Carbapenem-resistant Enterobacteriaceae: A retrospective review of treatment and outcomes in a long-term acute care hospital

Published:August 17, 2019DOI:


      • This is a retrospective analysis of our clinical experience treating CRE infections in an LTACH.
      • Current treatment paradigms for infections caused by CRE have produced suboptimal results.
      • We propose an algorithmic approach when an infection with CRE is suspected.


      Long-term acute care hospitals (LTACHs) have a unique patient population, with multiple risk factors for carbapenem-resistant Enterobacteriaceae (CRE) colonization and infection.


      We performed a retrospective analysis of patients in LTACHs who were diagnosed with and treated for CRE infections. Baseline data, antimicrobial treatment, and outcomes were collected in patients with bacteremia, health care–associated pneumonia, and complicated urinary tract infection/acute pyelonephritis due to CRE diagnosed between January 2017 and December 2017.


      A total of 57 cases of CRE infection were identified over the study period, including 12 cases of bacteremia, 20 cases of health care–associated pneumonia, and 25 cases of complicated urinary tract infection/acute pyelonephritis. Patient had significant comorbidities: 31.5% with diabetes, 40.4% with heart failure, 29.8% with kidney disease, and 10% with solid tumors. The majority (56) of 57 patients received empiric antibiotics known to have activity against gram-negative bacteria, but only 38.6% had in vitro activity against the CRE organism in cultured specimens. A total of 78.9% of patients received monotherapy. Overall outcome was poor, with 28-day mortality across all infection sites of 17.5% in patients but up to 25% in patients with bacteremia.


      In this retrospective analysis of our clinical experience treating CRE infections in an LTACH setting, we documented that CRE infections occur in patients with substantial comorbidities. Although clinical outcome remains of great concern, the 28-day mortality and rate of eradication of CRE in this study were comparatively better than other national estimates. Inappropriate empiric treatment may be one of many factors leading to overall poor treatment outcomes.

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        • Wei ZQ
        • Du XX
        • Yu YS
        • Shen P
        • Chen YG
        • Li LJ
        Plasmid-mediated KPC-2 in a Klebsiella pneumoniae isolate from China.
        Antimicrob Agents Chemother. 2007; 51: 763-765
        • Marchaim D
        • Chopra T
        • Bhargava A
        • Bogan C
        • Dhar S
        • Hayakawa K
        • et al.
        Recent exposure to antimicrobials and carbapenem-resistant Enterobacteriaceae: the role of antimicrobial stewardship.
        Infect Control Hosp Epidemiol. 2012; 33: 817-830
        • Schwaber MJ
        • Klarfeld-Lidji S
        • Navon-Venezia S
        • Schwartz D
        • Leavitt A
        • Carmeli Y
        Predictors of carbapenem-resistant Klebsiella pneumoniae acquisition among hospitalized adults and effect of acquisition on mortality.
        Antimicrob Agents Chemother. 2008; 52: 1028-1033
        • Bratu S
        • Landman D
        • Haag R
        • Recco R
        • Eramo A
        • Alam M
        • et al.
        Rapid spread of carbapenem-resistant Klebsiella pneumoniae in New York City: a new threat to our antibiotic armamentarium.
        Arch Intern Med. 2005; 165: 1430
        • Nordmann P
        • Naas T
        • Poirel L
        Global spread of carbapenemase-producing Enterobacteriaceae.
        Emerg Infect Dis. 2011; 17: 1791
        • Hyle EP
        • Ferraro MJ
        • Silver M
        • Lee H
        • Hooper DC.
        Ertapenem-resistant Enterobacteriaceae: risk factors for acquisition and outcomes.
        Infect Control Hosp Epidemiol. 2010; 31: 1242-1249
        • Walsh TR
        Emerging carbapenemases: a global perspective.
        Int J Antimicrob Agents. 2010; 36: S8-S14
        • Patel G
        • Huprikar S
        • Factor SH
        • Jenkins SG
        • Calfee DP
        Outcomes of carbapenem-resistant Klebsiella pneumoniae infection and the impact of antimicrobial and adjunctive therapies.
        Infect Control Hosp Epidemiol. 2008; 29: 1099-1106
      1. World Health Organization. Ebola virus disease. Available from: Accessed September 19, 2017.

