Pathogen-Specific Hygiene Measures

Hygiene measures in the event of ESBL/CRE


The increasing prevalence of gram-negative Enterobacteriaceae being resistant to antibiotics poses new challenges to healthcare facilities around the globe. Enterobacteriaceae that are able to form enzymes with extended beta-lactamase spectrum – also referred to as – extended-spectrum beta-lactamases – or ESBL-producing organisms – are most relevant here. ESBL can additionally result in an extended resistance to third-generation cephalosporins. Hence, it is also called cephalosporin-resistant Enterobacteriaceae (CRE).

In Germany, the incidence of ESBL-associated infections on intensive care units has tripled between 2006 and 2010. 34 per cent of these infections have been acquired in hospitals and probably could have been prevented by good infection control measures1.

In case of ESBL, experts2 recommend a differentiated, risk-related hygiene management.
Grading criteria are:

  • Resistance pattern.
    To which antibiotics is the respective germ resistant and what are the remaining treatment options?
  • Risks for fellow patients or co-residents.
    The hygiene regime should be stricter, the more the fellow patients are vulnerable to infections.

These criteria determine if it is sufficient to carry out basic hygiene or if additional measures such as barrier nursing and isolation precautions need to be taken.

ESBL/CRE hygiene management dependent on antibiotic resistance

ESBL/CRE hygiene management dependent on antibiotic resistance
Source: von Baum et al., HygMed 2010 / *both rectal and from all previously positive colonisation areas

Stepwise approach of ESBL/CRE hygiene management:

Standard precautions

  • hand disinfection following the "5 Moments"
  • single-use gloves when having contact with colonised body areas, secretions, fluids, etc.
  • disposable gown when contamination is expected (change of dressing, washing, etc.)
  • face mask when exposure to infectious aerosol is expected (suction)
  • continuous surface disinfection and cleaning of surfaces near patients, targeted disinfection in case of contamination, and final disinfection after discharge/transfer

Standard precautions + barrier precautions

  • In addition to basic hygiene, the following measures have to be carried out:
  • prior to any therapeutic contact: long-sleeved protective gown and single-use gloves
  • additional disposable gown impermeable to liquids when it has to be expected that clothes are drenched

Standard precautions + barrier precautions + isolation

In addition to standard hygiene and barrier nursing, patients need to be isolated.

  • isolation in single rooms
  • isolation in cohorts is possible when patients share the same CRE species with the same resistance pattern


1 Leistner R. et al.
Secular trends in ESBL, MRSA and VRE incidence in German intensive care units.
From International Conference on Prevention & Infection Control (ICPIC 2011)
Geneva, Switzerland. 29 June – 2 July 2011.
BMC Proceedings 2011, 5(Suppl 6):O4.

Please click here to download the article.

2 von Baum H, Dettenkofer M, Heeg P, Schröppel K, Wendt C.
Konsensusempfehlung Baden-Württemberg: Umgang mit Patienten mit hochresistenten Enterobakterien inklusive ESBL-Bildnern.
HygMed 2010; 35: 40-45.

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