Carbapenem-Resistant Enterobacterales in Long-Term Care Facilities: A Global and Narrative Review

Abstract

The emergence of carbapenem-resistant Enterobacterales (CRE) has become a major public health concern. Moreover, its colonization among residents of long-term care facilities (LTCFs) is associated with subsequent infections and mortality. To further explore the various aspects concerning CRE in LTCFs, we conducted a literature review on CRE colonization and/or infections in long-term care facilities. The prevalence and incidence of CRE acquisition among residents of LTCFs, especially in California, central Italy, Spain, Japan, and Taiwan, were determined. There was a significant predominance of CRE in LTCFs, especially in high-acuity LTCFs with mechanical ventilation, and thus may serve as outbreak centers. The prevalence rate of CRE in LTCFs was significantly higher than that in acute care settings and the community, which indicated that LTCFs are a vital reservoir for CRE. The detailed species and genomic analyses of CRE among LTCFs reported that Klebsiella pneumoniae is the primary species in the LTCFs in the United States, Spain, and Taiwan. KPC-2-containing K. pneumoniae strains with sequence type 258 is the most common sequence type of KPC-producing K. pneumoniae in the LTCFs in the United States. IMP-11- and IMP-6-producing CRE were commonly reported among LTCFs in Japan. OXA-48 was the predominant carbapenemase among LTCFs in Spain. Multiple risk factors associated with the increased risk for CRE acquisition in LTCFs were found, such as comorbidities, immunosuppressive status, dependent functional status, usage of gastrointestinal devices or indwelling catheters, mechanical ventilation, prior antibiotic exposures, and previous culture reports. A high CRE acquisition rate and prolonged CRE carriage duration after colonization were found among residents in LTCFs. Moreover, the patients from LTCFs who were colonized or infected with CRE had poor clinical outcomes, with a mortality rate of up to 75% in infected patients. Infection prevention and control measures to reduce CRE in LTCFs is important, and could possibly be controlled via active surveillance, contact precautions, cohort staffing, daily chlorhexidine bathing, healthcare-worker education, and hand-hygiene adherence.

Global Threat of Carbapenem-Resistant Gram-Negative Bacteria

“…Infections caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB) have become major challenges for global health institutions because of the limited antibiotic options and high mortality rates ( Li et al., 2020 ; Chen H.Y. et al., 2021 ; Wang et al., 2021 ; Zhang et al., 2021b ).…”

Whole-Genome Sequencing (WGS) of Carbapenem-Resistant K. pneumoniae Isolated in Long-Term Care Facilities in the Northern Italian Region

“…One reason for the rapid dissemination of K. pneumoniae is the presence of antibiotic resistance genes in mobile genetic elements and the Inc-groups, which belong to plasmids IncF, IncFII(K1), IncR, IncX, IncX3, IncI2, and ColE1 [15][16][17][18][19]. However, carbapenem-resistant K. pneumoniae strains are not only confined to healthcare settings, but also to the community and among residents of LTCFs [20][21][22][23][24]. In Italy, the carbapenem-resistant Enterobacterales from LTCFs have been reported since 2010 in different endemic areas [25][26][27][28].…”

Intra- and Extra-Hospital Dissemination of IMP-22-Producing Klebsiella pneumoniae in Northern Portugal: The Breach of the Hospital Frontier Toward the Community

“…The early identification of CPE in hospitalized patients and the implementation of adequate infection control measures are, thus, extremely important to prevent the persistence and spread of carbapenem-resistant bacteria ( Magiorakos et al, 2017 ), such as the IMP-22-producing K. pneumoniae strains we report in this study, not only in the hospital settings but also in the community. In fact, after hospital discharge, patients can remain colonized and contribute for the dissemination of these MDR K. pneumoniae within extra-hospital care settings, namely, LTCF, and nursing homes ( Chen et al, 2021 ). Therefore, the early identification of carriers and the implementation of adequate control strategies are essential to prevent nosocomial outbreaks.…”