Carbapenem-resistant Enterobacteriaceae Screening Research Articles

Mortality Risk and the Clinical Outcome of Carbapenem-Resistant Enterobacteriaceae Carriers with Neutropenia: A Matched Case-Control Study

Patients with hematologic diseases are often accompanied by immunodeficiency, treatments as well as the disease itself can lead to granulocyte deficiency. Patients with granulocyte deficiency are under the high risk of infection. In recent years, the rate of Carbapenem-resistant Enterobacteriaceae (CRE) infection has gradually increased. Treatment options of CRE infection is limited, and effective anti-infection treatment is usually delayed, leading to the death of patients due to infection. CRE screening can provide clinical evidence for early detection of CRE by clinicians, thereby formulating antimicrobial treatment strategies. However, whether the initial empirical treatment covering CRE can improve the adverse outcomes of patients still lacks a definitive conclusion. We collected clinical data on patients with neutropenia who also undergoing CRE screening between January 2017 and December 2022. To further analyze the impact of CRE positivity on patient mortality risk and the clinical effectiveness of initial empirical treatment for CRE, we conducted two case-cohort studies with clinical baseline data matching. In total, we performed 3529 fecal CRE screenings from 664 patients. Out of these, 345 screenings from 135 patients tested positive for CRE. We identified 16 different strains, with the most common being Klebsiella pneumoniae (184/345), followed by Escherichia coli (76/345). To determine the influence of CRE positivity on patient mortality rates, we conducted a 1:2 case matching based on age, gender, diagnosis, and medical history of CRE-positive patients (Table 1). The results showed that in the overall analysis, CRE positivity, age over 60, and male gender were adverse factors influencing mortality. However, in the subgroup analysis of CRE-positive patients, no adverse factors affecting mortality were observed. To further assess the impact of CRE positivity on patient infection outcomes, we defined the initial antibiotic treatment strategies for a total of 4,872 infection events in screened patients. We divided them into the following groups: the empirical treatment group without CRE results (n=3,954), the empirical treatment group not covering CRE (n=122), and the CRE based empirical treatment group (n=796). The CRE based empirical treatment group had a higher success rate in initial empirical treatment compared to the group without covering CRE (65.5% vs. 59.0%). To further investigate the differences in initial empirical treatment success rates and 30-day mortality rates between patients in the CRE-based empirical treatment group and empirical treatment group without CRE covering, we performed 1:2 case matching for clinical baseline data on age, sex, diagnosis, past history, and disease status at infection according to the clinical characteristics of the CRE-based anti-infection treatment group. The results indicated that there were no significant differences in initial empirical treatment success rate and 30-day mortality rate between the CRE-based empirical treatment group and case-matched controls. In conclusion, diagnosing and treating patients with CRE infection presents significant challenges. Early screening for CRE and empirical treatment targeting CRE can increase the success rate of initial empirical treatment in CRE-positive patients.

Importance of carbapenem-resistant Enterobacteriaceae screening to prevent transmission within an acute-care hospital

Background: Carbapenem-resistant Enterobacteriaceae (CRE) present a serious public health risk because they are transmissible within the acute-care hospital setting, and they are associated with significant morbidity and mortality. Timely identification of CRE among hospitalized patients is essential to ensure that appropriate infection prevention measures are enforced to prevent transmission events. In 2022, 9 index CRE cases (5 Klebsiella pneumoniae carbapenemase (KPC)–producing and 4 New Delhi Metallo-β-lactamase (NDM)–producing cases) were identified within the University of Colorado Hospital (UCH) inpatient population. In response to index case identification, tracing was performed to identify patients with an epidemiologic link for targeted CRE screening to detect asymptomatic CRE carriage. Methods: In total, 645 patients were screened allowing for timely identification of CRE colonization within 6 patients (3-KPC; 1-OXA-48; 1-NDM; 1-KPC/OXA-48). Secondary case identification elicited additional evaluation of service team and mobile-device crossover between positive patients, as well as primary and ancillary treatment locations. Results: Investigations revealed 3 possible transmission events in 0.47% of the total screened population. Identification of secondary CRE cases prompted additional testing of exposed patients performed at 7-day intervals to capture a 21-day colonization period. In total, 95 additional patients were screened for CRE during secondary and tertiary CRE screening events. Discussion: Nursing staff collaboration and engagement were critical to achieving a high rate of compliance with CRE screening activities, not only collecting screening specimens but also providing explanation and reassurance to patients. Due to this partnership and diligence, UCH was able to achieve 77% compliance with initial CRE screening events. Secondary and tertiary CRE screening revealed testing compliance of 83% and 69%, respectively. To further reduce the risk of CRE transmission within hospitalized patients, UCH has implemented an enhanced cleaning process for high-risk patient rooms, which includes patients infected or asymptomatically colonized with CRE. This enhanced process is prompted based on CRE or infection status as documented in the electronic medical record (EMR), and it initiates a mandatory 2-phase cleaning process. Future plans include environmental testing audits to validate room decontamination and leveraging the EMR to capture pertinent healthcare and travel histories. Active engagement with public health partners will be pursued to enable molecular testing of high-risk touch points. Conclusions: Patient screening, enhanced decontamination, and monitoring activities are key elements to effectively prevent the spread of CRE within vulnerable patient populations and must be continuously evaluated for improvement opportunities.Disclosures: None

