Cre Infection

Overview

CRE stands for carbapenem-resistant Enterobacteriaceae (say: kar-buh-PEN-em re-ZIS-tunt en-tuh-roh-bak-teer-ee-AY-see-ee). That is a long name for a simple idea. Enterobacteriaceae are a large family of bacteria that normally live in everyone's gut. Some of these bacteria have learned to survive the antibiotics doctors usually rely on, including a strong group called carbapenems. When bacteria can survive an antibiotic, we say they are 'resistant.' So a CRE infection is an illness caused by these hard-to-treat bacteria. Many people have CRE living in their bowel without feeling ill at all. This is called 'carrying' or 'colonisation' and it is not an infection. An infection happens when the bacteria get into a place they should not be, such as the bladder, a wound, the lungs or the blood, and the body reacts with fever and other symptoms.

For most healthy people living at home, CRE infection is uncommon. These bacteria are a growing concern in hospitals and care settings around the world, but they are still a small share of all infections. Being told you carry CRE does not mean you are likely to become seriously ill. It means your care team will take extra care to stop the bacteria spreading and will watch for signs of infection.

CRE infections are seen most often in people who are already in hospital or in long-term care, especially those who are seriously unwell. Risk is higher for people who have had a long stay in hospital, a stay in intensive care, recent surgery, a urinary catheter, a drip or breathing tube, or many courses of antibiotics. Older adults, people with weak immune systems (the body's defence system), people with diabetes, and those with serious illnesses such as kidney or liver disease are also more likely to be affected. Babies and young children can get CRE infections too, but this is uncommon and usually happens in hospital.

Symptoms

Common symptoms

• Fever or chills, sometimes with shivering
• Feeling very tired, weak or generally unwell
• Pain or burning when passing urine, or needing to pass urine more often (if the bladder is affected)
• Cough, chest pain or shortness of breath (if the lungs are affected)
• Redness, warmth, swelling or discharge around a wound or where a tube enters the skin
• Feeling sick, being sick, or pain in the tummy
• A fast heartbeat or feeling faint
• In serious cases, low blood pressure, confusion or difficulty staying awake

Symptoms in children

• Fever, or sometimes a low temperature instead of a high one
• Being unusually sleepy, floppy or hard to wake
• Refusing feeds, or feeding much less than usual
• Fewer wet nappies than normal
• Being very unsettled or crying more than usual
• Fast breathing or grunting
• A rash that does not fade when you press on it

Symptoms in older adults

• New confusion, drowsiness or a sudden change in behaviour, which can be the first sign of infection
• Fever may be missing; a low body temperature can also be a warning sign
• Falls or a sudden loss of mobility
• Not eating or drinking, or new incontinence (loss of bladder control)
• Fast heartbeat, fast breathing or feeling faint
• Generally 'not themselves' or more frail than usual

Causes

Main causes

• CRE bacteria spread from person to person, most often on the hands of healthcare workers or visitors who have not cleaned their hands
• Contact with shared equipment, beds, bedside tables or medical devices that have not been properly cleaned
• Medical tubes such as urinary catheters, intravenous drips and breathing tubes can give bacteria a way into the body
• Bacteria from the person's own gut can move to another part of the body, for example the bladder or a wound, and cause infection there
• Antibiotics treat other infections but also kill harmless gut bacteria, which can leave room for resistant bacteria to grow and spread

Risk factors

• A long stay in hospital, especially in an intensive care unit
• Recent surgery or a stay in a care home or nursing home
• Having a urinary catheter, a central line, a feeding tube or a breathing tube
• Weak immune system (the body's defence system) from illness or from treatments that suppress it
• Many or long courses of antibiotics in the past
• Being older, frail or having a serious long-term condition such as diabetes, kidney disease or liver disease
• Being in a hospital or country where CRE is more common
• Close contact with someone who carries CRE, especially in a care setting

When to see a doctor

See a doctor urgently if:

