title: Epidemiology of Carbapenem-Resistant Enterobacteriaceae in 7 US Communities, 2012-2013.
abstract: OBJECTIVE
  Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly reported worldwide as a cause of infections with high-mortality rates. Assessment of the US epidemiology of CRE is needed to inform national prevention efforts.
  
  
  OBJECTIVE
  To determine the population-based CRE incidence and describe the characteristics and resistance mechanism associated with isolates from 7 US geographical areas.
  
  
  METHODS
  Population- and laboratory-based active surveillance of CRE conducted among individuals living in 1 of 7 US metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. Cases of CRE were defined as carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, or Klebsiella oxytoca that were recovered from sterile-site or urine cultures during 2012-2013. Case records were reviewed and molecular typing for common carbapenemases was performed.
  
  
  METHODS
  Demographics, comorbidities, health care exposures, and culture source and location.
  
  
  METHODS
  Population-based CRE incidence, site-specific standardized incidence ratios (adjusted for age and race), and clinical and microbiological characteristics.
  
  
  RESULTS
  Among 599 CRE cases in 481 individuals, 520 (86.8%; 95% CI, 84.1%-89.5%) were isolated from urine and 68 (11.4%; 95% CI, 8.8%-13.9%) from blood. The median age was 66 years (95% CI, 62.1-65.4 years) and 284 (59.0%; 95% CI, 54.6%-63.5%) were female. The overall annual CRE incidence rate per 100<000 population was 2.93 (95% CI, 2.65-3.23). The CRE standardized incidence ratio was significantly higher than predicted for the sites in Georgia (1.65 [95% CI, 1.20-2.25]; P < .001), Maryland (1.44 [95% CI, 1.06-1.96]; P = .001), and New York (1.42 [95% CI, 1.05-1.92]; P = .048), and significantly lower than predicted for the sites in Colorado (0.53 [95% CI, 0.39-0.71]; P < .001), New Mexico (0.41 [95% CI, 0.30-0.55]; P = .01), and Oregon (0.28 [95% CI, 0.21-0.38]; P < .001). Most cases occurred in individuals with prior hospitalizations (399/531 [75.1%; 95% CI, 71.4%-78.8%]) or indwelling devices (382/525 [72.8%; 95% CI, 68.9%-76.6%]); 180 of 322 (55.9%; 95% CI, 50.0%-60.8%) admitted cases resulted in a discharge to a long-term care setting. Death occurred in 51 (9.0%; 95% CI, 6.6%-11.4%) cases, including in 25 of 91 cases (27.5%; 95% CI, 18.1%-36.8%) with CRE isolated from normally sterile sites. Of 188 isolates tested, 90 (47.9%; 95% CI, 40.6%-55.1%) produced a carbapenemase.
  
  
  CONCLUSIONS
  In this population- and laboratory-based active surveillance system in 7 states, the incidence of CRE was 2.93 per 100<000 population. Most CRE cases were isolated from a urine source, and were associated with high prevalence of prior hospitalizations or indwelling devices, and discharge to long-term care settings.
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alice Y
authors.initials: AY
authors.lastname: Guh
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Sandra N
authors.initials: SN
authors.lastname: Bulens
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Yi
authors.initials: Y
authors.lastname: Mu
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia3Georgia Emerging Infections Program, Decatur.
authors.forename: Jesse T
authors.initials: JT
authors.lastname: Jacob
authors.affiliation: Georgia Emerging Infections Program, Decatur4Atlanta Research and Education Foundation, Decatur, Georgia5Atlanta Veterans Affairs Medical Center, Atlanta, Georgia.
authors.forename: Jessica
authors.initials: J
authors.lastname: Reno
authors.affiliation: Georgia Emerging Infections Program, Decatur4Atlanta Research and Education Foundation, Decatur, Georgia5Atlanta Veterans Affairs Medical Center, Atlanta, Georgia.
authors.forename: Janine
authors.initials: J
authors.lastname: Scott
authors.affiliation: Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: Lucy E
authors.initials: LE
authors.lastname: Wilson
authors.affiliation: Maryland Department of Health and Mental Hygiene, Baltimore.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Vaeth
authors.affiliation: Minnesota Department of Health, St Paul.
authors.forename: Ruth
authors.initials: R
authors.lastname: Lynfield
authors.affiliation: Minnesota Department of Health, St Paul.
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Shaw
authors.affiliation: Minnesota Department of Health, St Paul.
authors.forename: Paula M Snippes
authors.initials: PM
authors.lastname: Vagnone
authors.affiliation: Colorado Department of Public Health and Environment, Denver.
authors.forename: Wendy M
authors.initials: WM
authors.lastname: Bamberg
authors.affiliation: Colorado Department of Public Health and Environment, Denver.
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Janelle
authors.affiliation: New York Emerging Infections Program and University of Rochester Medical Center, Rochester.
authors.forename: Ghinwa
authors.initials: G
authors.lastname: Dumyati
authors.affiliation: New York Emerging Infections Program and University of Rochester Medical Center, Rochester.
authors.forename: Cathleen
authors.initials: C
authors.lastname: Concannon
authors.affiliation: Oregon Health Authority, Portland.
authors.forename: Zintars
authors.initials: Z
authors.lastname: Beldavs
authors.affiliation: Oregon Health Authority, Portland.
authors.forename: Margaret
authors.initials: M
authors.lastname: Cunningham
authors.affiliation: Oregon Health Authority, Portland.
authors.forename: P Maureen
authors.initials: PM
authors.lastname: Cassidy
authors.affiliation: University of New Mexico, Albuquerque.
authors.forename: Erin C
authors.initials: EC
authors.lastname: Phipps
authors.affiliation: University of New Mexico, Albuquerque.
authors.forename: Nicole
authors.initials: N
authors.lastname: Kenslow
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Travis
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: David
authors.initials: D
authors.lastname: Lonsway
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: J Kamile
authors.initials: JK
authors.lastname: Rasheed
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Brandi M
authors.initials: BM
authors.lastname: Limbago
authors.affiliation: Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Kallen
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D001426:Bacterial Proteins / Q000032:analysis; D015780:Carbapenems / Q000494:pharmacology*; D002648:Child; D002675:Child, Preschool; D003120:Colorado / Q000453:epidemiology; D004755:Enterobacteriaceae / Q000187:drug effects*; D004756:Enterobacteriaceae Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000652:urine; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008396:Maryland / Q000453:epidemiology; D008875:Middle Aged; D008910:Minnesota / Q000453:epidemiology; D009516:New Mexico / Q000453:epidemiology; D009518:New York / Q000453:epidemiology; D009922:Oregon / Q000453:epidemiology; D011159:Population Surveillance; D017678:Sex Distribution; D018440:beta-Lactam Resistance; D001618:beta-Lactamases / Q000032:analysis
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D015780:Carbapenems; D001618:beta-Lactamases; C063912:carbapenemase