Background: Infections with carbapenem-resistant Enterobacteriaceae  (CRE) are increasingly being reported from patients in healthcare  settings. They are associated with high patient morbidity, attributable  mortality and hospital costs. Patients who are "at-risk" may be carriers  of these multidrug-resistant Enterobacteriaceae (MDR-E).The  purpose of this guidance is to raise awareness and identify the  "at-risk" patient when admitted to a healthcare setting and to outline  effective infection prevention and control measures to halt the entry  and spread of CRE.

Methods: The guidance was created by a group of experts who were  functioning independently of their organisations, during two meetings  hosted by the European Centre for Disease Prevention and Control. A list  of epidemiological risk factors placing patients "at-risk" for carriage  with CRE was created by the experts. The conclusions of a systematic  review on the prevention of spread of CRE, with the addition of expert  opinion, were used to construct lists of core and supplemental infection  prevention and control measures to be implemented for "at-risk"  patients upon admission to healthcare settings.

Results: Individuals with the following profile are "at-risk" for carriage  of CRE: a) a history of an overnight stay in a healthcare setting in the  last 12 months, b) dialysis-dependent or cancer chemotherapy in the  last 12 months, c) known previous carriage of CRE in the last 12 months  and d) epidemiological linkage to a known carrier of a CRE.Core  infection prevention and control measures that should be considered for  all patients in healthcare settings were compiled. Preliminary  supplemental measures to be implemented for "at-risk" patients on  admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures.

Conclusions: Strengthening the microbiological capacity, surveillance and  reporting of new cases of CRE in healthcare settings and countries is  necessary to monitor the epidemiological situation so that, if  necessary, the implemented CRE prevention strategies can be refined in a  timely manner. Creating a large communication network to exchange this  information would be helpful to understand the extent of the CRE  reservoir and to prevent infections in healthcare settings, by applying  the principles outlined here.This guidance document offers suggestions  for best practices, but is in no way prescriptive for all healthcare  settings and all countries. Successful implementation will result if  there is local commitment and accountability. The options for  intervention can be adopted or adapted to local needs, depending on the  availability of financial and structural resources.

Keywords: AMR; Active screening; Antimicrobial resistance; CRE;  Carbapenem-resistant Enterobacteriaceae; Core measures;  Healthcare-associated infections; MDR-E; Multidrug-resistant  Enterobacteriaceae; Supplemental measures.