• You have a fever and you have a catheter, drip or breathing tube, or you have had one recently
• You have a fever with a wound that is red, hot, swollen or leaking pus
• You feel very unwell, shaky or faint, or your heart is racing
• You are unable to keep fluids down, or you have not passed urine all day
• You have been told you carry CRE and you develop new symptoms such as fever, cough, pain when passing urine or a new wound problem
• Your baby or young child has a fever and seems floppy, very sleepy or is not feeding

Book a routine appointment if:

• You have been told you carry CRE and want to understand what it means for you and your family
• You are due to have surgery or a hospital stay and were previously told you carry CRE — your team will want to know
• You have mild urinary symptoms such as stinging or needing to go more often
• You have slow-healing wounds, or a wound that keeps coming back
• You keep getting infections and want to talk about why

Diagnosis

Doctors can only tell whether bacteria are CRE by testing a sample in a laboratory. If your care team thinks you may have an infection, they will take a sample from the likely place, such as urine, blood, spit from your lungs or a swab from a wound. In hospitals, they may also take a swab from the bowel, or a stool sample, to check whether someone is carrying CRE without being ill. This is called screening. The sample is put in a dish with nutrients so the bacteria can grow, and then it is tested against different antibiotics to see which ones work. Results often take a few days. In the meantime, your team may start treatment based on your symptoms and adjust it when the results come back.

Tests that may be done

• Urine test and urine culture if the bladder or kidneys may be affected
• Blood cultures if there is fever, shivering or signs of a serious infection
• A sample of spit or fluid from the lungs if there is a cough or breathing problems
• A swab or tissue sample from a wound, sore or drip site
• A bowel or stool swab to check for CRE carriage (screening), often done when someone is admitted to hospital or moved between wards
• Antibiotic sensitivity testing, which shows which antibiotics can kill the bacteria
• General blood tests to see how the body is responding to infection
• A chest X-ray or scan if the lungs or another deep area may be involved

What to expect at your appointment

You may be asked to give a urine or stool sample, or a nurse may take a blood sample or a swab. These are quick and usually only mildly uncomfortable. Screening swabs are simple and painless. If you are in hospital, you may be cared for in a single room while results are pending, and staff may wear gloves and aprons. This is standard practice to protect everyone and is not a sign that you are dangerously ill. Waiting a few days for results is normal. Ask your nurse or doctor to explain anything that is unclear — you are entitled to know what is happening and why.

Treatment

Treatment depends on where the infection is, how severe it is and which antibiotics the laboratory shows will work against your particular strain. Not every CRE needs antibiotic treatment. If you only carry the bacteria and feel well, you usually do not need any medicine at all. If you do have an infection, the team will aim to treat it promptly and support your body while it recovers. They will also remove or change any tubes, catheters or drips that may be feeding the infection, where that is possible.

Self-care at home

• Rest as much as your body needs, and go back to normal activity gradually
• Drink fluids regularly unless your doctor has told you to limit them
• Take all medicine exactly as prescribed, and finish the course even if you feel better
• Clean your hands well with soap and water, or alcohol gel if your hands are not visibly dirty, especially before touching a wound, catheter or drip site
• Keep any wound or tube site clean and dry, and follow the dressing instructions you were given
• Watch for new or worsening symptoms and write them down so you can tell your care team
• Ask a family member or friend to help with practical things while you recover
• Tell any new doctor, dentist or nurse that you carry CRE, so they can plan your care

Medical treatments

Doctors choose an antibiotic that laboratory tests show can kill your particular strain of bacteria. Some newer antibiotics are designed for resistant bacteria, and your specialist team will know whether one is suitable for you. Because bacteria differ from person to person, the choice is made for you individually rather than from a standard list. Alongside antibiotics, treatment may include fluids through a drip, oxygen, pain relief, and careful monitoring of blood pressure and urine output. Removing or replacing a catheter, drip or other device is often an important part of clearing the infection. In some cases, a specialist in infectious diseases or microbiology will be asked to advise. If you are in hospital, you may be nursed in a single room with extra infection-control precautions to protect other patients.

