Development of a multimodal strategy to decrease and/or limit the dissemination of carbapenem-resistant Enterobacterales in public health institutions in Colombia — LIMCRE
Antimicrobial resistance (AMR) is a growing threat to health systems globally and nationally. In Colombia, the spread of carbapenem-resistant Enterobacterales (CRE) —especially in hospital settings— has become a critical public health problem. This situation worsened after the COVID-19 pandemic, with an increase in CRE frequency and the coexistence of multiple resistance genes (blaKPC, blaNDM, blaVIM).
Despite regulatory advances, such as the National AMR Response Plan, significant challenges remain in the effective implementation of Infection Prevention and Control (IPC) programs, especially in public hospitals.
Due to the high clinical complexity and care burden, Intensive Care Units (ICUs), are environments especially prone to CRE outbreaks. This project responds to the urgent need to implement, evaluate, and adapt sustainable, evidence-based IPC strategies to reduce the spread of CRE in high-complexity public health institutions in Colombia.
Problem Statement
Main objective
Decrease and/or limit the dissemination of CRE in high-complexity public healthcare institutions in Colombia by implementing an Infection Prevention and Control (IPC) bundle program at their ICUs.
Specific objectives:
Establish a baseline and trend of the incidence of colonization and/or infection by CRE in ICU patients during the study period.
Design and assess the implementation of an IPC bundle program (IPC bundle SOPs, education and training, CRE detection and monitoring, monitoring and feedback).
Identify and develop behavior change strategies among healthcare workers and ICU staff related to hand hygiene, use of PPE, patient hygiene, contact isolation, and cleaning/disinfection of the hospital environment.
Identify existing barriers and facilitators for the implementation of IPC programs in ICUs of high-complexity public healthcare institutions in Colombia.
Evaluate the cost-effectiveness of implementing the IPC program to decrease and/or limit CRE spread.
Provide evidence for the development and expansion of national policies related to reducing and/or limiting CRE.
Our Theory of Change
This project begins from the premise that reducing CRE in public hospitals requires a strategy adapted to the institutional context and centered on behavior change. Effective implementation of IPC measures does not depend solely on the existence of protocols, but on their adoption by staff, resource availability, institutional leadership, and data-driven feedback.
Our model combines practical training, active monitoring, Standard Operating Procedures (SOPs) adapted to each hospital, CRE screening, understanding of the situation through qualitative methods, and an economic evaluation. This will enable measurable and sustainable change in infection prevention and control practices, with direct impact on reducing CRE and strengthening health system capacity.
Additionally, we expect that our results will create a base for the Ministry of Health and Social Protection to create the national policy for containing the spread of CRE in Colombia.
Project Structure
The project is organized into three integrated work packages that combine quantitative, qualitative, and economic approaches to evaluate the impact of the intervention from multiple dimensions.
Work Packages(WP)
WP1 – Quality improvement methodology implementation
This component applies a quasi-experimental design in five public hospitals with ICUs, structured in three phases: baseline, intervention, and post-intervention evaluation. It uses the PDSA (Plan–Do–Study–Act) quality-improvement methodology, which allows introducing changes, measuring their effect, and adapting them to the institutional context.
The interventions include:
Implementation of IPC bundles adapted per hospital.
In-person and online training for clinical and operational staff.
Provision of key supplies (PPE, luminometers, screening materials).
Monthly monitoring and structured feedback with local teams.
Indicators such as CRE incidence, adherence to IPC protocols, quality of hospital cleaning, and resource utilization will be evaluated.
WP2 – Qualitative implementation research
An interpretative approach will be used to understand participants' experiences and perceptions. Through semi-structured interviews and focus groups before, during, and after the intervention:
Barriers, facilitators, and contextual factors influencing adoption of IPC measures will be identified, along with behavioral diagnosis and understanding of the complexity of implementing IPC programs in Colombia and their sustainability. Included participants will be ICU health professionals, cleaning staff, public-policy decision-makers, and hospital managers. Data will be analyzed using thematic analysis to identify patterns and divergences. This study will be important to adapt the WP1 intervention and make it sustainable.
This component analyzes the cost-effectiveness, clinical cost savings, and return on investment (ROI) of the IPC program. Implementation costs are compared with costs avoided due to reduced CRE, including hospitalization, antimicrobial use, and prolonged stays.
The methods include:
Cost-effectiveness analysis (ICER).
Cost-benefit analysis (NPV and ROI).
Modelled scenarios for sustainability and scalability.
This analysis will generate evidence to guide institutional and public-policy decisions on investing in infection control strategies.
WP3 – Economic Evaluation
Reduction in the incidence of CRE colonization and infection in ICUs.
Increased institutional adherence to key IPC measures.
Generation of technical and economic evidence for public policies.
Expected Impact