Epidemiological characteristics of New Delhi Metallo-β-Lactamase-producing Enterobacteriaceae in the Fourth hospital of Hebei Medical University

The epidemiological characteristics of New Delhi Metallo-β-Lactamase-Producing (NDM) Enterobacteriaceae were analyzed to provide theoretical support for clarifying the distribution characteristics of carbapenem-resistant Enterobacteriaceae (CRE) in the hospital environment and early identification of susceptible patients. From January 2017 to December 2021,42 strains of NDM-producing Enterobacteriaceae were gathered from the Fourth Hospital of Hebei Medical University, primarily Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae. The micro broth dilution method combined with the Kirby-Bauer method was used to determine the minimal inhibitory concentrations (MICs) of antibiotics. The carbapenem phenotype was detected by the modified carbapenem inactivation method (mCIM) and EDTA carbapenem inactivation method (eCIM). Carbapenem genotypes were detected by colloidal gold immunochromatography and real-time fluorescence PCR. The results of antimicrobial susceptibility testing showed that all NDM-producing Enterobacteriaceae were multiple antibiotic resistant, but the sensitivity rate to amikacin was high. Invasive surgery prior to culture, the use of excessive amounts of different antibiotics, the use of glucocorticoids, and ICU hospitalization were clinical characteristics of NDM-producing Enterobacteriaceae infection. Molecular typing of NDM-producing Escherichia coli and Klebsiella pneumoniae was carried out by Multilocus Sequence Typing (MLST), and the phylogenetic trees were constructed. Eight sequence types (STs) and two NDM variants were detected in 11 strains of Klebsiella pneumoniae, primarily ST17, and NDM-1. A total of 8 STs and 4 NDM variants were detected in 16 strains of Escherichia coli, mainly ST410, ST167, and NDM-5. For high-risk patients who have CRE infection, CRE screening should be done as soon as feasible to adopt prompt and efficient intervention measures to prevent outbreaks in the hospital.

Intestinal Colonization with Carbapenem-Resistant Enterobacteriaceae in Acute Leukemia Patients: Risk Factors and Molecular Characteristics.

BackgroundCarbapenem-resistant Enterobacteriaceae (CRE) colonization is associated with bacterial translocation, which can result in subsequent endogenous CRE infection. In the present study, we aim to investigate the colonization-related risk factors and molecular epidemiological characteristics of CRE in patients with acute leukemia.MethodsFrom January 2021 to December 2021, acute leukemia patients were screened for CRE by fecal/perianal swabs. We identified the species, carbapenemase-encoding genes, and virulence genes of the colonizing strains and performed antimicrobial susceptibility tests and ERIC-PCR typing. Risk factors for CRE colonization were identified by univariate and multivariate analysis.ResultsWe collected a total of 21 colonizing strains from 320 patients. All strains were resistant to meropenem. Klebsiella pneumoniae was the most abundant species, and ERIC-PCR typing showed low diversity. Univariate analysis showed that age, cephalosporins, penicillins, tigecyclines, and hematopoietic stem cell transplantation status were risk factors for CRE colonization; simultaneously discovered CRE strains played a dominant role in invasive infection of colonized patients. Logistic multivariate regression analysis showed that age, cephalosporins, and tigecyclines were independent risk factors for CRE intestinal colonization.ConclusionCRE colonization can increase the incidence of CRE infection in patients with acute leukemia. Early detection of CRE colonization through CRE screening is an important measure to control the spread of CRE.

An analysis of risk factors for carbapenem-resistant Enterobacteriaceae infection

This study aims to explore the high-risk factors of carbapenem-resistant Enterobacteriaceae (CRE) infection of hospitalised patients in high-risk departments. This study is a multicentre, retrospective study. CRE screening positive patients from 1 January 2016 to 31 December 2018 of high-risk departments in five tertiary first-class teaching hospitals in Beijing collect the patients' CRE test specimen information, CRE infection information and outcomes. The patients were divided into a colonisation group and an infection group for comparative analysis. A logistic regression model was established to explore the risk factors of CRE infection. Subgroup analysis was conducted according to invasive procedures and the type of the infection. In total, 344 patients were included in this study, including 85 (24.71%) colonisation and 259 (75.29%) infection; 36.09% CRE colonisation converted to infection, and the mean conversion time from colonisation to infection was 6.5 (4.0, 18.8) days. Renal disease, granulocytosis, invasive procedures and the time from hospital stay to positive CRE were the risk factors for CRE infection. The subgroup analysis showed that the rate of CRE infection in the invasive group was higher than in the non-invasive group (P < 0.001), and the rate of exacerbation or death in the invasive group was also higher than in the non-invasive group (P=0.019). The average length of ICU and hospitalisation in the healthcare-associated infection group were significantly higher than those in the community infection group, but there was no difference in the proportion of final exacerbation or death between them (P=0.727). Kidney disease, granulocytosis, invasive procedures and CRE detection time are the risk factors for CRE infection. Carrying out CRE screening in patients as early as possible and taking effective intervention measures in time to avoid adverse consequences is all important.

