Dear colleagues,
Further to earlier e-mail correspondence dated 9th September 2016, I am contacting you to provide an update on the CRE outbreak currently being managed by our colleagues in Tallaght Hospital. The outbreak is caused by an OXA-48 carbapenemase which appears to be on a very easily transmissible plasmid and to date has been detected in several different species of Enterobacteriaceae including; E. coli, K. pneumoniae, K. oxytoca, Enterobacter cloaceae and Citrobacter species.
The exact start date of this outbreak is not yet known and an epidemiological investigation has commenced. This CRE outbreak continues and to date, cases have been confined to the adult hospital and involving several wards.
A local outbreak control team is managing the outbreak, but new cases continue to be detected with expanded screening and it may be expected that the outbreak will take some time to control. While the local IPCT in Tallaght will endeavour to inform receiving hospitals if a patient is known to be CRE positive, the team is not resourced to provide 24/7 cover, CRE results may not be available for every patient transferred and cognisance that our colleagues are busy managing an outbreak is required.

With this in mind, the following recommendations are made:
1. A robust local system is necessary to ensure that every adult inpatient coming from Tallaght Hospital is identifiable in the event that they are transferred to your hospital, ideally prior to arrival and the patient should be isolated with contact precautions and screened for CRE on arrival to your hospital.
2. A risk assessment is advised to decide whether screening and pre-emptive isolation and contact precautions is indicated for the adult patient directly transferred from Tallaght ED, to be guided by whether or not there is a history of inpatient admission to Tallaght Hospital in the past 12 months (September 2015 onwards), along with existing National Guidelines for Screening for Resistant Enterobacteriaceae available at the following link:
http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialResistanceinIrelandSARI/CarbapenemResistantEnterobacteriaceaeCRE/ScreeningforCREinIreland/
3. While logistically challenging, given the ongoing increased incidence of CRE nationally and the ongoing CRE outbreak in Tallaght, efforts to implement screening recommendation number 6 in the national guidelines should be prioritised to prevent further dissemination between hospitals.
Screening recommendation 6 = Patients with a history of admission to another Irish hospital should be screened, as necessary, after consideration of the source hospital history and unit/s to which the patient will be admitted.

If you detect a new CRE case in a patient with a history of admission to Tallaght Hospital since September 2015, please let me know, so the patient may be considered for inclusion in the epidemiological investigation.
Please continue to ensure that any invasive CRE infection is notified via CIDR, in keeping with Infectious Diseases Regulations.
CRE enhanced surveillance forms are welcomed on any confirmed carbapenemase producing CRE case, whether colonisation or infection. The forms and accompanying protocol are available at the following link and completed forms should be returned to Stephen Murchan, Surveillance Scientist, HPSC:
http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialResistanceinIrelandSARI/CarbapenemResistantEnterobacteriaceaeCRE/SurveillanceForms/

Kind regards,
Karen

Dr Karen Burns.
HPSC