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CRE surveillance reveals high prevalence of prior hospitalizations, indwelling devices
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Recently published surveillance data suggest carbapenem-resistant Enterobacteriaceae occurs often among patients with prior hospitalizations or indwelling devices.
In addition, the low incidence rates observed among study areas could imply that intervention efforts could have a significant impact on disease burden.
“These multidrug-resistant organisms cause infections associated with high mortality and limited treatment options, and are increasingly recognized as an important cause of health care-associated infections,” Alice Y. Guh, MD, MPH, of the CDC’s division of health care quality promotion, and colleagues wrote. “To date, 23 states have required some form of CRE reporting; however, requirements and definitions vary by state.”
Alic Y. Guh
To examine CRE epidemiology, the researchers analyzed data from the Multi-Site Gram-negative Surveillance Initiative, an ongoing population- and laboratory-based surveillance system. CRE incidence data from seven U.S. metropolitan areas between 2012-2013 were included, with cases of the infection defined as Escherichia coli, Enterobacter aerogenes, E. cloacae complex, Klebsiella pneumoniae or K. oxytoca specimens that were carbapenem-nonsusceptible and extended-spectrum cephalosporin-resistant. Isolates were recovered from either the bloodstream or from urine, identified by local laboratories and submitted to the CDC.
There were 599 cases of CRE among 481 of the estimated 13.2 million people included in the surveillance area, resulting in an overall annual CRE incidence of 2.93 per 100,000 population (95% CI, 2.65-3.23). Standardized incidence ratios adjusted for age and race were higher than predicted in Georgia, Maryland and New York, but lower than predicted in Colorado, New Mexico and Oregon.
Among the cases, 86.8% were isolated from urine and 11.4% were isolated from blood. Those infected were aged a median 66 years and 59% female. The majority of CRE cases occurred among patients with prior hospitalization (75.1%) or indwelling urinary catheters (72.8%), and 55.9% of admitted cases resulted in discharge to a long-term care facility. Death occurred in 9% of cases, and 47.9% of tested isolates produced a carbapenemase.
“The low CRE incidence in the catchment areas, compared with other more established resistant organisms, highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” the researchers wrote. “The fact that heterogeneity exists (with respect to the incidence and the types of CRE found in these different surveillance areas) further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States.”
In a related editorial, Mary K. Hayden, MD, of Rush University Medical Center, Chicago, said that large-scale surveillance efforts are “a critical step toward control of CRE,” and that the findings from Guh and colleagues suggest trends that are both worrying and encouraging.
“The bad news is that CRE were identified in every surveillance site in the Multi-site Gram-negative Surveillance Initiative network … with incidence rates in some regions high enough to suggest that CRE are endemic,” Hayden wrote. “The good news is that even in the region with the highest number of cases, the estimated crude incidence rate of CRE was relatively low … and suggests that interventions implemented now to control CRE could have a sizeable effect.” – by Dave Muoio
Disclosure: The researchers report no relevant financial disclosures. Hayden reports receiving grants from the CDC.
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