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About 3 in every 100,000 individuals developed a carbapenem-resistant Enterobacteriaceae infection in 2012-2013, most of whom had previously been hospitalized or had an indwelling device, researchers reported Oct. 5 in JAMA.
The relatively low incidence of these serious infections compared with other resistant organisms “highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” wrote Dr. Alice Guh of the Centers for Disease Control and Prevention in Atlanta, and her associates. But the high rates of recent hospitalizations and discharges to nursing homes underscore the need for local control efforts, the researchers added.
Carbapenem-resistant Enterobacteriaceae have become a global public health problem since emerging in 2001. In 2012, the Emerging Infections Program of the CDC began active CRE surveillance in metropolitan areas of Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. The researchers studied reported cases of carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, and Klebsiella oxytoca infections cultured from urine or sterile sites (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12480.).
In all, 599 CRE infections occurred in 481 individuals, including 87% in urine and 11% in sterile sites, the investigators reported. Patients averaged 66 years of age and 59% were female. Overall CRE incidence was 2.93 cases per 100,000 population – substantially lower than rates of methicillin-resistant Staphylococcus aureus (about 25 per 100,000 population), invasive candidiasis (13-26 per 100,000 population), and Clostridium difficile (147 per 100,000 population).
Most of the CRE infections were among individuals who has been hospitalized in the past year (75%), who had an indwelling device (73%), or who had been discharged to a long-term care setting (56%). The indwelling devices with the highest rates of infection were urinary catheters, central venous catheters, and gastrostomy or jejunostomy tubes.
The case-fatality rate was 9% overall, but exceeded 27% when CRE was isolated from sterile sites, according to the study.
The standardized incidence ratio was significantly higher than predicted for sites in Georgia, Maryland, and New York, but significantly lower than expected for sites in Colorado, New Mexico, and Oregon. Such heterogeneity “further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States,” the researchers wrote.
And only 48% of CRE strains produced a carbapenemase, which carries antimicrobial resistance genes on mobile plasmids that can move between organisms, allowing for a potentially wider and more rapid spread. This suggests “the potential need for a tiered response to these organisms as well as the need for more rapid and readily available laboratory tests to differentiate these strains,” the researchers added.
The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The researchers reported having no financial disclosures.
Carbapenem-resistant Enterobacteriaceae (CRE) may be the most concerning contemporary antibiotic resistance threat. Enterobacteriaceae comprise a large group of bacteria, including Escherichia coli and Klebsiella pneumoniae, and are common causes of healthcare–associated and community-acquired infections. Carbapenems, such as imipenem, meropenem, ertapenem, and doripenem are among the broadest-spectrum and most potent beta-lactam antibiotics.
The study by Guh et al represents an important step forward for CRE control in the United States. Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts.
Whether the resources needed for this work will be made available is unclear. The 2014 presidential executive order on combating antibiotic resistance contained actions to strengthen national surveillance efforts for resistant bacteria, including the establishment of regional public health laboratories with advanced molecular diagnostic capabilities. These actions were not approved for funding in fiscal year 2015; however, an appropriation to support the initiative currently awaits congressional approval of the fiscal year 2016 federal budget. In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.
Dr. Mary K. Hayden is at Rush University Medical Center, Chicago. She reported having received grants from the Centers for Disease Control and Prevention, which funded this study. These comments were adapted from her accompanying editorial (JAMA 2015 Oct. 5, doi: 10.1001/jama.2015.11629.).
Carbapenem-resistant Enterobacteriaceae (CRE) may be the most concerning contemporary antibiotic resistance threat. Enterobacteriaceae comprise a large group of bacteria, including Escherichia coli and Klebsiella pneumoniae, and are common causes of healthcare–associated and community-acquired infections. Carbapenems, such as imipenem, meropenem, ertapenem, and doripenem are among the broadest-spectrum and most potent beta-lactam antibiotics.
The study by Guh et al represents an important step forward for CRE control in the United States. Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts.
Whether the resources needed for this work will be made available is unclear. The 2014 presidential executive order on combating antibiotic resistance contained actions to strengthen national surveillance efforts for resistant bacteria, including the establishment of regional public health laboratories with advanced molecular diagnostic capabilities. These actions were not approved for funding in fiscal year 2015; however, an appropriation to support the initiative currently awaits congressional approval of the fiscal year 2016 federal budget. In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.
Dr. Mary K. Hayden is at Rush University Medical Center, Chicago. She reported having received grants from the Centers for Disease Control and Prevention, which funded this study. These comments were adapted from her accompanying editorial (JAMA 2015 Oct. 5, doi: 10.1001/jama.2015.11629.).
Carbapenem-resistant Enterobacteriaceae (CRE) may be the most concerning contemporary antibiotic resistance threat. Enterobacteriaceae comprise a large group of bacteria, including Escherichia coli and Klebsiella pneumoniae, and are common causes of healthcare–associated and community-acquired infections. Carbapenems, such as imipenem, meropenem, ertapenem, and doripenem are among the broadest-spectrum and most potent beta-lactam antibiotics.
The study by Guh et al represents an important step forward for CRE control in the United States. Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts.
Whether the resources needed for this work will be made available is unclear. The 2014 presidential executive order on combating antibiotic resistance contained actions to strengthen national surveillance efforts for resistant bacteria, including the establishment of regional public health laboratories with advanced molecular diagnostic capabilities. These actions were not approved for funding in fiscal year 2015; however, an appropriation to support the initiative currently awaits congressional approval of the fiscal year 2016 federal budget. In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.
