Abstract
The emergence of carbapenem-resistant Enterobacterales (CRE) has become a major public health concern. Moreover, its colonization among residents of long-term care facilities (LTCFs) is associated with subsequent infections and mortality. To further explore the various aspects concerning CRE in LTCFs, we conducted a literature review on CRE colonization and/or infections in long-term care facilities. The prevalence and incidence of CRE acquisition among residents of LTCFs, especially in California, central Italy, Spain, Japan, and Taiwan, were determined. There was a significant predominance of CRE in LTCFs, especially in high-acuity LTCFs with mechanical ventilation, and thus may serve as outbreak centers. The prevalence rate of CRE in LTCFs was significantly higher than that in acute care settings and the community, which indicated that LTCFs are a vital reservoir for CRE. The detailed species and genomic analyses of CRE among LTCFs reported that Klebsiella pneumoniae is the primary species in the LTCFs in the United States, Spain, and Taiwan. KPC-2-containing K. pneumoniae strains with sequence type 258 is the most common sequence type of KPC-producing K. pneumoniae in the LTCFs in the United States. IMP-11- and IMP-6-producing CRE were commonly reported among LTCFs in Japan. OXA-48 was the predominant carbapenemase among LTCFs in Spain. Multiple risk factors associated with the increased risk for CRE acquisition in LTCFs were found, such as comorbidities, immunosuppressive status, dependent functional status, usage of gastrointestinal devices or indwelling catheters, mechanical ventilation, prior antibiotic exposures, and previous culture reports. A high CRE acquisition rate and prolonged CRE carriage duration after colonization were found among residents in LTCFs. Moreover, the patients from LTCFs who were colonized or infected with CRE had poor clinical outcomes, with a mortality rate of up to 75% in infected patients. Infection prevention and control measures to reduce CRE in LTCFs is important, and could possibly be controlled via active surveillance, contact precautions, cohort staffing, daily chlorhexidine bathing, healthcare-worker education, and hand-hygiene adherence.
Highlights
The emergence of antimicrobial resistance has become a major public health concern
Regarding the median cost of carbapenemresistant Enterobacterales (CRE) infections with an incidence of 2.93 per 100,000 persons in the United States, it would cost hospitals $275 million, third party payers $147 million, and the society $553 million (Bartsch et al, 2017), indicating a high economic burden caused by CRE infections
The environmental factors associated with a significant risk for CRE colonization or infection among residents of long-term care facilities (LTCFs) were usage of gastrointestinal devices (Cunha et al, 2016; Mckinnell et al, 2019), mechanical ventilation (Mills et al, 2016), the presence of indwelling devices, such as central venous catheters or urinary catheters, long-term acute care hospital (LTACs) facility subtype (Lin et al, 2013), high acuity facilities with mechanical ventilation, prolonged length of stay (Ben-David et al, 2011; Lin et al, 2013), and sharing a room with a known carrier (Chitnis et al, 2012)
Summary
The emergence of antimicrobial resistance has become a major public health concern. Since the identification of carbapenemresistant Enterobacterales (CRE) in the 1990s, CRE has spread worldwide during the past two decades (Centers for Disease Control and Prevention, 2013). A high prevalence of colonization by multi-drug resistant organisms (MDRO) among residents in long-term care facilities (LTCFs) was reported. Even though a low prevalence rate was noted, the high association of CRE colonization with LTCF was still noted from the hospital admission data in Spain, reporting that about 37% of cases were health-care associated, of which 42% were nursing home residents (Palacios-Baena et al, 2016). A previous systematic review of CRE in the United States between 2000 and 2016 reported higher infection rates in LTACs than in ACHs and community settings (Livorsi et al, 2018), and community-onset cases mostly had health care exposure within the previous 90 days (Brennan et al, 2014). The HARP-DC studies (one of the first study to measure the prevalence of CRE colonization in a region aligning with CDC’s recommendation of collaborative approach), highlighted that the CRE prevalence in Frontiers in Cellular and Infection Microbiology | www.frontiersin.org
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