title: The Complex Epidemiology of Carbapenem-Resistant Enterobacter Infections: A Multicenter Descriptive Analysis.
abstract: BACKGROUND
  The pandemic of carbapenem-resistant Enterobacteriaceae (CRE) was primarily due to clonal spread of bla KPC producing Klebsiella pneumoniae. Thus, thoroughly studied CRE cohorts have consisted mostly of K. pneumoniae.
  
  
  OBJECTIVE
  To conduct an extensive epidemiologic analysis of carbapenem-resistant Enterobacter spp. (CREn) from 2 endemic and geographically distinct centers.
  
  
  METHODS
  CREn were investigated at an Israeli center (Assaf Harofeh Medical Center, January 2007 to July 2012) and at a US center (Detroit Medical Center, September 2008 to September 2009). bla KPC genes were queried by polymerase chain reaction. Repetitive extragenic palindromic polymerase chain reaction and pulsed-field gel electrophoresis were used to determine genetic relatedness.
  
  
  RESULTS
  In this analysis, 68 unique patients with CREn were enrolled. Sixteen isolates (24%) were from wounds, and 33 (48%) represented colonization only. All isolates exhibited a positive Modified Hodge Test, but only 93% (27 of 29) contained bla KPC. Forty-three isolates (63%) were from elderly adults, and 5 (7.4%) were from neonates. Twenty-seven patients died in hospital (40.3% of infected patients). Enterobacter strains consisted of 4 separate clones from Assaf Harofeh Medical Center and of 4 distinct clones from Detroit Medical Center.
  
  
  CONCLUSIONS
  In this study conducted at 2 distinct CRE endemic regions, there were unique epidemiologic features to CREn: (i) polyclonality, (ii) neonates accounting for more than 7% of cohort, and (iii) high rate of colonization (almost one-half of all cases represented colonization). Since false-positive Modified Hodge Tests in Enterobacter spp. are common, close monitoring of carbapenem resistance mechanisms (particularly carbapenemase production) among Enterobacter spp. is important.
authors.affiliation: 1Clinical Microbiology Laboratory,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Tsilia
authors.initials: T
authors.lastname: Lazarovitch
authors.affiliation: 2Department of Internal Medicine A,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Keren
authors.initials: K
authors.lastname: Amity
authors.affiliation: 3Division of Communicable Diseases,Bureau of Disease Control,Prevention and Epidemiology,Michigan Department of Community Health,Lansing,Michigan.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Coyle
authors.affiliation: 4Unit of Infectious Diseases,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Ackerman
authors.affiliation: 5Sackler School of Medicine,Tel-Aviv University,Tel-Aviv,Israel.
authors.forename: Ruthy
authors.initials: R
authors.lastname: Tal-Jasper
authors.affiliation: 3Division of Communicable Diseases,Bureau of Disease Control,Prevention and Epidemiology,Michigan Department of Community Health,Lansing,Michigan.
authors.forename: Hadas
authors.initials: H
authors.lastname: Ofer-Friedman
authors.affiliation: 6Division of Infectious Diseases,Detroit Medical Center,Wayne State University,Detroit,Michigan.
authors.forename: Kayoko
authors.initials: K
authors.lastname: Hayakawa
authors.affiliation: 6Division of Infectious Diseases,Detroit Medical Center,Wayne State University,Detroit,Michigan.
authors.forename: Christopher
authors.initials: C
authors.lastname: Bogan
authors.affiliation: 6Division of Infectious Diseases,Detroit Medical Center,Wayne State University,Detroit,Michigan.
authors.forename: Paul R
authors.initials: PR
authors.lastname: Lephart
authors.affiliation: 4Unit of Infectious Diseases,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Tamir
authors.initials: T
authors.lastname: Kaplansky
authors.affiliation: 4Unit of Infectious Diseases,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Moran
authors.initials: M
authors.lastname: Maskit
authors.affiliation: 4Unit of Infectious Diseases,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Tal
authors.initials: T
authors.lastname: Azouri
authors.affiliation: 2Department of Internal Medicine A,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Ronit
authors.initials: R
authors.lastname: Zaidenstein
authors.affiliation: 7Research Service,Louis Stokes Veterans Affairs Medical Center,Cleveland,Ohio.
authors.forename: Federico
authors.initials: F
authors.lastname: Perez
authors.affiliation: 7Research Service,Louis Stokes Veterans Affairs Medical Center,Cleveland,Ohio.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Bonomo
authors.affiliation: 6Division of Infectious Diseases,Detroit Medical Center,Wayne State University,Detroit,Michigan.
authors.forename: Keith S
authors.initials: KS
authors.lastname: Kaye
authors.affiliation: 4Unit of Infectious Diseases,Assaf Harofeh Medical Center,Zerifin,Israel.
authors.forename: Dror
authors.initials: D
authors.lastname: Marchaim
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D015780:Carbapenems / Q000494:pharmacology; D004269:DNA, Bacterial / Q000235:genetics; D024881:Drug Resistance, Bacterial; D016521:Electrophoresis, Gel, Pulsed-Field; D004754:Enterobacter / Q000235:genetics / Q000302:isolation & purification*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007557:Israel; D053208:Kaplan-Meier Estimate; D007711:Klebsiella pneumoniae / Q000235:genetics / Q000302:isolation & purification*; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008824:Michigan; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015999:Multivariate Analysis; D016133:Polymerase Chain Reaction; D012189:Retrospective Studies; D012720:Severity of Illness Index
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems; D004269:DNA, Bacterial