Management of Carbapenem-resistant Enterobacteriaceae Infections in a Long-term Acute Care Hospital

Background: Long-term acute care Hospital (LTACH) systematically selects a unique patient population with multiple risk factors for Carbapenem-resistant Enterobacteriaceae (CRE) colonization and infection leading to an increase CRE prevalence at these facilities. This selection bias creates a fertile ground to harness scientific data and test hypothesis. We performed a retrospective analysis of patients with CRE infections diagnosed and treated in one LTACH.

Methods: Baseline data, antimicrobial treatment, and outcomes were collected in patients with bacteremia, health care associated pneumonia (HCAP) and complicated urinary tract infection (cUTI)/acute pyelonephritis (AP) due to CRE diagnosed between January 2017 and December 2017.

Results: 57 cases of CRE infections were identified over the study period; 12 bacteremia, 20 HCAP and 25 cUTI/AP. The proportion of patient with significant comorbidities include; 31.5% diabetes, 40.4% heart failure, 29.8% kidney disease and 10% with solid tumors. 89.5% of patients presented with sepsis and 33.3% had septic shock. Among 57 patients, majority (56) received empiric antibiotics known to have activity against Gram negative but only 38.6% had invitro activity against the CRE organism recovered from cultured specimen. 85% of index CRE isolate was Klebsiella pneumoniae, 8.7% Enterobacter cloacae, 3.5% Proteus mirabilis and 1.8% Escherichia coli. Treatment regimen varied; however 78.9% received monotherapy. Overall outcome was poor with 28-day mortality of 17.5% across all infection sites but up to 25% in patients with bacteremia.

Conclusion: In this study we report our clinical experience treating CRE infections in LTACH. We proved that CRE infections occurred in patients with substantial co-morbidities. Even though clinical outcome remain of great concern, 28-day mortality and rate of eradication of CRE in the study were comparatively better than other national estimates. Inappropriate empiric treatment may be one of the many factors leading to overall poor treatment outcomes.