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Tesfa T, Mitiku H, Edae M, Assefa N. Prevalence and incidence of carbapenem-resistant K. pneumoniae colonization: systematic review and meta-analysis. Syst Rev 2022; 11:240. [PMID: 36380387 PMCID: PMC9667607 DOI: 10.1186/s13643-022-02110-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 10/30/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a gram-negative rod belonging to the order Enterobacterales and having a wide distribution in the environment, including the human colon. Recently, the bacterium is one of the known problems in the healthcare setting as it has become resistant to last-resort drugs like carbapenems. The colonized person can serve as a reservoir for his/herself and others, especially in the healthcare setting leading to nosocomial and opportunistic infections. Therefore, we aimed to quantitatively estimate the rate of prevalence and incidence of colonization with carbapenem-resistant K. pneumoniae. METHODS A literature search was conducted on PubMed/MEDLINE, Google Scholar, Science Direct, Cochrane Library, WHO Index Medicus, and university databases. The study includes all published and unpublished papers that addressed the prevalence or incidence of K. pneumoniae colonization. Data were extracted onto format in Microsoft Excel and pooled estimates with a 95% confidence interval calculated using Der-Simonian-Laird random-effects model. With the use of I2 statistics and prediction intervals, the level of heterogeneity was displayed. Egger's tests and funnel plots of standard error were used to demonstrate the publication bias. RESULTS A total of 35 studies were included in the review and 32 records with 37,661 patients for assessment of prevalence, while ten studies with 3643 patients for incidence of colonization. The prevalence of carbapenem-resistant K. pneumoniae colonization varies by location and ranges from 0.13 to 22%, with a pooled prevalence of 5.43%. (3.73-7.42). Whereas the incidence of colonization ranges from 2 to 73% with a pooled incidence of 22.3% (CI 12.74-31.87), both prevalence and incidence reports are majorly from developed countries. There was a variation in the distribution of carbapenem resistance genes among colonizing isolates with KPC as a prominent gene reported from many studies and NDM being reported mainly by studies from Asian countries. A univariate meta-regression analysis indicated continent, patient type, study design, and admission ward do not affect the heterogeneity (p value>0.05). CONCLUSION The review revealed that colonization with K. pneumoniae is higher in a healthcare setting with variable distribution in different localities, and resistance genes for carbapenem drugs also have unstable distribution in different geographic areas.
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Affiliation(s)
- Tewodros Tesfa
- Department of Medical Laboratory Sciences, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia.
| | - Habtamu Mitiku
- Department of Medical Laboratory Sciences, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia
| | - Mekuria Edae
- Hiwot Fana Specialized University Hospital, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia
| | - Nega Assefa
- School of Nursing Midwifery, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia
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Abstract
Antimicrobial Resistance (AMR) has become a global threat to public health systems around the world in recent decades. In 2017, Italy was placed among the worst-performing nations in Europe by the European Centre for Disease Prevention and Control, due to worryingly high levels of AMR in Italian hospitals and regions. The aim of this systematic review was to investigate the state of the art of research on AMR in Italy over the last five years. The PubMed database was searched to identify studies presenting original data. Forty-three of the 9721 records identified were included. Overall, AMR rates ranged from 3% (in a group of sheep farmers) to 78% (in a hospital setting). The methods used to identify the microorganisms, to test their susceptibility and the criteria adopted for the breakpoint were deficient in 7, 7 and 11 studies, respectively. The main findings of our review were that most studies (79.1%) considered hospitalised patients only, 4 studies (9.3%) analysed non-hospitalised populations only. In addition, only 7 studies were multicentric and no scientific literature on the subject was produced in 7 Italian regions. In order to have a solid basis on the topic for the interventions of public health professionals and other stakeholders, studies analysing the phenomenon should be conducted in a methodologically standardised manner, should include all areas of the country and should also focus on out-of-hospital and community-based care and work settings.