Rapid increase in occurrence of carbapenem-resistant Enterobacteriaceae in healthy rural residents in Shandong Province, China, from 2015 to 2017

The global increase in carbapenem-resistant Enterobacteriaceae (CRE) is a growing health concern. Infections caused by CRE are associated with increased mortality and length of hospital stay, emphasising the health and economic burden posed by these pathogens. Although CRE can inhabit the human gut asymptomatically, colonisation with CRE is associated with an increased risk of CRE infection and mortality. In this study, we investigated the occurrence and characteristics of CRE in faecal samples from healthy persons in 12 villages in Shandong Province, China. Screening for CRE in faecal samples was performed by selective cultivation. Minimum inhibitory concentrations (MICs) of meropenem were determined by the agar dilution method. Multilocus sequence typing (MLST) and carbapenemase gene carriage of the isolates were determined by whole-genome sequencing. Genetic relatedness of Escherichia coli isolates was determined by core genome MLST. CRE carriage increased from 2.4% in 2015 to 13.4% in 2017. Most CRE isolates (93.0%) were E. coli and all carried NDM-type carbapenemases. Sequence types (STs) among the E. coli isolates were diverse. The single most common ST was the highly epidemic strain ST167, which was only observed in 2017. We report a rapid increase in occurrence of CRE (from 2.4% to 13.4%) among faecal samples collected from healthy rural residents of Shandong Province from 2015 to 2017. Colonisation with CRE is known to increase the risk of CRE infection, and the worrying deterioration of the epidemiological situation in the region reported here indicates a need for further monitoring and possible interventions.

Admission screening and cohort care decrease carbapenem resistant enterobacteriaceae in Vietnamese pediatric ICU\u2019s

ObjectivesTo assess if admission screening for Carbapenem Resistant Enterobacteriaceae (CRE) and cohort care can reduce CRE acquisition (CRE colonization during hospital stay), Hospital Acquired Infections (HAI), hospital-stay, mortality, and costs in three Intensive Care Units (ICU’s) at the Vietnamese National Children’s Hospital.MethodCRE screening using rectal swabs and ChromIDCarbas elective culture at admission and if CRE negative, once weekly. Patients were treated in cohorts based on CRE colonization status.ResultsCRE colonization at baseline point-prevalence screening was 76.9% (103/134). Of 941 CRE screened at admission, 337 (35.8%) were CREpos. 694 patients met inclusion criteria. The 244 patients CRE negative at admission and screened > 2 times were stratified in 8 similar size groups (periods), based on time of admission. CRE acquisition decreased significant (OR − 3.2, p < 0.005) from 90% in period 2 (highest) to 48% in period 8 (last period). Patients with CRE acquisition compared to no CRE acquisition had a significantly higher rate of culture confirmed HAI, n = 20 (14%) vs. n = 2 (2%), longer hospital stays, 3.26 vs. 2.37 weeks, and higher total treatment costs, 2852 vs. 2295 USD.ConclusionAdmission CRE screening and cohort care in pediatric ICU’s significantly decreased CRE acquisition, cases of HAI and duration of hospital-stay.

Evaluation of carbapenem-resistant Enterobacteriaceae (CRE) guideline implementation in the Veterans Affairs Medical Centers using the consolidated framework for implementation research

