Risk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review

doi:10.1016/j.ajic.2015.12.005

American Journal of Infection Control

Volume 44, Issue 5, 1 May 2016, Pages 539-543

https://doi.org/10.1016/j.ajic.2015.12.005 Get rights and content

Background

Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as important health care-associated pathogens. Colonization precedes infection but the risk of developing infection amongst those colonized with CRE is not clear.

Methods

We searched multiple databases for studies reporting rates of CRE-colonized patients subsequently developing infection.

Results

Ten studies fulfilled our inclusion criteria, including 1,806 patients used in our analysis. All studies were observational and conducted among adult inpatients. The cumulative rate of infection was 16.5% in our study. The most common site of infection was the lung, identified in half of patients, followed in decreasing frequency by urinary tract; primary bloodstream; and skin and soft tissue, including surgical sites. Colonization or infection by CRE prolonged stay and was associated with a 10% overall mortality in our analysis.

Conclusion

Our study results suggest an overall 16.5% risk of infection with CRE amongst patients colonized with CRE. Given the high mortality rate observed with CRE infection and the difficulty in treating these infections, research to investigate and develop strategies to eliminate the colonization state are needed.

Section snippets

Methods

During September 2014 and June 2015 we searched PubMed, Medline, Cochrane Library database, Cumulative Index to Nursing and Allied Health Literature, and Scielo databases from January 1, 1991, the year before the first reported case of CRE, for relevant publications. No language restrictions were used. Key words used in the search, alone or in combination, were: carbapenem-resistant Enterobacteriaceae, Klebsiella pneumonia carbapenemase, KPC, Verona integron-mediated metallo-beta-lactamase, CRE

Study characteristics

Our search strategy yielded 1,709 reports, of which 178 were considered potentially relevant and abstracts were reviewed. Of these, the full text of 42 studies was retrieved and reviewed; 33 were ultimately excluded because data on the numbers of patients initially colonized who subsequently went on to develop infection were not reported. In fact, many were point prevalence reports of those colonized or infected and not consistent with the aim of our review (Fig 1). One additional study¹¹ was

Discussion

Our results show that a substantial proportion of patients colonized the CRE go on to develop clinical infection with CRE. We summarized the results of the available literature and found an overall 16.5% risk of infection with CRE amongst patients colonized with CRE. Individual studies that have examined this question have found varying rates of infection, probably due to differences in type of organism, patient population, and clinical setting. Thus, the overall magnitude of risk was unclear.

Conclusions

We found that colonization with CRE poses a 16.5% risk of subsequent CRE infection. With a high rate of mortality associated with CRE infection, pending further research, eradication of colonization with CRE should be considered in select situations such as outbreaks. Future research should attempt to determine the utility of widespread routine surveillance for CRE amongst hospitalized patients as an infection control strategy as well as determine strategies of eradication of CRE colonization.

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Citation Excerpt :
CPE bloodstream infections are also on the rise [3] illustrating the potential negative impact a diagnosis of CPE may have on the health of an individual. Colonisation with CPE is also a risk to patient wellbeing with a systematic review that included 10 studies (n=1806 patients) observing a 16.5% risk of CPE infection in those already colonized with CPE [4]. The costs involved in managing CPE are substantial with estimates from the United States ranging from $22,484 to $66,031 per single case [5].
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: Supported by Agency for Healthcare Research and Quality grant No. 11670428, Department of Veterans Affairs Quality Enhancement Research Initiative 11901470, and a MERIT award from the Department of Veterans Affairs.

: Conflicts of Interest: None to report.

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Major articleRisk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review

Background

Methods

Results

Conclusion

Section snippets

Methods

Study characteristics

Discussion

Conclusions

Am J Infect Control

Am J Infect Control

J Hosp Infect

Diagn Microbiol Infect Dis

Am J Infect Control

Carbapenem-resistant Enterobacteriaceae: biology, epidemiology, and management

Ann N Y Acad Sci

Carbapenem-resistant Enterobacteriaceae: a potential threat

JAMA

Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities

MMWR Morb Mortal Wkly Rep

Colistin-resistant isolates of Klebsiella pneumoniae emerging in intensive care unit patients: first report of a multiclonal cluster

J Antimicrob Chemother

Molecular epidemiology of KPC-producing Klebsiella pneumoniae isolates in the United States: clonal expansion of multilocus sequence type 258

Antimicrob Agents Chemother

Carbapenem resistant Enterobacteriaceae: CRE definition

Hospital-acquired infections due to gram-negative bacteria

N Engl J Med

Major article
Risk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review