Dr. Mary K. Hayden is at Rush University Medical Center, Chicago. She reported having received grants from the Centers for Disease Control and Prevention, which funded this study. These comments were adapted from her accompanying editorial (JAMA 2015 Oct. 5, doi: 10.1001/jama.2015.11629.).
About 3 in every 100,000 individuals developed a carbapenem-resistant Enterobacteriaceae infection in 2012-2013, most of whom had previously been hospitalized or had an indwelling device, researchers reported Oct. 5 in JAMA.
The relatively low incidence of these serious infections compared with other resistant organisms “highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” wrote Dr. Alice Guh of the Centers for Disease Control and Prevention in Atlanta, and her associates. But the high rates of recent hospitalizations and discharges to nursing homes underscore the need for local control efforts, the researchers added.
Carbapenem-resistant Enterobacteriaceae have become a global public health problem since emerging in 2001. In 2012, the Emerging Infections Program of the CDC began active CRE surveillance in metropolitan areas of Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. The researchers studied reported cases of carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, and Klebsiella oxytoca infections cultured from urine or sterile sites (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12480.).
In all, 599 CRE infections occurred in 481 individuals, including 87% in urine and 11% in sterile sites, the investigators reported. Patients averaged 66 years of age and 59% were female. Overall CRE incidence was 2.93 cases per 100,000 population – substantially lower than rates of methicillin-resistant Staphylococcus aureus (about 25 per 100,000 population), invasive candidiasis (13-26 per 100,000 population), and Clostridium difficile (147 per 100,000 population).
Most of the CRE infections were among individuals who has been hospitalized in the past year (75%), who had an indwelling device (73%), or who had been discharged to a long-term care setting (56%). The indwelling devices with the highest rates of infection were urinary catheters, central venous catheters, and gastrostomy or jejunostomy tubes.
The case-fatality rate was 9% overall, but exceeded 27% when CRE was isolated from sterile sites, according to the study.
The standardized incidence ratio was significantly higher than predicted for sites in Georgia, Maryland, and New York, but significantly lower than expected for sites in Colorado, New Mexico, and Oregon. Such heterogeneity “further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States,” the researchers wrote.
And only 48% of CRE strains produced a carbapenemase, which carries antimicrobial resistance genes on mobile plasmids that can move between organisms, allowing for a potentially wider and more rapid spread. This suggests “the potential need for a tiered response to these organisms as well as the need for more rapid and readily available laboratory tests to differentiate these strains,” the researchers added.
The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The researchers reported having no financial disclosures.
About 3 in every 100,000 individuals developed a carbapenem-resistant Enterobacteriaceae infection in 2012-2013, most of whom had previously been hospitalized or had an indwelling device, researchers reported Oct. 5 in JAMA.
The relatively low incidence of these serious infections compared with other resistant organisms “highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” wrote Dr. Alice Guh of the Centers for Disease Control and Prevention in Atlanta, and her associates. But the high rates of recent hospitalizations and discharges to nursing homes underscore the need for local control efforts, the researchers added.
Carbapenem-resistant Enterobacteriaceae have become a global public health problem since emerging in 2001. In 2012, the Emerging Infections Program of the CDC began active CRE surveillance in metropolitan areas of Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. The researchers studied reported cases of carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, and Klebsiella oxytoca infections cultured from urine or sterile sites (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12480.).
In all, 599 CRE infections occurred in 481 individuals, including 87% in urine and 11% in sterile sites, the investigators reported. Patients averaged 66 years of age and 59% were female. Overall CRE incidence was 2.93 cases per 100,000 population – substantially lower than rates of methicillin-resistant Staphylococcus aureus (about 25 per 100,000 population), invasive candidiasis (13-26 per 100,000 population), and Clostridium difficile (147 per 100,000 population).
Most of the CRE infections were among individuals who has been hospitalized in the past year (75%), who had an indwelling device (73%), or who had been discharged to a long-term care setting (56%). The indwelling devices with the highest rates of infection were urinary catheters, central venous catheters, and gastrostomy or jejunostomy tubes.
The case-fatality rate was 9% overall, but exceeded 27% when CRE was isolated from sterile sites, according to the study.
The standardized incidence ratio was significantly higher than predicted for sites in Georgia, Maryland, and New York, but significantly lower than expected for sites in Colorado, New Mexico, and Oregon. Such heterogeneity “further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States,” the researchers wrote.
And only 48% of CRE strains produced a carbapenemase, which carries antimicrobial resistance genes on mobile plasmids that can move between organisms, allowing for a potentially wider and more rapid spread. This suggests “the potential need for a tiered response to these organisms as well as the need for more rapid and readily available laboratory tests to differentiate these strains,” the researchers added.
The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The researchers reported having no financial disclosures.
FROM JAMA
Key clinical point: Carbapenem-resistant Enterobacteriaceae infections developed in about 3 in every 100,000 individuals, most often in association with recent hospitalization or indwelling devices.
Major finding: The incidence of CRE was 2.93 per 100,000 population, 75% of patients had been hospitalized in the past year, and 73% had an indwelling device.
Data source: Analysis of active surveillance data for 2012-2013 from metropolitan areas in seven states reported through the CDC Emerging Infections Program.
Disclosures: The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The investigators reported having no financial disclosures.
