Containment Strategies for Carbapenem-Resistant Enterobacteriaceae in Low- and Middle-Income Countries

Background: Carbapenem-resistant Enterobacteriaceae (CRE) represent one of the most critical emerging antimicrobial-resistance threats globally. Data from low-and middle-income countries (LMICs) are increasingly reported as a part of global efforts to improve surveillance, and they demonstrate a high and increasing burden of CRE. However, containment of CRE using all recommended infection prevention and control (IPC) strategies requires substantial resources, which may be limited in LMICs. We conducted a review of the literature to better understand how approaches to CRE containment in LMICs have varied. Methods: We conducted a literature search using electronic databases (Medline, Embace, Cochrane Library, and Global Health) with no limit to study design or publication year. Search terms consisted of 3 categories: CRE, IPC, and LMIC. Additional publications were also identified from the references of identified articles. Publications were screened for eligibility; non-English articles and studies on other gram-negative organisms were excluded from the analysis. Control measures in included studies were categorized as active surveillance, hand hygiene, contact precautions, isolation, education, environmental control, monitoring and feedback, and other. Results: In total, 2,667 publications were identified using the databases and an additional 24 were manually identified. After deduplicating and screening for eligibility, 27 publications were included in the analysis. Overall, 21 publications (78%) were outbreak reports and 3 (11%) were quasi-experimental studies in settings of high rates of CRE. Also, 23 (85%) described a successful reduction in CRE. Among those 23 publications, 22 publications described adequate descriptions of IPC measures implemented, and the median number of IPC measures was 4.5 (range, 1–8). Environmental control was the most commonly utilized intervention (n = 19, 86%), followed by hand hygiene (n = 14, 64%) and contact precautions (n = 14, 64%). Three publications did not show a reduction in CRE despite the combination of IPC measures (median, 4.5). Overall, 13 publications utilized some method of active surveillance, but complete details on methodology were often lacking. In addition, 4 studies (15%) used only horizontal measures (defined as hand hygiene, environmental control, and/or education) and successfully controlled the CRE outbreaks. Conclusions: Among published reports, successful approaches to CRE control have been reported from LMICs. Use of only horizontal approaches, which are often lower cost and simpler to implement than some vertical strategies, have demonstrated some success; however, additional experience with identifying and implementing cost-effective strategies is needed. Funding: None Disclosures: None