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

RESULTS

DISCUSSIONCarbapenems 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.

METHODS

CONCLUSIONS

REFERENCES1. 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. 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.  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. 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. 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 .

FIGURES

• 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.

• 43.5% had two sites of infection with CRE.

• Infection sites included urine (19), blood (6), sputum (5), wounds (3), and gastrostomy tubes (1).

• 3/6 (50%) of bacteremic patients died.

• 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.

• 83% of patients with chronic indwelling urinary catheter presented with CRE in the urine. 

• 32/34 CRE cultures (93.7%) were identified as K. pneumoniae. 1 (4%) isolate was E. coli and 1 (4%) isolate was P. mirabilis.

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.

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.

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. • Patients in extended care facilities

are at risk for acquiring CRE.

• Use of contact precautions, hand hygiene, and other infection control measures may limit the spread of CRE.

• Screening for CRE should be considered in areas of high CRE endemicity.

• Development of new antimicrobial agents is needed.

• 85% 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.

Represents the location of our institution Represents the residence locations of CRE positive cases

AMPICILLIN/

SULBACTAM