BackgroundInfections caused by carbapenem-resistant Enterobacteriaceae (CRE) and carbapenemase-producing (CP) CRE are difficult to treat, resulting in high mortality in healthcare settings every year. The Veterans Health Administration (VHA) disseminated guidelines in 2015 and an updated directive in 2017 for control of CRE focused on laboratory testing, prevention, and management. The Consolidated Framework for Implementation Research (CFIR) framework was used to analyze qualitative interview data to identify contextual factors and best practices influencing implementation of the 2015 guidelines/2017 directive in VA Medical Centers (VAMCs). The overall goals were to determine CFIR constructs to target to improve CRE guideline/directive implementation and understand how CFIR, as a multi-level conceptual model, can be used to inform guideline implementation.MethodsSemi-structured interviews were conducted at 29 VAMCs with staff involved in implementing CRE guidelines at their facility. Survey and VHA administrative data were used to identify geographically representative large and small VAMCs with varying levels of CRE incidence. Interviews addressed perceptions of guideline dissemination, laboratory testing, staff attitudes and training, patient education, and technology support. Participant responses were coded using a consensus-based mixed deductive-inductive approach guided by CFIR. A quantitative analysis comparing qualitative CFIR constructs and emergent codes to sites actively screening for CRE (vs. non-screening) and any (vs. no) CRE-positive cultures was conducted using Fisher’s exact test.ResultsForty-three semi-structured interviews were conducted between October 2017 and August 2018 with laboratory staff (47%), Multi-Drug-Resistant Organism Program Coordinators (MPCs, 35%), infection preventionists (12%), and physicians (6%). Participants requested more standardized tools to promote effective communication (e.g., electronic screening). Participants also indicated that CRE-specific educational materials were needed for staff, patient, and family members. Quantitative analysis identified CRE screening or presence of CRE as being significantly associated with the following qualitative CFIR constructs: leadership engagement, relative priority, available resources, team communication, and access to knowledge and information.ConclusionsEffective CRE identification, prevention, and treatment require ongoing collaboration between clinical, microbiology, infection prevention, antimicrobial stewardship, and infectious diseases specialists. Our results emphasize the importance of leadership’s role in promoting positive facility culture, including access to resources, improving communication, and facilitating successful implementation of the CRE guidelines.

Investigation and Analysis of the Colonization and Prevalence of Carbapenem-Resistant Enterobacteriaceae in Pediatric Liver Transplant Recipients.

ObjectiveThis study aimed to investigate the colonization and prevalence of carbapenem-resistant Enterobacteriaceae (CRE) in pediatric liver transplant recipients and analyze the high-risk factors and prognosis of CRE infection.MethodsA prospective study involving 152 pediatric patients undergoing liver transplantation was carried out. Anal swab bacteria cultures were collected when the patients entered the intensive care unit (ICU) and when they left in order to screen for intestinal CRE colonization. The results were grouped according to the occurrence of CRE infection following surgery, and the patients were divided into two groups: a CRE infection group and a non-CRE infection group. Univariate analysis and multiple logistic regression analysis were conducted to determine the independent risk factors of CRE infection and analyze the survival rate.ResultsOf the 152 pediatric liver transplant recipients enrolled in the study, there were 13 cases of postoperative CRE infection and 139 cases of non-CRE infection. The incidence of preoperative CRE infection, preoperative cytomegalovirus (CMV) infection, and preoperative sepsis in the CRE infection group was significantly higher than in the non-CRE infection group (P < 0.005). Intraoperative bleeding volume and operation times in the CRE infection group were also significantly higher than in the non-CRE infection group (P < 0.05). Furthermore, postoperative ICU treatment time, postoperative occurrence of unplanned surgery, postoperative mechanical ventilation of more than 24 hours, and the incidence of pre-ICU CRE colonization in the CRE infection group were significantly higher than in the non-CRE infection group (P < 0.05). Finally, the difference between the CRE infection group and the non-CRE infection group in six-month survival rate following surgery was significant (P < 0.001).ConclusionThe independent risk factors of CRE infection following pediatric liver transplantation include preoperative CRE infection and pre-ICU CRE colonization. CRE infection progresses quickly, with a poor prognosis and a high mortality rate. The CRE screening of anal swabs is crucial for the early detection of CRE infection.

Prevalence of carbapenem-resistant Enterobacteriaceae and emergence of high rectal colonization rates of blaOXA-181-positive isolates in patients admitted to two major hospital intensive care units in Kuwait.

BackgroundFecal colonization by carbapenem-resistant Enterobacteriaceae (CRE) can be the main reservoir for transmission of these resistant organisms especially in the Intensive Care Units (ICUs).AimThis study was conducted to evaluate the rate of rectal carriage and molecular characterization of CRE in patients hospitalized in the ICUs of 2 major hospitals (Adan and Mubarak Al Kabeer Hospitals) in Kuwait.Materials and methodsRectal swabs were collected from all patients at admission, 48 h after admission and once weekly from April 2017- March 2018. Initial CRE screening was carried out on MacConkey agar on which meropenem disc 10μg was placed. Identification of isolates was by API 20E. Susceptibility testing was performed using the E-test method. Polymerase chain reaction (PCR) was used to detect the carbapenemase-encoding genes. Clonal relationship was investigated by pulsed-field electrophoresis (PFGE). Genes of blaOXA-181 and blaNDM-5–carrying plasmids were detected in some strains.ResultsA total of 590 patients were recruited into the study. Of these, 58 were positive for CRE, giving a prevalence of 9.8%; 25/320 (7.8%) in Adan and 33/270 (12.2%) in Mubarak Al Kabeer Hospitals. All isolates were resistant to multiple antibiotics. Resistance rates to colistin and tigecycline were 17% and 83%, respectively. Single genes of blaOXA-181 were detected in isolates from 38 (65.5%) out of 58 patients and in 5 patients colonized by blaOXA-48-positive CRE. A combination of 2 genes was detected in 12 isolates; 5 blaKPC-2 and blaOXA-181, 4 blaVIM-1 and blaOXA-181, and 3 blaNDM-5 and blaOXA-181. PFGE showed an overall level of similarity of 38%. Southern hybridization studies localized the blaOXA-181 and blaNDM-5 genes to a large plasmid of 200kb in 3 K. pneumoniae isolates and a small plasmid of 80kb in 2 E. coli isolates, respectively.ConclusionThe prevalence of CRE colonization in the 2 hospital ICUs was relatively high and the emergence of blaOXA-181-mediated CRE is a cause for concern as there is the possibility of rapid horizontal spread among hospital patients in Kuwait. Active surveillance of CRE in the ICUs is highly recommended to stem its spread.

