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Carbapenemase-producing Enterobacteriaceae (CPE)

Also known as: CRE (carbapenem-resistant Enterobacteriaceae), CPC (Carbapenemase-producing coliform).

Classification: Bacteria

Industry of interest: Healthcare

Enterobacteriaceae are a family of fermentative, oxidase-negative, motile or non-motile, facultatively anaerobic, Gram-negative rods that commonly cause infections in health-care settings as well as in the community. The family includes more than 70 genera but Klebsiella pneumoniae, Escherichia coli and Enterobacter species are the most common in healthcare settings. K. pneumoniae is most commonly associated with carbapenemase genes (Munoz-Price, Poirel et al. 2013). A number of different carbapenemase genes have been reported, most commonly KPC, NDM, VIM, IMP and OXA types (Nordmann, Naas et al. 2011). Carbapenemase genes are mobile and can be spread between Enterobacteriaceae and other Gram-negative bacteria


Habitat and transmission: Enterobacteriaceae inhabit the human and animal gastrointestinal tract, and water. In humans, the gastrointestinal tract can become colonized with multidrug-resistant Enterobacteriaceae, and the duration of colonization can be long – often exceeding one year (Apisarnthanarak, Bailey et al. 2008). Risk factors for CPE include: prior antimicrobial use, length of stay, severity of illness, mechanical ventilation, admission to the ICU, high procedure score, presence of wounds, prior surgery, prior hospital stay, presence of indwelling medical devices and recent transplantation (ECDC 2011)

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Treatment and antibiotic resistance: CPE are resistant to the carbapenems, the last effective drug left to treat many multidrug-resistant Gram-negative rods. This makes infections with CPE difficult to treat, and reliant on older, less effective and less well-tolerated antibiotics, such as colistin (Nordmann, Naas et al. 2011). Ominously, pan-drug resistant strains have been reported (Bogdanovich, Adams-Haduch et al. 2011).

Disease and symptoms: CPE can be carried as part of the normal gut flora without any symptoms or cause infections. CPE have the capacity to cause infections at a wide range of body sites, including urinary tract infections, wound infections and occasionally bloodstream infections. The attributable mortality associated with CPE infections is very high, and can exceed 50% (Snitkin, Zelazny et al. 2012). CPE have emerged in recent years as a global public health threat (Nordmann, Naas et al. 2011). Several countries (such as Greece and Italy) now have endemic CPE problems, whereas the prevalence in most parts of the world is low but increasing sharply. CPE are currently emerging as a series of outbreaks in the USA, UK and elsewhere in Europe.

Prevention and control: In terms of preventing the spread of infection in healthcare settings, measures such as hand hygiene compliance, environmental decontamination, prompt identification and strict isolation of carriers, enhanced surveillance, improved antibiotic stewardship and screening of patients that have been transferred or have recently returned from overseas hospitals should reduce the transmission of CPE strains (Palmore and Henderson 2013). However, effective control measures to prevent the spread of CPE in hospital and community settings require urgent research.

Apisarnthanarak, A., T. C. Bailey, et al. (2008). "Duration of stool colonization in patients infected with extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae." Clin Infect Dis 46(8): 1322-1323.
Bogdanovich, T., J. M. Adams-Haduch, et al. (2011). "Colistin-Resistant, Klebsiella pneumoniae Carbapenemase (KPC)-Producing Klebsiella pneumoniae Belonging to the International Epidemic Clone ST258." Clin Infect Dis 53(4): 373-376.
ECDC (2011). "Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer. Stockholm, ECDC.".
Munoz-Price, L. S., L. Poirel, et al. (2013). "Clinical epidemiology of the global expansion of Klebsiella pneumoniae carbapenemases." Lancet Infect Dis 13(9): 785-796.
Nordmann, P., T. Naas, et al. (2011). "Global spread of Carbapenemase-producing Enterobacteriaceae." Emerg Infect Dis 17(10): 1791-1798.
Palmore, T. N. and D. K. Henderson (2013). "Managing Transmission of Carbapenem-Resistant Enterobacteriaceae in Healthcare Settings: A View From the Trenches." Clin Infect Dis 57: 1593-1599.
Snitkin, E. S., A. M. Zelazny, et al. (2012). "Tracking a hospital outbreak of carbapenem-resistant Klebsiella pneumoniae with whole-genome sequencing." Sci Transl Med 4(148): 148ra116.

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