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The World Health Organization and Centers for Disease Control and Prevention consider the global increase in multidrug‐resistant organisms (MDROs) to be one of the greatest modern threats to public health. Limited treatment options exist for microorganisms such as carbapenem‐resistant Enterobacterales and Candida auris; as a result, infected patients may experience poor outcomes. Perioperative nurses should use infection prevention measures (eg, contact precautions) to prevent the spread of emerging MDROs when transporting patients to and from procedures, caring for patients during procedures, and completing between‐procedure cleaning. Because nurses are involved with all phases of perioperative care, they are well‐positioned to serve as infection prevention champions and provide education to personnel, patients, and caregivers. This article describes actions and steps the perioperative nurse should take during implementation of contact precautions to prevent the transmission of MDROs—specifically, emerging pathogens carbapenem‐resistant Enterobacterales and C auris.

Infections due to multidrug-resistant organisms (MDROs) are a health threat due to increasing patient morbidity and mortality and the burden on healthcare systems. Robust infection prevention and control (IPC) measures are needed to minimize their emergence in hospitals. Therefore, various international and national IPC guidelines exist, yet the lack of harmonized IPC guidelines complicates the management of patients seeking healthcare across European borders. This study explores the similarities and differences in IPC measures for vancomycin-resistant enterococci (VRE) and multidrug-resistant (MDR) Enterobacterales both on local and national levels within the northern Dutch-German cross-border region. In Germany, IPC efforts are often led by hospital hygiene doctors, whereas in the Netherlands, they involve a collaboration between infection preventionists and clinical microbiologists, with local variations. The local guidelines in both countries, as expected, are based on national recommendations, yet introduce specific regulations in various aspects. The Dutch guidelines are more stringent for VRE management compared to the German guidelines, often imposing additional local measures beyond national requirements. The Dutch and German guidelines largely diverge in definitions of MDR Gram-negative bacteria. Unlike the Dutch guidelines, the German guidelines do not currently recommend screening or isolation for extended-spectrum beta-lactamase-producing Enterobacterales . For carbapenem-resistant and carbapenemase-producing Enterobacterales , there is no notable distinction between the countries’ guidelines, with both sharing the objective of maintaining a low prevalence and actively working towards containment. Inconsistencies in guidelines can lead to inefficient information exchange and inconsistent hygienic measures during patient transfers. Despite common commitments, differences in focus may reflect evolving understanding of MDRO transmission and ongoing debates on their management. Our findings highlight the divergence of IPC guidelines for the management of MDROs across two countries and call for collaboration in cross-border regions to increase the effectiveness of MDRO management in these regions and improve patient care.

The global emergence of carbapenemase-producing bacteria capable of hydrolyzing the once effective carbapenem antibiotics is considered a contemporary public health concern. Carbapenemase enzymes, once constrained to isolates of Klebsiella pneumoniae, are now routinely reported in different bacteria within the Enterobacterales order of bacteria, creating the acronym CRE which now defines Carbapenem-Resistant Enterobacterales. CRE harboring different types of enzymes, including the most prevalent types KPC, VIM, IMP, NDM, and OXA-48, are now routinely reported and more importantly, are now frequently present in many infections world-wide. Defining and updating the contemporary epidemiology of both the US and global burden of carbapenem-resistant infections is now more important than ever. This review describes the global distribution and continued evolution of carbapenemases which continue to spread at alarming rates. Informed understanding of the current epidemiology of CRE, coupled with advances in antibiotic options, and the use rapid diagnostics offers the potential for rapid identification and management of carbapenem-resistant infections.Plain Language SummaryCarbapenems are a subclass of antibiotic used to treat infections caused by Gram-negative bacteria, particularly in resistant and multidrug-resistant (MDR) infections where penicillin and cephalosporins are no longer effective. However, carbapenem-resistant Enterobacterales (CRE) have emerged due to acquisition of carbapenemase enzymes, most prevalent types are KPC, VIM, IMP, NDM, and OXA-48; infections caused by these bacteria have disseminated globally in both the healthcare and community setting. Resulting in a significant public health issue and clinical burden, these CRE infections are associated with increased morbidity and mortality, in part because carbapenems are the last therapeutic line of defense against resistant and MDR bacterial infections. The author wanted to investigate current US and global epidemiology of carbapenem-resistant infections, identify factors driving changes, as well as diagnostic technologies, and reporting or surveillance methods in place to track trends and inform therapeutic protocols and development. Overall, carbapenemase enzymes originally only reported in one country or region in 2006-2007, by 2013 and onwards have spread not only to surrounding countries but to other continents, which has impacted antibiotic resistance patterns and susceptibility. Increasing human travel and environmental factors, such as livestock care, food distribution, sewage, and recreational water, have contributed to global dissemination of CRE. Active surveillance programs are key to tracking resistance in real time, in order to update susceptibility breakpoints and epidemiology, which can inform antibiotic treatment choices, management guidelines, and the development of new therapeutics. Together, these factors will help to identify, control, and treat the spread of carbapenem resistance.