Active screening of intestinal carbapenem-resistant Enterobacteriaceae in high-risk patients admitted to the hematology wards and its effect evaluation

目的观察血液科肠道碳青霉烯类耐药的肠杆菌科细菌（CRE）主动筛查患者CRE定植、感染的特征，并评价主动筛查结合加强干预在血液科患者CRE感染预防控制中的效果。方法以2017年3月至2019年12月血液内科接受化疗或免疫抑制治疗且预期会出现粒细胞缺乏（粒缺）的患者为研究对象，进行至少3个时间点（治疗前、治疗后粒缺期、粒缺伴发热期）的肠道CRE筛查，以2016年12月至2017年2月血液内科未开展肠道CRE主动筛查的、接受化疗或免疫抑制治疗的115例患者为历史对照组，两组患者均进行CRE感染实时监测，CRE筛查阳性者均采取接触隔离措施，CRE筛查阳性者出现发热或者感染症状时启动针对CRE联合抗生素治疗。结果主动筛查患者CRE定植率为16.46%（66/401）；病种分布上，以急性白血病定植率最高，为23.03%（26/113）。66例筛查阳性患者中，其中第1次筛查阳性患者为27例，占40.9%（27/66），第2次筛查阳性患者为15例，占22.7%（15/66），第3次及以后筛查阳性患者为24例，占36.4%（24/66）。CRE定植病原菌中耐碳青霉烯类肺炎克雷伯菌（CRKP）最多，占54.55%（36/66）。主动筛查患者CRE感染率（2.49%）及死亡率（50.00%）低于历史对照组的11.30%及69.23%；干预期间10例CRE血流感染患者病原菌种类与前期主动筛查病原菌完全相同，符合率为100.0%。结论血液科病房急性白血病患者CRE定植率最高，CRKP是CRE定植、感染的主要病原菌，提高筛查频率可以显著提高筛查阳性率，采取主动筛查并及早干预能有效降低血液科患者CRE发生率及死亡率，CRE筛查阳性病原菌与后续CRE感染病原菌符合率高。恶性血液病患者肠道CRE筛查可以对后期CRE血流感染起到预警以及优化抗菌药物使用的作用。

A Collaborative Public Health and Veterinary Facility Approach to an NDM-5 Escherichia coli Outbreak

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are an important cause of healthcare-associated infections (HAIs) in human hospitals. The Philadelphia Department of Public Health (PDPH) made CRE reportable in April 2018. In May 2019, the Matthew J. Ryan Veterinary Hospital (MJRVH) reported an NDM-5 Escherichia coli cluster in companion animals to the PDPH. In total, 15 infected animals (14 dogs and 1 cat) were reported between July 2018 and June 2019, with no new infections after June 2019. Limited literature is available on the prevalence of CRE in companion animals, and recommendations for dealing with CRE infections currently target human healthcare settings. Methods: A collaborative containment response included assessing interspecies transmission to veterinary staff and a comprehensive evaluation of the infection control program at MJRVH. MJRVH notified all owners of affected animals verbally and via notification letters with PDPH recommendations for CRE colonization screening of high-risk individuals. CRE screening of exposed high-risk employees was conducted by the University of Pennsylvania Occupational Health service and PDPH. Human rectal swabs were analyzed at the Antibiotic Resistance Laboratory Network (ARLN) Maryland Laboratory. PDPH were invited to conduct an onsite infection control assessment and to suggest improvements. Results: No pet owners self-identified in high-risk groups to be screened. In total, 10 high-risk staff were screened, and no colonized individuals were detected. Recommendations made by the PDPH to MJRVH included improvement of infection prevention and control policies (eg, consolidation of the infection control manual and identification of lead staff member), improvement in hand hygiene (HH) compliance (eg, increasing amount of HH supplies), improvement of environment of care (eg, decluttering and evaluation of mulched animal relief area), and improvement of respiratory care processes (eg, standardization of care policies). MJRVH made substantial improvements across recommendation areas including revision of infection control manual, creation of a full-time infection preventionist position, individual alcohol hand sanitizers for patient cages, and environmental decluttering and decontamination. PDPH and MJRVH maintained frequent communication about infection control improvements. Conclusions: No positive transmission to high-risk staff members suggest that, like in human healthcare facilities, transmission of CRE to caretakers may not be a common event. Stronger communication and collaboration is required from Departments of Public Health (DPH) to the veterinary profession regarding the reporting requirements of emerging pathogens such as CRE. Veterinary facilities should view DPH as a valuable resource for recommendations to fill in gaps that exist in infection control “best practices,” particularly for novel pathogens in veterinary settings.Funding: NoneDisclosures: Jane M. Gould reports that her spouse receives salary from Incyte.