        • Souli M
        • Kontopidou FV
        • Papadomichelakis E
        • Galani I
        • Armaganidis A
        • Giamarellou H
        Clinical experience of serious infections caused by producing VIM-1 metallo-beta-lactamase in a Greek University Hospital.
        Clin Infect Dis. 2008; 46: 847
        • Alexander EL
        • Loutit J
        • Tumbarello M
        • Wunderink R
        • Felton T
        • Daikos G
        • et al.
        Carbapenem-resistant Enterobacteriaceae infections: results from a retrospective series and implications for the design of prospective clinical trials.
        Open Forum Infect Dis. 2017; 4: ofx063
        • Tzouvelekis LS
        • Markogiannakis A
        • Psichogiou M
        • Tassios PT
        • Daikos GL
        Carbapenemases in Klebsiella pneumoniae and other Enterobacteriaceae: an evolving crisis of global dimensions.
        Clin Microbiol Rev. 2012; 25: 682-707
        • Zarkotou O
        • Pournaras S
        • Tselioti P
        • Dragoumanos V
        • Pitiriga V
        • Ranellou K
        • et al.
        Predictors of mortality in patients with bloodstream infections caused by KPC-producing Klebsiella pneumoniae and impact of appropriate antimicrobial treatment.
        Clin Microbiol Infect. 2011; 17: 1798-1803
        • Tumbarello M
        • Viale P
        • Viscoli C
        • Trecarichi EM
        • Tumietto F
        • Marchese A
        • et al.
        Predictors of mortality in bloodstream infections caused by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae: importance of combination therapy.
        Clin Infect Dis. 2012; 55: 943-950
        • Tumbarello M
        • Trecarichi EM
        • De Rosa FG
        • Giannella M
        • Giacobbe DR
        • Bassetti M
        • et al.
        Infections caused by KPC-producing Klebsiella pneumoniae: differences in therapy and mortality in a multicentre study.
        J Antimicrob Chemother. 2015; 70: 2133-2143
        • Kitchel B
        • Sundin DR
        • Patel JB
        Regional dissemination of KPC-producing Klebsiella pneumoniae.
        Antimicrob Agents Chemother. 2009; 53: 4511-4513
        • Falagas ME
        • Lourida P
        • Poulikakos P
        • Rafailidis PI
        • Tansarli GS
        Antibiotic treatment of infections due to carbapenem-resistant Enterobacteriaceae: systematic evaluation of the available evidence.
        Antimicrob Agents Chemother. 2014; 58: 654-663
        • Shields RK
        • Nguyen MH
        • Chen L
        • Press EG
        • Potoski BA
        • Marini RV
        • et al.
        Ceftazidime-avibactam is superior to other treatment regimens against carbapenem-resistant Klebsiella pneumoniae bacteremia.
        Antimicrob Agents Chemother. 2017; 61: 1-7
        • Shields RK
        • Nguyen MH
        • Press EG
        • Chen L
        • Kreiswirth BN
        • Clancy CJ
        Emergence of ceftazidime-avibactam resistance and restoration of carbapenem susceptibility in Klebsiella pneumoniae carbapenemase-producing K. pneumoniae: a case report and review of literature.
        Open Forum Infect Dis. 2017; 4 (ofx101)
        • Kaye KS
        • Vazquez J
        • Mathers A
        • Daikos G
        • Alexander E
        • Loutit J
        • et al.
        Clinical outcomes of serious infections due to carbapenem-resistant Enterobacteriaceae (CRE) in TANGO-II, a phase 3, randomized, multi-national, open-label trial of meropenem-vaborbactam (M-V) versus best available therapy (BAT).
        in: Poster Presented at: IDWeek, San Diego, CA2017 Oct 4-8