When is surgery considered?

Surgery is not usually needed for a CRE infection. Occasionally an operation or a small procedure may be needed to drain a collection of pus, clean an infected wound, or remove an infected device or tissue that is not clearing with antibiotics. Your team will explain the reasons and the risks if this applies to you.

Living with this condition

Most people who carry CRE live completely normal lives, work, go to school and care for family. Carrying the bacteria does not stop you from being around other people. In hospital or a care home, staff may take extra steps such as single rooms, gloves and aprons, or screening on admission. These are routine safety measures, not a sign that you are a danger to others. If you are recovering from an infection, expect to feel tired for a while. Build your strength back slowly, and keep in touch with your care team about how you are doing.

Lifestyle tips

• Make hand cleaning a habit for you and everyone in your household, especially before meals and after using the toilet or changing dressings
• Keep a simple record of your medicine, allergies and any bacteria you carry, and bring it to appointments
• Do not share towels, razors, toothbrushes or other personal items
• Keep follow-up appointments, including any repeat tests your team recommends
• Avoid using leftover or borrowed antibiotics — they can make resistance worse
• Keep your home clean, particularly the bathroom and kitchen surfaces

Diet and exercise

There is no special diet that clears CRE. A balanced, varied diet with plenty of fluids helps your body recover and supports your immune system. If you have lost weight or your appetite during illness, ask about a referral to a dietitian. Gentle activity, such as short walks and light stretching, helps you rebuild strength after an infection. Start slowly and build up. If you have a long-term condition, ask your care team what level of exercise is safe for you.

Mental health and emotional wellbeing

Being told you carry a resistant germ, or being treated for one, can bring up worry, embarrassment or loneliness, especially if you have been in a single room. These feelings are very common and understandable. It can help to talk to someone you trust, to ask your care team questions until things feel clearer, and to remember that carrying CRE is a medical situation, not a personal failing. If low mood, anxiety or worry is affecting your sleep, appetite or daily life, please tell your doctor or nurse. They can offer support, and talking therapies are available in most places.

Prevention

The spread of CRE can be greatly reduced, although it cannot be prevented completely. Clean hands are the single most important step — for healthcare staff, visitors and patients alike. Hospitals use screening, single rooms, careful cleaning of equipment and 'antibiotic stewardship' (using antibiotics only when needed, at the right dose and for the right length of time) to limit spread. At home, good hand hygiene, safe food handling and not sharing personal items all help. If you carry CRE, washing your hands well after using the toilet and before preparing food lowers the chance of passing it on.

Vaccines

There is no vaccine available for CRE. The routine vaccines recommended for your age and health are still important, because preventing other infections means fewer illnesses and fewer courses of antibiotics.

Screening programmes

Many hospitals screen people for CRE on admission, when moving between wards, or after a stay in a hospital where CRE is common. Screening is usually a simple swab of the bowel area or a stool sample, sometimes with a swab from the skin or throat. Screening is painless and helps staff protect you and other patients. If you have been told before that you carry CRE, mention it whenever you are admitted anywhere, including for day surgery or a care home stay.

Complications

If left untreated

• The infection can spread from the bladder or a wound into the bloodstream
• Sepsis (the body's extreme response to infection) can develop, which is a medical emergency
• Organs such as the kidneys, lungs or heart can be affected in severe cases
• A longer stay in hospital and a longer recovery
• Delayed healing of wounds or recovery after surgery
• Some resistant infections are harder to treat, which can mean a more serious illness, especially in frail or very unwell people

Long-term outlook

The outlook is much better than many people expect. Most people who carry CRE never become ill, and many CRE infections can be treated once the laboratory identifies an antibiotic that works. Hospitals now have clear systems for spotting these bacteria early, limiting their spread and choosing the right treatment. Recovery can take time, especially after a serious infection, so give yourself permission to rest and rebuild. If you have questions about your own situation, your doctor or specialist team is the best place to get answers — they know your full picture and can tell you what to expect.

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