Carbapenem-resistant enterobacteriaceae: don’t trust your neighbour

Abstract Background The spread of carbapenem-resistant enterobacteriaceae (CRE) outbreaks consists not only of germs producing KPC and OXA-48, endemic already, but also metallo-beta-lactamase such as NDM or VIM. In Tuscany, Italy, a multidisciplinary regional task force has extended, since NDM alert spread out, from 1st Oct 2019 the CRE screening programme, via molecular testing, to newly admitted patients in high risk settings (medical, intensive care, oncology, transplant, infectious diseases, cardiac surgery units) to fight cross-contamination. The aim of the study is to assess levels and types of CRE in an italian teaching hospital (615 beds) after the programme became effective. Methods The surveillance team began recording daily all the CRE positive cases, defined as laboratory confirmed colonizations/infections with CRE. Our retrospective, descriptive study covers the time span between 30th Sep - 16th Dec 2019. Cases were classified by infected apparatus and by resistance phenotype, and we calculated descriptive statistics. Results In total we identified 97 cases (male 60.82%, mean (+/-SD) age 71.58+/-17.34 years, 74.23% in medical wards); 5 patients had two body districts infected and 9 carried two different phenotypes. Out of 102 positive samples, 92.16% were bowel colonization, 1.96% BSI, 3.92% urinary and 1.96% respiratory. Among these, 21 were NDM (19.81%), 29 KPC (27.36%), 4 OXA-48 (3.77%), 52 VIM (49.06%). The most detected germ was Klebsiella pneumoniae (30.19%), followed by Escherichia coli (2.83%), Enterobacter cloacae (2.83%), Citrobacter freundii and braakii (2.83%), Klebsiella oxytoca (1.89%). 61 agents were unspecified (57.55%). Among the 21 NDM, 76.19% were K. pneumoniae, only one was a BSI. Conclusions CREs continue to be present despite constant surveillance. Although high levels of KPC-producing agents persist, the new spread of VIM phenotype is significant, highlighting, however, that the pathogen wasn't detected in over 50% of the samples. Key messages Despite increased surveillance, there is still a consistent portion of patients colonized with unidentified CRE. A surveillance mainly focused on NDM-producing CREs had incidentally highlighted an unexpected spread of VIM phenotype.

What are acute NHS trusts in England doing to prevent the cross-border spread of carbapenem-resistant Enterobacteriaceae?

Carbapenem-resistant Enterobacteriaceae (CRE) pose a significant threat to global public health as these organisms have the potential to cause infections which are easily spread and are associated with high mortality rates. The aim of this study was to establish which screening strategies acute NHS trusts in England have chosen to adopt and whether or not that strategy has prevented or is likely to prevent the cross-border spread of CRE. All acute NHS trusts in England were invited to participate in a multicentre quantitative study. Participants were asked to complete a questionnaire relating to their local CRE screening protocol. Of the 91 participating trusts, 83 (91.2%) adhere to Public Health England (2013) guidance. However, only 22 (24.2%) trusts have adopted the European Centre for Disease Prevention and Control (2016) recommendations. In total, 31 (34.1%) trusts reported incidences of person-to-person transmission, of which 45.2% were related to foreign travel. Furthermore, 31 (34.1%) trusts reported that patients who have had an admission to a hospital in the UK not known to have a high prevalence of healthcare-associated CRE in the last 12 months had screened positive. This study has demonstrated that inter-hospital transmission is as much of a concern as cross-border spread. Mandatory participation in enhanced surveillance could provide PHE with the epidemiological evidence required to support this stance and help to develop new national guidance.

Different screening frequencies of carbapenem-resistant Enterobacteriaceae in patients undergoing hematopoietic stem cell transplantation: which one is better?

