Skip to main content Accessibility help
×
×
Home

Rising Rates of Carbapenem-Resistant Enterobacteriaceae in Community Hospitals: A Mixed-Methods Review of Epidemiology and Microbiology Practices in a Network of Community Hospitals in the Southeastern United States

  • Joshua T. Thaden (a1), Sarah S. Lewis (a1) (a2), Kevin C. Hazen (a3), Kirk Huslage (a4), Vance G. Fowler (a1), Rebekah W. Moehring (a1) (a2) (a5), Luke F. Chen (a1) (a2), Constance D. Jones (a6), Zack S. Moore (a6), Daniel J. Sexton (a1) (a2) and Deverick J. Anderson (a1) (a2)...

Extract

(See the commentary by Pfeiffer and Beldavs, on pages  984–986.)

Objective

Describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) and examine the effect of lower carbapenem breakpoints on CRE detection.

Design

Retrospective cohort.

Setting

Inpatient care at community hospitals.

Patients

All patients with CRE-positive cultures were included.

Methods

CRE isolated from 25 community hospitals were prospectively entered into a centralized database from January 2008 through December 2012. Microbiology laboratory practices were assessed using questionnaires.

Results

A total of 305 CRE isolates were detected at 16 hospitals (64%). Patients with CRE had symptomatic infection in 180 cases (59%) and asymptomatic colonization in the remainder (125 cases; 41%). Klebsiella pneumoniae (277 isolates; 91%) was the most prevalent species. The majority of cases were healthcare associated (288 cases; 94%). The rate of CRE detection increased more than fivefold from 2008 (0.26 cases per 100,000 patient-days) to 2012 (1.4 cases per 100,000 patient-days; incidence rate ratio (IRR), 5.3 [95% confidence interval (CI), 1.22–22.7]; P = .01). Only 5 hospitals (20%) had adopted the 2010 Clinical and Laboratory Standards Institute (CLSI) carbapenem breakpoints. The 5 hospitals that adopted the lower carbapenem breakpoints were more likely to detect CRE after implementation of breakpoints than before (4.1 vs 0.5 cases per 100,000 patient-days; P < .001; IRR, 8.1 [95% CI, 2.7–24.6]). Hospitals that implemented the lower carbapenem breakpoints were more likely to detect CRE than were hospitals that did not (3.3 vs 1.1 cases per 100,000 patient-days; P = .01).

Conclusions

The rate of CRE detection increased fivefold in community hospitals in the southeastern United States from 2008 to 2012. Despite this, our estimates are likely underestimates of the true rate of CRE detection, given the low adoption of the carbapenem breakpoints recommended in the 2010 CLSI guidelines.

Copyright

Corresponding author

Clinical Fellow in Division of Infectious Diseases, Duke University Medical Center, 315 Trent Drive, Durham, NC 27710 (joshua.thaden@duke.edu).

References

Hide All
1. Nordmann, P, Naas, T, Poirel, L. Global spread of carbapenemase-producing Enterobacteriaceae. Emerg Infect Dis 2011;17(10):17911798.
2. Ben-David, D, Kordevani, R, Keller, N, et al. Outcome of carbapenem resistant Klebsiella pneumoniae bloodstream infections. Clin Microbiol Infect 2012;18(1):5460.
3. Borer, A, Saidel-Odes, L, Riesenberg, K, et al. Attributable mortality rate for carbapenem-resistant Klebsiella pneumoniae bacteremia. Infect Control Hosp Epidemiol 2009;30(10):972976.
4. Daikos, GL, Petrikkos, P, Psichogiou, M, et al. Prospective observational study of the impact of VIM-1 metallo-beta-lactamase on the outcome of patients with Klebsiella pneumoniae bloodstream infections. Antimicrob Agents Chemother 2009;53(5):18681873.
5. Patel, G, Huprikar, S, Factor, SH, Jenkins, SG, Calfee, DP. Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol 2008;29(12):10991106.
6. Centers for Disease Control and Prevention. 2012 CRE toolkit: guidance for control of carbapenem-resistant Enterobacteriaceae. http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html. Published 2012. Accessed November 2, 2013.
7. Wise, R. The urgent need for new antibacterial agents. J Antimicrob Chemother 2011;66(9):19391940.
8. Gupta, N, Limbago, BM, Patel, JB, Kallen, AJ. Carbapenem-resistant Enterobacteriaceae: epidemiology and prevention. Clin Infect Dis 2011;53(1):6067.
9. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). http://www.ahrq.gov/research/data/hcup/index.html. Published 2013. Accessed October 13, 2013.
10. Anderson, KF, Lonsway, DR, Rasheed, JK, et al. Evaluation of methods to identify the Klebsiella pneumoniae carbapenemase in Enterobacteriaceae. J Clin Microbiol 2007;45(8):27232725.
11. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing: Twentieth Informational Supplement. Wayne, PA: CLSI, 2010. CLSI document M100-S20.
12. Anderson, DJ, Miller, BA, Chen, LF, et al. The network approach for prevention of healthcare-associated infections: long-term effect of participation in the Duke Infection Control Outreach Network. Infect Control Hosp Epidemiol 2011;32(4):315322.
13. Freeman, JT, Sexton, DJ, Anderson, DJ. Emergence of extended-spectrum β-lactamase-producing Escherichia coli in community hospitals throughout North Carolina: a harbinger of a wider problem in the United States? Clin Infect Dis 2009;49(2):e30e32.
14. Lin, MY, Lyles-Banks, RD, Lolans, K, et al. The importance of long-term acute care hospitals in the regional epidemiology of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis 2013;57(9):12461252.
15. Woodford, N, Eastaway, AT, Ford, M, et al. Comparison of BD Phoenix, Vitek 2, and MicroScan automated systems for detection and inference of mechanisms responsible for carbapenem resistance in Enterobacteriaceae. J Clin Microbiol 2010;48(8):29993002.
16. Lewis, SS, Moehring, RW, Chen, LF, Sexton, DJ, Anderson, DJ. Defining multidrug resistance (MDR) for gram-negative (GN) infections: who gets the gown? In: Program and abstracts of IDWeek 2013. San Francisco, CA: IDWeek, 2013. Abstract 40634.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed