of individual infection control measures.