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Russo I, Bencardino D, Napoleoni M, Andreoni F, Schiavano GF, Baldelli G, Brandi G, Amagliani G. Prevalence, Antibiotic-Resistance, and Replicon-Typing of Salmonella Strains among Serovars Mainly Isolated from Food Chain in Marche Region, Italy. Antibiotics (Basel) 2022; 11:antibiotics11060725. [PMID: 35740132 PMCID: PMC9219957 DOI: 10.3390/antibiotics11060725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 02/01/2023] Open
Abstract
Nontyphoidal salmonellosis (NTS) is the second most commonly reported gastrointestinal infection in humans and an important cause of food-borne outbreaks in Europe. The use of antimicrobial agents for animals, plants, and food production contributes to the development of antibiotic-resistant Salmonella strains that are transmissible to humans through food. The aim of this study was to investigate the presence and the potential dissemination of multidrug-resistant (MDR) Salmonella strains isolated in the Marche Region (Central Italy) via the food chain. Strains were isolated from different sources: food, human, food animal/livestock, and the food-processing environment. Among them, we selected MDR strains to perform their further characterization in terms of resistance to tetracycline agent, carriage of tet genes, and plasmid profiles. Tetracycline resistance genes were detected by PCR and plasmid replicons by PCR-based replicon typing (PBRT). A total of 102 MDR Salmonella strains were selected among the most prevalent serovars: S. Infantis (n = 36/102), S. Derby (n = 20/102), S. Typhimurium (n = 18/102), and a monophasic variant of S. Typhimurium (MVST, n = 28/102). Resistance to sulfisoxazole (86%) and tetracycline (81%) were the most common, followed by ampicillin (76%). FIIS was the most predominant replicon (17%), followed by FII (11%) and FIB (11%) belonging to the IncF incompatibility group. Concerning the characterization of tet genes, tetB was the most frequently detected (27/89), followed by tetA (10/89), tetG (5/89), and tetM (1/89). This study showed the potential risk associated with the MDR Salmonella strains circulating along the food chain. Hence, epidemiological surveillance supported by molecular typing could be a very useful tool to prevent transmission of resistant Salmonella from food to humans, in line with the One Health approach.
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Affiliation(s)
- Ilaria Russo
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, 61029 Urbino, Italy; (I.R.); (D.B.); (F.A.); (G.B.); (G.B.)
| | - Daniela Bencardino
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, 61029 Urbino, Italy; (I.R.); (D.B.); (F.A.); (G.B.); (G.B.)
| | - Maira Napoleoni
- Istituto Zooprofilattico Sperimentale dell’Umbria e Delle Marche “Togo Rosati”, 06126 Perugia, Italy;
| | - Francesca Andreoni
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, 61029 Urbino, Italy; (I.R.); (D.B.); (F.A.); (G.B.); (G.B.)
| | | | - Giulia Baldelli
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, 61029 Urbino, Italy; (I.R.); (D.B.); (F.A.); (G.B.); (G.B.)
| | - Giorgio Brandi
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, 61029 Urbino, Italy; (I.R.); (D.B.); (F.A.); (G.B.); (G.B.)
| | - Giulia Amagliani
- Department of Biomolecular Sciences, University of Urbino Carlo Bo, 61029 Urbino, Italy; (I.R.); (D.B.); (F.A.); (G.B.); (G.B.)
- Correspondence: ; Tel.: +39-0722-303540
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4
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Agosta M, Bencardino D, Argentieri M, Pansani L, Sisto A, Ciofi Degli Atti ML, D’Amore C, Putignani L, Bagolan P, Iacobelli BD, Dotta A, Martini L, Di Chiara L, Magnani M, Perno CF, Andreoni F, Bernaschi P. Prevalence and Molecular Typing of Carbapenemase-Producing Enterobacterales among Newborn Patients in Italy. Antibiotics (Basel) 2022; 11:antibiotics11040431. [PMID: 35453183 PMCID: PMC9032973 DOI: 10.3390/antibiotics11040431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/10/2022] Open
Abstract
The spread of carbapenemase-producing Enterobacterales (CPE), especially Klebsiella pneumoniae (K. pneumoniae) and Escherichia coli (E. coli), is a serious public health threat in pediatric hospitals. The associated risk in newborns is due to their underdeveloped immune system and limited treatment options. The aim was to estimate the prevalence and circulation of CPE among the neonatal intensive units of a major pediatric hospital in Italy and to investigate their molecular features. A total of 124 CPE were isolated from rectal swabs of 99 newborn patients at Bambino Gesù Children’s Hospital between July 2016 and December 2019. All strains were characterized by antimicrobial susceptibility testing, detection of resistance genes, and PCR-based replicon typing (PBRT). One strain for each PBRT profile of K. pneumoniae or E. coli was characterized by multilocus-sequence typing (MLST). Interestingly, the majority of strains were multidrug-resistant and carried the blaNDM gene. A large part was characterized by a multireplicon status, and FII, A/C, FIA (15%) was the predominant. Despite the limited size of collection, MLST analysis revealed a high number of Sequence Types (STs): 14 STs among 28 K. pneumoniae and 8 STs among 11 E. coli, with the prevalence of the well-known clones ST307 and ST131, respectively. This issue indicated that some strains shared the same circulating clone. We identified a novel, so far never described, ST named ST10555, found in one E. coli strain. Our investigation showed a high heterogeneity of CPE circulating among neonatal units, confirming the need to monitor their dissemination in the hospital also through molecular methods.