BackgroundA consensus has been reached that carbapenem-resistant Enterobacteriaceae (CRE) screening in immunosuppressed individuals can reduce the incidence of CRE bloodstream infection (BSI).MethodsWe retrospectively studied the clinical data of 395 consecutive HSCT patients from September 2017 to April 2019. From September 2017 to June 2018 (period 1), 200 patients received single CRE screening before transplantation. From July 2018 to April 2019 (period 2), 195 patients received continuous weekly CRE screening after admission. For patients colonized with CRE, targeted managements were received: (1) contact precautions and (2) preemptive CRE-targeted treatment if necessary.ResultsDuring period 1, 3 patients with CRE colonization were detected (1.5%). The CRE BSI rate was 2.0% (4 patients), and the related 30-day mortality was 50.0% (2 out of 4 patients). During period 2, 21 patients with CRE colonization were detected, and the detection rate was significantly higher than that in period 1 (P < 0.001). Of the 21 colonized patients, 4 (19.0%) patients were identified as positive for CRE at the first screening, 5 (23.8%) were identified at the second screening, and the remaining 12 (57.1%) were identified at the third or later screening. The CRE BSI rate decreased to 0.5% (1/195), and there were no CRE-related death.Fifteen colonized patients developed neutropenic fever. Thirteen colonizers were preemptively treated with tigecycline within 24 h of fever onset, and they achieved rapid temperature control. One colonizer received tigecycline later than 48 h after fever onset and ultimately survived due to the addition of polymyxin. The other received tigecycline later than 72 h after fever onset and died of septic shock.ConclusionThe increase in screening frequency contributed to the detection of patients with CRE colonization. Targeted managements for these colonized patients may contribute to reducing the incidence and mortality of CRE BSI, therefore improving the prognosis of patients.

Evaluation of patient risk factors for infection with carbapenem-resistant Enterobacteriaceae

To evaluate risk factors for infection or colonization with carbapenem-resistant Enterobacteriaceae (CRE) to develop an algorithm for targeted CRE screening. We conducted a case-control study of 50 CRE-positive cases and 100 CRE-negative controls to identify risk factors that were significant for CRE infection or colonization. The setting was at an acute care academic hospital. Patients who tested positive for CRE or other microbiological laboratory tests during the study period were included. We reviewed medical records of 50 patients who were CRE-positive and 100 matched controls who had a non-CRE culture at a similar anatomic site within the closest time period to the case's culture date. Risk factors were assessed using logistic regression with SAS 9.4, observing the 95% confidence interval (CI) to determine significance. Significant risk factors for CRE infection or colonization included the use of fluoroquinolones (odds ratio [OR], 3.75; 95% CI, 1.35, 10.38) and cephalosporins (OR, 2.37; 95% CI, 1.17, 4.86). In addition, undergoing an invasive procedure with a scope device was also a significant risk factor for our participants (OR, 4.57; 95% CI, 1.31, 16.02). Significance of these risk factors varied within the community-acquired and hospital-acquired cases. Our results suggest that exposure to certain antimicrobials and invasive procedures with a scope device (endoscopic retrograde cholangiopancreatography, duodenal endoscope) are risk factors for CRE. The findings of significant differences in antimicrobials received highlight the necessity to understand antimicrobial stewardship in the development of CRE colonization and infection. Along with antibiotics, inaccessibility to components within scope devices may be increasing the risk of CRE spread.

Comparison of Four Commercial Screening Assays for the Detection of blaKPC, blaNDM, blaIMP, blaVIM, and blaOXA48 in Rectal Secretion Collected by Swabs.

The spread of carbapenem-resistant Enterobacteriaceae (CRE) has been enabled by the lack of control measures directed at carriers of multidrug-resistant organisms in healthcare settings. Screening patients for asymptomatic colonization on the one hand, and implementation of contact precautions on the other hand, reduces patient-to-patient transmission. Screening plates represents a relatively low-cost method for isolating CRE from rectal swabs; however, molecular assays have become widely available. This study compared the performance of four commercial molecular platforms in detecting clinically significant carbapenemase genes versus routine screening for CRE. A total of 1015 non-duplicated rectal swabs were cultured on a chromogenic carbapenem-resistant selective medium. All growing Enterobacteriaceae strains were tested for carbapenemase-related genes. The same specimens were processed using the following molecular assays: Allplex™ Entero-DR, Amplidiag® CarbaR + MCR, AusDiagnostics MT CRE EU, and EasyScreen™ ESBL/CPO. The prevalence of Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae detected by swab culture was 2.2%, while organisms producing oxacillinase (OXA)-48 and metallo-β-lactamases were infrequent. The cost of CRE-related infection control precautions, which must be kept in place while waiting for screening results, are significant, so the molecular tests could become cost-competitive, especially when the turnaround time is decreased dramatically. Molecular assays represent a powerful diagnostic tool as they allow the rapid detection of the most clinically relevant carbapenemases.

