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Antimicrob Agents Chemother. 2017 Mar 24;61(4). pii: e02349-16. doi: 10.1128/AAC.02349-16. Print 2017 Apr.

Multicenter Clinical and Molecular Epidemiological Analysis of Bacteremia Due to Carbapenem-Resistant Enterobacteriaceae (CRE) in the CRE Epicenter of the United States.

Author information

1
Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA mjs9012@med.cornell.edu.
2
Public Health Research Institute, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
3
Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
4
Division of Infectious Diseases, Columbia University Medical Center, New York, New York, USA.
5
Division of Infectious Diseases, Albert Einstein College of Medicine, Bronx, New York, USA.
6
Division of Infectious Diseases, Northwell Health, Manhasset, New York, USA.
7
Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
8
Department of Medicine, Jersey Shore University Medical Center, Neptune City, New Jersey, USA.
9
Department of Medicine, St. Peter's University Hospital, New Brunswick, New Jersey, USA.
10
Division of Infectious Diseases, Hackensack University Medical Center, Hackensack, New Jersey, USA.
11
Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.
12
Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
13
Department of Pathology, Albert Einstein College of Medicine, Bronx, New York, USA.
14
Division of Infectious Diseases, Stony Brook University Medical Center, Stony Brook, New York, USA.
15
Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
16
Department of Pathology, Northwell Health, Manhasset, New York, USA.
17
Department of Pathology, Jersey Shore University Medical Center, Neptune City, New Jersey, USA.
18
Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA.
19
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
20
Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
21
Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA.
22
Departments of Pediatrics and Microbiology & Immunology, Weill Cornell Medicine, New York, New York, USA.
23
Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA.
24
Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Abstract

Although the New York/New Jersey (NY/NJ) area is an epicenter for carbapenem-resistant Enterobacteriaceae (CRE), there are few multicenter studies of CRE from this region. We characterized patients with CRE bacteremia in 2013 at eight NY/NJ medical centers and determined the prevalence of carbapenem resistance among Enterobacteriaceae bloodstream isolates and CRE resistance mechanisms, genetic backgrounds, capsular types (cps), and antimicrobial susceptibilities. Of 121 patients with CRE bacteremia, 50% had cancer or had undergone transplantation. The prevalences of carbapenem resistance among Klebsiella pneumoniae, Enterobacter spp., and Escherichia coli bacteremias were 9.7%, 2.2%, and 0.1%, respectively. Ninety percent of CRE were K. pneumoniae and 92% produced K. pneumoniae carbapenemase (KPC-3, 48%; KPC-2, 44%). Two CRE produced NDM-1 and OXA-48 carbapenemases. Sequence type 258 (ST258) predominated among KPC-producing K. pneumoniae (KPC-Kp). The wzi154 allele, corresponding to cps-2, was present in 93% of KPC-3-Kp, whereas KPC-2-Kp had greater cps diversity. Ninety-nine percent of CRE were ceftazidime-avibactam (CAZ-AVI)-susceptible, although 42% of KPC-3-Kp had an CAZ-AVI MIC of ≥4/4 μg/ml. There was a median of 47 h from bacteremia onset until active antimicrobial therapy, 38% of patients had septic shock, and 49% died within 30 days. KPC-3-Kp bacteremia (adjusted odds ratio [aOR], 2.58; P = 0.045), cancer (aOR, 3.61, P = 0.01), and bacteremia onset in the intensive care unit (aOR, 3.79; P = 0.03) were independently associated with mortality. Active empirical therapy and combination therapy were not associated with survival. Despite a decade of experience with CRE, patients with CRE bacteremia have protracted delays in appropriate therapies and high mortality rates, highlighting the need for rapid diagnostics and evaluation of new therapeutics.

KEYWORDS:

carbapenem-resistant Enterobacteriaceae; clinical outcomes; molecular epidemiology; resistance mechanisms

PMID:
28167547
PMCID:
PMC5365653
DOI:
10.1128/AAC.02349-16
[Indexed for MEDLINE]
Free PMC Article

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