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Affiliation(s)
- Marilena Agosta
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.A.); (M.A.); (L.P.); (A.S.); (C.F.P.)
| | - Daniela Bencardino
- Department of Biomolecular Sciences, University of Urbino “Carlo Bo”, 61032 Fano, Italy; (D.B.); (M.M.); (F.A.)
| | - Marta Argentieri
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.A.); (M.A.); (L.P.); (A.S.); (C.F.P.)
| | - Laura Pansani
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.A.); (M.A.); (L.P.); (A.S.); (C.F.P.)
| | - Annamaria Sisto
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.A.); (M.A.); (L.P.); (A.S.); (C.F.P.)
| | - Marta Luisa Ciofi Degli Atti
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.C.D.A.); (C.D.)
| | - Carmen D’Amore
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.L.C.D.A.); (C.D.)
| | - Lorenza Putignani
- Human Microbiome Unit, Department of Diagnostics and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Pietro Bagolan
- Neonatal Surgery Unit, Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (P.B.); (B.D.I.)
| | - Barbara Daniela Iacobelli
- Neonatal Surgery Unit, Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (P.B.); (B.D.I.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.D.); (L.M.)
| | - Ludovica Martini
- Neonatal Intensive Care Unit, Medical and Surgical Department of the Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.D.); (L.M.)
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Mauro Magnani
- Department of Biomolecular Sciences, University of Urbino “Carlo Bo”, 61032 Fano, Italy; (D.B.); (M.M.); (F.A.)
| | - Carlo Federico Perno
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.A.); (M.A.); (L.P.); (A.S.); (C.F.P.)
| | - Francesca Andreoni
- Department of Biomolecular Sciences, University of Urbino “Carlo Bo”, 61032 Fano, Italy; (D.B.); (M.M.); (F.A.)
| | - Paola Bernaschi
- Microbiology and Diagnostic Immunology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (M.A.); (M.A.); (L.P.); (A.S.); (C.F.P.)
- Correspondence: ; Tel.: +39-06-6859-2205
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Di Mento G, Gona F, Russelli G, Cuscino N, Barbera F, Carreca AP, Di Carlo D, Cardinale F, Monaco F, Campanella M, Mularoni A, Grossi P, Conaldi PG, Douradinha B. A retrospective molecular epidemiological scenario of carbapenemase-producing Klebsiella pneumoniae clinical isolates in a Sicilian transplantation hospital shows a swift polyclonal divergence among sequence types, resistome and virulome. Microbiol Res 2021; 256:126959. [PMID: 34995971 DOI: 10.1016/j.micres.2021.126959] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 12/24/2022]
Abstract
In this work, we assessed and characterized the epidemiological scenario of carbapenem-resistant Klebsiella pneumoniae strains (CR-Kp) at IRCCS-ISMETT, a transplantation hospital in Palermo, Italy, from 2008 to 2017. A total of 288 K. pneumoniae clinical isolates were selected based on their resistance to carbapenems. Molecular characterization was also done in terms of the presence of virulence and resistance genes. All patients were inpatients from our facility and clinical isolates were collected from several sources, either from infection or colonization cases. We observed that, in agreement with the Italian epidemiological scenario, initially only ST258 and ST512 clade II (but not from clade I) were identified from 2008 to 2011. From 2012 onwards, other STs have been observed, including the clinically relevant ST101 and ST307, but also others not previously observed in other Italian health settings, such as ST220 and ST753. The presence of genes involved in resistance and virulence was confirmed, and a heterogeneous genetic resistance profile throughout the years was observed. Our work highlights that resistance genes are rapidly disseminating between different and novel K. pneumoniae clones which, combined with resistance to multiple antibiotics, can derive into more aggressive and pathogenic multidrug-resistant strains of clinical importance. Our results stress the importance of continuous surveillance of CR Enterobacterales in health facilities so that novel STs carrying resistance and virulence genes that may become increasingly pathogenic can be identified and adequate therapies to adopted to avoid their dissemination and derived pathologies.