Education and Consistent Infection Prevention Practices Prevail: An Outbreak of CRE in a Long Term Acute Care Hospital

Carbapenem-resistant Enterobacteriaceae (CRE) infections are difficult to treat and pose a significant threat to public health. In July 2018, an infection preventionist (IP) notified Los Angeles County Department of Public Health (LACDPH) of eight cases of healthcare-onset carbapenem-resistant Klebsiella pneumoniae (CRKP) among residents of a 54-bed long term acute care facility (LTAC). LACDPH initiated an investigation to identify risks for infection and disrupt transmission. A case was defined as a LTAC patient with laboratory confirmation for CRKP or carbapenemase-producing organism from June 28- August 7, 2018 and no previous CRE history. LACDPH conducted two site visits of the facility to observe infection prevention practices. Medical records, staff training records, and infection prevention audits were reviewed. Facility-wide surveillance cultures were collected on three dates. The first facility-wide screening yielded 13 additional cases; no further cases were identified during subsequent screenings. Medical record review found one additional case. A total of 22 cases were identified; overall prevalence was 39%. Site observations revealed missed hand hygiene opportunities, unclear contact precaution signage, and a knowledge deficit among staff regarding CRE and control measures. LACDPH recommended enhanced environmental cleaning, infection control trainings for all staff, hand hygiene and personal protective equipment audits, placing new admissions on contact precautions pending CRE screening results, and the use of an interfacility transfer form upon discharge of all known CRE patients. We identified a high prevalence of CRE in an LTAC, a setting where patients generally have higher invasive device and antibiotic utilization than other settings. However, the implementation of evidence-based infection prevention practices enabled the facility to stop the spread of infection. Identification and containment of a CRE outbreak in a healthcare facility relies on several factors, including the collaboration of a facility's IP with the local health department and continuing frontline staff education.

Impact of individualized active surveillance of carbapenem-resistant enterobacteriaceae on the infection rate in intensive care units: a 3-year retrospective study in a teaching hospital of People's Republic of China.

Purpose: Active surveillance of carbapenem-resistant Enterobacteriaceae (CRE) may contribute to the decline of the infection rate. Individualized active surveillance of CRE could cost less than screening all patients. However, the impact of individualized active surveillance on the CRE infection rate in intensive care units (ICUs) has not been well described.Patients and methods: We retrospectively studied the clinical data of all patients admitted in the ICUs of a tertiary-care hospital in China from 2015 to 2017 during two periods, before and after the implementation of individualized active surveillance. During period 1 (January 2015–April 2016), no screening protocol was used. During period 2 (May 2016–December 2017), we implemented active CRE screening for selected patients according to their clinical characteristics. The trend of CRE rate infection was analyzed by a joinpoint regression model, and multivariate analysis was performed to analyze the association of active surveillance, Acute Physiology and Chronic Health Evaluation (APACHE) II score, prior antimicrobial use, length of mechanical ventilation (MV) before infection, and other risk factors with CRE infection rate.Results: A total of 5,372 patients were included. After assessing the patients’ clinical characteristics, 72.3% (3,882/5,372) were considered to be at high risk of CRE infection. During period 1, the infection percent of CRE increased by 13.04% every month (95% CI: 5.2–21.5). During period 2, the infection rate decreased (monthly percent change, −3.57%; 95% CI −6.9 to −0.1, P<0.05). Multivariate analysis showed that individualized active surveillance (odds ratio, 0.146; 95% CI, 0.061–0.347; P<0.001) was associated with a reduction of the CRE infection rate, whereas APACHE II score, prior antimicrobial use, and length of MV before infection were independent risk factors.Conclusion: Individualized active surveillance may be associated with a reduction of the overall CRE infection rate in ICUs.

Carbapenem-Resistant Enterobacteriaceae Infections: Taiwan Aspects.

Carbapenem-resistant Enterobacteriaceae (CRE), a major resistance concern emerging during the last decade because of significantly compromising the efficacy of carbapenem agents, has currently become an important focus of infection control. Many investigations have shown a high association of CRE infections with high case-fatality rates. In Taiwan, a few surveys observed that a significant proportion (29–47%) of the CR-Klebsiella pneumoniae isolates harbored a plasmidic allele encoding K. pneumoniae carbapenemases (KPC, especially KPC-2). A significant increase in the number of oxacillinase (OXA)-48-like carbapenemases among CR-K. pneumoniae isolates was observed between 2012 and 2015. By striking contrast, isolates of CR-Escherichia coli and CR-Enterobacter species in Taiwan had a much lower percentage of carbapenemase production than CR-K. pneumoniae isolates. This differs from isolates found in China as well as in the India subcontinent. Apart from the hospital setting, CRE was also cultured from the inpatients from communities or long-term care facilities (LTCF). Therefore, implementation of regular CRE screening of LTCF residents, strict disinfectant use in nursing homes and hospital settings, and appropriate control of antibiotic prescriptions is suggested to alleviate the spread of clinical CRE isolates in Taiwan. Although there are some promising new antibiotics against CRE, such as ceftazidime-avibactam, meropenem-vaborbactam, aztreonam-avibactam and cefiderocol, these agents are not available in Taiwan currently. Therefore, in order to effectively decrease case-fatality rates among patients with the infections owing to carbapenemase-producing CRE isolates, combination antibiotic schemes, including colistin (or amikacin) and/or tigecycline in combination with an anti-pseudomonal carbapenem agent, remain the mainstay for treating clinical CRE infections.