|Year : 2013 | Volume
| Issue : 2 | Page : 45-47
Controlling the spread of carbapenemase-producing Gram-negative bacteria
Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State, Nigeria
|Date of Web Publication||23-May-2014|
Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Aliyu S. Controlling the spread of carbapenemase-producing Gram-negative bacteria. Ann Nigerian Med 2013;7:45-7
The rapid spread of carbapenemase producing Gram-negatives (CPGNs) continues to pose a significant health threat globally. The potential threat to patients and health personnel is unprecedented. This has heightened the global awareness of the need to prioritize infection prevention and control (IPC) strategies, with the aim of reducing the burden of infection caused by these bacteria. Developing countries have experienced unfavorable trends in antimicrobial resistance.  CPGNs have now emerged as a significant threat in Africa.  Implementation of effective infection control strategies are hampered by many factors, some of which are specific to developing countries. An understanding of the basic principles of CPGN IPC is crucial to the battle against these multidrug resistant bacteria.
Risk factors for colonization or infection
Many risk factors for the acquisition of CPGNs have been identified. These have been characterized as individual- and facility-level factors.  Some of the most important risk factors include prior use of antimicrobials, use of multiple antimicrobials, prolonged hospital stay, severe illness, mechanical ventilation, invasive medical devices, intensive care stay, the presence of wounds, prior surgery, invasive procedures, and recent transplantation. 
Carbapenemase producing Gram-negative colonization and introduction back to native country following hospitalization in foreign hospitals has also been documented.  Reports have also recently emerged of healthy travelers becoming colonized by CPGNs after travelling to countries where carbapenemases-producing enterobacteriacae (CPE) are endemic, even without contact with the local health care system.  These cases highlight the potential risks associated with foreign travel, especially medical tourism.
Risk factors for transmissions
Some CPGN-colonized patients are more likely to contaminate the hands of healthcare worker and the environment. These include patients with diarrhea or fecal incontinence, patients with enterostomies, patients with discharging wounds, catheterized patients with carbapenem-resistant enterobacteriaceae (CRE) colonization of the urinary tract, and patients who are incapable of maintaining their own personal hygiene. 
Many guidelines have been developed for the control of CPGNs. Many of these guidelines have been developed and evaluated in countries in Western Europe and North America, which have well-functioning health care systems. At the core of every guideline, is the understanding that control programs must include strategies for preventing the emergence of CPGNs, as well as containing resistant organisms that have already emerged.
Proactive and reactive approaches have been advocated for the control of CPGNs. The reactive approach to infection control advocates directed action after a cluster of CPGNs have been detected, while the proactive approach advocates the allocation of resources upfront, before the problem becomes evident.  The proactive approach involves early detection, and containment through patient isolation and cohorting. This approach assumes it is more cost effective to control the problem before it becomes a huge issue. The reactive approach, however, involves allocation of resources only when the problem has become evident.  The disadvantage of the reactive approach is that sometimes by the time the problem becomes evident, it become more difficult and more expensive to control.
The US Centers for Disease Control and Prevention (CDC) advocates the proactive approach.  For all acute and long-term care facilities, the US CDC recommend the following core measures: Hand hygiene, contact precautions, patient isolation and dedicated staff, minimization of the use of invasive devices-particularly urinary catheters, promotion or reinforcement of antibiotic stewardship and screening for CPE.  For health care facilities with CPE transmission, CDC recommends other supplemental measures such active surveillance and chlorhexidine baths. [Table 1] shows the CDC summary of CRE prevention strategies for acute and long-term care Facilities. 
|Table 1: Summary of CDC - CPE prevention strategies for acute and long-term care facilities|
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Effective control of CPGNs requires that plans are developed and implemented depending on the epidemiological situation in the health care facility and the country as a whole. Control measures differ substantially between settings with sporadic occurrence or complete absence of CPGNs and countries with ongoing CPGN outbreaks or endemic CPGNs.  These plans should be implemented accordingly.
| Conclusion|| |
To insure containment of CPGN bacteria, wide dissemination of information and robust multifaceted strategies involving microbiologist, clinicians, and decision makers are essential. Decreasing the impact of these organisms will require a coordinated effort involving all stakeholders including health care facilities and providers, public health, industry, and government. There is an urgent need to develop and implement infection control guidelines that can be used in resource limited setting such as Africa.
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