OVERVIEW

Carbapenems (imipenem, meropenem and ertapenem) are beta-lactam antibiotics with very broad-spectrum antibacterial activity. These antibiotics often maintain activity against bacteria which demonstrate resistance to broad-spectrum cephalosporins and penicillins such as extended-spectrum beta-lactamase (ESBL) and AmpC producing organisms. Enterobacterales is an order of enteric gram-negative bacteria that includes common human pathogens such as Escherichia coli, Klebsiella spp., Proteus mirabilis, Enterobacter spp. and others. Escherichia coli and Klebsiella pneumoniae are the two most common enteric pathogens causing infections displaying resistance to beta-lactams, including carbapenem resistance.

Infections due to CRE present treatment challenges often leading to poor patient outcomes.

ESBL-producing Enterobacterales should be regarded as precursors to CRE in that they represent bacteria that have developed resistance to most antibiotics, including most beta-lactams. High ESBL rates typically result in increased carbapenem use which may drive increases in Carbapenem Resistant Enterobacterales (CRE).  When these ESBL-producing bacteria acquire additional resistance mechanisms (such as carbapenemases), they become CRE. There are two major types of carbapenemases, non-metalloenzymes (KPC and OXA) and metalloenzymes (NDM, VIM, IMP and SIM). The most common carbapenemase in Indiana is KPC. Not all microbiology laboratories routinely identify the specific carbapenemases when carbapenem resistant enterobacterales are cultured. Knowledge of the type of carbapenemase responsible for resistance is paramount to selecting appropriate antibiotic treatment.

Both ESBL and CRE are significant concerns in healthcare settings due to their ability to cause infections that are challenging to treat with available antibiotics, highlighting the importance of infection control measures and antibiotic stewardship to prevent their spread.

NHSN HAI Resistance: Indiana 2017-2021
Carbapenem Resistant (CR) Klebsiella species in HAI 

NHSN HAI Resistance: Indiana 2021
Cephalosporin and Carbapenem Resistant Klebsiella species in HAIS

Indiana NHSN data reported Healthcare Associated Infections (HAI) details Cephalosporin Resistance (ESBL) and Carbapenem resistance (CRE) in Catheter-associated Urinary Tract Infections-CAUTI, Central Line-associated Bloodstream Infections-CLABSI, and Surgical Site Infections-SSI.  This data indicates that ESBL producing organisms, and what typically follows due to increased carbapenem use is CRE organisms, both represent a significant portion of acute care facilities HAI infections. Once reliable empiric antibiotic regimens designed for treatment of these infections are being rendered ineffective, increasing the likelihood of worse patient outcomes. 

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