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CARBAPENEM RESISTANT ENTEROBACTERIACEAE:
RISK FACTORS AND ROLE OF EXTENDED CARE FACILITIES
A. Makarem, MD; P. Alvarez, MD; T. Chou, MPH, CIC; M. Kulkarni, MD; J. Kerridge, MA, RN, CIC; K.Wickman, MS, RN; M. Costello, PhD; J. Malow, MD, FIDSA
BACKGROUND
METHODS
Carbapenems are the treatment of choice for
multidrug
resistant
Enterobacteriaceae.
However, there have been multiple reports of
carbapenem resistant Enterobacteriaceae (CRE),
and their prevalence has increased since they
were first described in 2001.
CRE are resistant to almost all available
antimicrobial agents. Infections with CRE have
been associated with high rates of morbidity and
mortality, even when treated appropriately,
particularly among individuals with prolonged
hospitalization and those who are critically ill
and exposed to invasive devices.
Outbreaks have been reported in many
countries, predominately Asia and South
America. In the U.S., CRE were first reported in
North Carolina, with the first reported
healthcare-related outbreak in New York. Since
then, CRE have been reported in at least 32
states.
FIGURES
The study population included adults who were
hospitalized in our institution (level 1 trauma
community-teaching hospital with 551 licensed
beds, 2 adult intensive care units and a
neonatal intensive care unit) from July 2008
through September 2010 and had positive
cultures for CRE.
DISCUSSION
RESIDENCE OF PATIENTS WITH
CRE POSITIVE CULTURES
27%
58%
CRE detection: all Enterobacteriaceae with MIC
>1mcg/ml for any carbapenem and resistance to
any 3rd generation cephalosporin are
considered screen positive. These are confirmed
as CRE by modified Hodge test and Etest.
11%
4%
Patient records were reviewed for the
following: type and location of residence,
presence of indwelling devices (urinary
catheter, central line, tracheostomy, and
gastrostomy tubes), recent antibiotic exposure,
signs and symptoms of infection, sites of
positive cultures, co-morbidities, and mortality.
NURSING HOME
LONG TERM ACUTE CARE FACILITY
PRIVATE RESIDENCE
REHABILITATION INSTITUTION
ANTIBIOTIC SUSCEPTIBILITIES
OF CRE ISOLATES
100%
RESULTS
• There were a total of 26 patients with 34 CRE
positive cultures in our institution during the
study period.
• 23/26 (88.5%) were infected, only 3 (11.5%)
were colonized.
• Only one patient had previous carbapenem
exposure.
• 3/6 (50%) of bacteremic patients died.
CONCLUSIONS
60%
• Patients in extended care facilities are at risk
for acquiring CRE.
40%
• Use of contact precautions, hand hygiene,
and other infection control measures may limit
the spread of CRE.
20%
0%
• Screening for CRE should be considered in
areas of high CRE endemicity.
SUSCEPTIBLE
INTERMEDIATE
NOT TESTED
RESISTANT
CRE POSITIVE CULTURE SITES
• 88.5% had at least one type of chronic
indwelling supportive device (urinary catheter,
central line, tracheostomy , gastrostomy tube).
• 92% had at least one chronic co-morbidity.
• Development of new antimicrobial agents is
needed.
REFERENCES
1. Bratu S, Landman D, Haag R, et al. Rapid spread of carbapenem-resistant K. pneumoniae in New York City. Arch Intern
Med 2005; 165:1430-1435.
2. Aubron C. Poirel L, Ash RJ, et al. Carbapenemase-producing Enterobacteriaceae, U.S. rivers. Emerg Infect Dis 2005; 11:
260-264.
17%
3. Tenover FC, Kalsi RK, Williams PP, Carey RB, et al. Carbapenem resistance in Klebsiella pneumoniae not detected by
automated susceptibility testing. Emerg Infect Dis 2006 Aug; 12(8):1209-1213.
4. Schwaber MJ, Carmeli Y. Carbapenem-resistant Enterobacteriaceae: A potential threat. JAMA 2008; 300:2911-2913.
56%
15%
• 83% of patients with chronic indwelling urinary
catheter presented with CRE in the urine.
5. Kelesidis T, Karageorgopoulos DE, Kelesidis I, Falagas ME. Tigecycline for the treatment of multidrug-resistant
Enterobacteriaceae: a systematic review of the evidence from microbiological and clinical studies. J Antimicrob Chemother
2008; 62:895-904 .
6. CDC. Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in
acute care facilities. MMWR 2009;58:256--260.
9%
7. Dwivedi M., Mishra A, Azim A, Singh RK, Baronia AK, Prasad KN, Dhole TN, Dwivedi UN. Ventilator-associated
pneumonia caused by carbapenem-resistant Enterobacteriaceae carrying multiple metallo-beta-lactamase genes. Indian J
Pathol Microbiol 2009 Jul-Sep; 52(3): 339-342.
3%
• 32/34 CRE cultures (93.7%) were identified as
K. pneumoniae. 1 (4%) isolate was E. coli and 1
(4%) isolate was P. mirabilis.
Represents the location of our institution
Represents the residence locations of CRE positive cases
patients with CRE resided in an
extended care facilities (ECF) prior to
admission.
• CRE were found in ECF throughout the
Chicago metropolitan area, not just those near
the hospital.
• With a mortality rate of 50%, CRE
bacteremia poses a serious challenge unless
appropriately addressed.
• All CRE isolates were multidrug-resistant,
limiting therapeutic options.
• Since only one patient had previous exposure
to a carbapenem, horizontal transmission
appears to have an important role in the
emergence of CRE infections.
• Chronic illnesses and indwelling devices
appear to increase the risk of acquiring CRE
infections.
• A larger sample size is needed for a more
accurate assessment.
80%
• 43.5% had two sites of infection with CRE.
• Infection sites included urine (19), blood (6),
sputum (5), wounds (3), and gastrostomy tubes
(1).
• 85%
8. Ben-David D, Maor Y, Keller N, Regev-Yochay G, Tal I, Shachar D, Zlotkin A, Smollan G, Rahav G. Potential role of active
surveillance in the control of a hospital-wide outbreak of carbapenem-resistant Klebsiella pneumoniae infection. Infect
Control Hosp Epidemiol 2010; 31:620-626.
9. Zarkotou O, Pournaras S, Voulgari E, et al. Risk factors and outcomes associated with acquisition of colistin-resistant
KPC-producing Klebsiella pneumoniae: a matched case-control study. J Clin Microbiol 2010; 48:2271-2274 .
URINE
BLOOD
SPUTUM
WOUND
PEG TUBE