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Affiliation(s)
- Giuseppina Di Mento
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Floriana Gona
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Giovanna Russelli
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Nicola Cuscino
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Floriana Barbera
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Anna Paola Carreca
- Unità di Medicina Rigenerativa ed Immunologia, Fondazione Ri.MED, Palermo, Italy
| | - Daniele Di Carlo
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Francesca Cardinale
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Francesco Monaco
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Maria Campanella
- Dipartimento per la Cura e lo Studio delle Patologie Addominali e dei Trapianti Addominali, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Alessandra Mularoni
- Dipartimento per la Cura e lo Studio delle Patologie Addominali e dei Trapianti Addominali, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Paolo Grossi
- Dipartimento di Malattie Infettive e Tropicali, Università di Insubria, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Pier Giulio Conaldi
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Bruno Douradinha
- Dipartimento di Ricerca, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Unità di Medicina Rigenerativa ed Immunologia, Fondazione Ri.MED, Palermo, Italy.
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Magi G, Tontarelli F, Caucci S, Sante LD, Brenciani A, Morroni G, Giovanetti E, Menzo S, Mingoia M. High prevalence of carbapenem-resistant Klebsiella pneumoniae ST307 recovered from fecal samples in an Italian hospital. Future Microbiol 2021; 16:703-711. [PMID: 34223790 DOI: 10.2217/fmb-2020-0246] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: This study reports the characterization of carbapenem-resistant colonizing strains of K. pneumoniae. Methods: 650 stool samples were screened for carbapenem-resistant K. pneumoniae (CR-Kp). All strains were characterized for antibiotic susceptibility, typing features, main carbapenemases and extended-spectrum ß-lactamases. The carbapenemase transferability was assessed by interspecific conjugation. Results: Eighteen CR-Kp were multidrug resistant, five were KPC producing. A predominance of ST307 isolates, constituting the predominant cluster by PFGE analysis, was identified (50% were KPC-2 producers). Conjugation data showed the co-transfer of blaKPC-2, blaTEM-1, blaOXA-1, blaCTX-M-15 in a single large pKPN3-like plasmid. Conclusion: Our data pointed out the diversity of colonizing K. pneumoniae strains compared with clinical ones. The predominance of ST307 strains suggested an increased spreading, even in our area, of this high-risk clone.
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Affiliation(s)
- Gloria Magi
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Federica Tontarelli
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Sara Caucci
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Laura Di Sante
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Andrea Brenciani
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Gianluca Morroni
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Eleonora Giovanetti
- Unit of Microbiology, Department of Life & Environmental Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Stefano Menzo
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
| | - Marina Mingoia
- Unit of Microbiology, Department of Biomedical Sciences & Public Health, Polytechnic University of Marche Medical School, Ancona, Italy
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Tompkins K, van Duin D. Treatment for carbapenem-resistant Enterobacterales infections: recent advances and future directions. Eur J Clin Microbiol Infect Dis 2021; 40:2053-2068. [PMID: 34169446 DOI: 10.1007/s10096-021-04296-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/15/2021] [Indexed: 12/16/2022]
Abstract
Carbapenem-resistant Enterobacterales (CRE) are a growing threat to human health worldwide. CRE often carry multiple resistance genes that limit treatment options and require longer durations of therapy, are more costly to treat, and necessitate therapies with increased toxicities when compared with carbapenem-susceptible strains. Here, we provide an overview of the mechanisms of resistance in CRE, the epidemiology of CRE infections worldwide, and available treatment options for CRE. We review recentlyapproved agents for the treatment of CRE, including ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, cefiderocol, and novel aminoglycosides and tetracyclines. We also discuss recent advances in phage therapy and antibiotics that are currently in development targeted to CRE. The potential for the development of resistance to these therapies remains high, and enhanced antimicrobial stewardship is imperative both to reduce the spread of CRE worldwide and to ensure continued access to efficacious treatment options.
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Affiliation(s)
- Kathleen Tompkins
- Division of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA.
| | - David van Duin
- Division of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
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