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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

Published online by Cambridge University Press:  10 May 2016

Joshua T. Thaden ,
Sarah S. Lewis ,
Kevin C. Hazen ,
Kirk Huslage ,
Vance G. Fowler Jr ,
Rebekah W. Moehring ,
Luke F. Chen ,
Constance D. Jones ,
Zack S. Moore  and
Daniel J. Sexton
...Show all authors
Joshua T. Thaden*
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina
Sarah S. Lewis
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina Duke Infection Control Outreach Network, Durham, North Carolina
Kevin C. Hazen
Affiliation:
Duke Clinical Microbiology Laboratory, Duke University, Durham, North Carolina
Kirk Huslage
Affiliation:
Statewide Program for Infection Control and Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Vance G. Fowler Jr
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina
Rebekah W. Moehring
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina Duke Infection Control Outreach Network, Durham, North Carolina Durham Veterans Affairs Medical Center, Durham, North Carolina
Luke F. Chen
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina Duke Infection Control Outreach Network, Durham, North Carolina
Constance D. Jones
Affiliation:
North Carolina Division of Public Health, Raleigh, North Carolina
Zack S. Moore
Affiliation:
North Carolina Division of Public Health, Raleigh, North Carolina
Daniel J. Sexton
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina Duke Infection Control Outreach Network, Durham, North Carolina
Deverick J. Anderson
Affiliation:
Duke University Division of Infectious Diseases, Durham, North Carolina Duke Infection Control Outreach Network, Durham, North Carolina
*
Clinical Fellow in Division of Infectious Diseases, Duke University Medical Center, 315 Trent Drive, Durham, NC 27710 ([email protected]).
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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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue 8 , August 2014 , pp. 978 - 983
Copyright
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

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