Infectious disease outbreaks have caused thousands of deaths and hospitalizations, along with severe negative global economic impacts. Among these, infections caused by antimicrobial-resistant microorganisms are a major growing concern. The misuse and overuse of antimicrobials have resulted in the emergence of antimicrobial resistance (AMR) worldwide. Carbapenem-resistant Enterobacterales (CRE) are among the bacteria that need urgent attention globally. The emergence and spread of carbapenem-resistant bacteria are mainly due to the rapid dissemination of genes that encode carbapenemases through horizontal gene transfer (HGT). The rapid dissemination enables the development of host colonization and infection cases in humans who do not use the antibiotic (carbapenem) or those who are hospitalized but interacting with environments and hosts colonized with carbapenemase-producing (CP) bacteria. There are continuing efforts to characterize and differentiate carbapenem-resistant bacteria from susceptible bacteria to allow for the appropriate diagnosis, treatment, prevention, and control of infections. This review presents an overview of the factors that cause the emergence of AMR, particularly CRE, where they have been reported, and then, it outlines carbapenemases and how they are disseminated through humans, the environment, and food systems. Then, current and emerging techniques for the detection and surveillance of AMR, primarily CRE, and gaps in detection technologies are presented. This review can assist in developing prevention and control measures to minimize the spread of carbapenem resistance in the human ecosystem, including hospitals, food supply chains, and water treatment facilities. Furthermore, the development of rapid and affordable detection techniques is helpful in controlling the negative impact of infections caused by AMR/CRE. Since delays in diagnostics and appropriate antibiotic treatment for such infections lead to increased mortality rates and hospital costs, it is, therefore, imperative that rapid tests be a priority.

Background The burden of carbapenem resistance is not well studied in the Middle East. We aimed to describe the molecular epidemiology and outcome of carbapenem-resistant Enterobacterales (CRE) infections from several Saudi Arabian Centers. Methods This is a multicenter prospective cohort study conducted over a 28-month period. Patients older than 14 years of age with a positive CRE Escherichia coli or Klebsiella pneumoniae culture and a clinically established infection were included in this study. Univariate and multivariable logistic models were constructed to assess the relationship between the outcome of 30-day all-cause mortality and possible continuous and categorical predictor variables. Results A total of 189 patients were included. The median patient age was 62.8 years and 54.0% were male. The most common CRE infections were nosocomial pneumonia (23.8%) and complicated urinary tract infection (23.8%) and 77 patients (40.7%) had CRE bacteremia. OXA-48 was the most prevalent gene (69.3%). While 100 patients (52.9%) had a clinical cure, 57 patients (30.2%) had died within 30 days and 23 patients (12.2%) relapsed. Univariate analysis to predict 30-day mortality revealed that the following variables are associated with mortality: older age, high Charlson comorbidity index, increased Pitt bacteremia score, nosocomial pneumonia, CRE bacteremia and diabetes mellitus. In multivariable analysis, CRE bacteremia remained as an independent predictor of 30 day all-cause mortality [AOR and 95% CI = 2.81(1.26–6.24), p = 0.01]. Conclusions These data highlight the molecular epidemiology and outcomes of CRE infection in Saudi Arabia and will inform future studies to address preventive and management interventions.

Objectives: To evaluate the potency of Manuka honey UMF +15 against Carbapenem-resistant Enterobacterales (CRE). Bacterial resistance is a worldwide problem that is increasing year by year, especially Carbapenem resistance. Alternatives to antibiotics are needed to both reduce costs, and to reduce the spread of antibiotic resistance, with the ultimate goal of saving lives. Methods: The efficacy of Manuka honey UMF +15 was tested by 2 methods; Well diffusion assay and minimum bactericidal concentration (MBC) against twenty Carbapenem-resistant isolates which collected from Makkah city hospitals during three months of study from 1st of September 2023 up to 1st of December 2023. Results: The growth of all isolates of Carbapenem-resistant Enterobacterales (CRE) was severely inhibited by low concentrations of Manuka honey, affecting 25% of isolates at 15% and 75% of isolates at 18% of Manuka honey. In addition, using the honey at different concentrations in a well diffusion assay resulted, as expected, in a variable zone diameter, ranging from large zones(14mm) to small zones (2 mm) according to the concentration of the honey. Conclusion: This study shows the remarkable antibacterial activity of Manuka honey and suggests that this natural remedy might be used in the future as an alternative treatment option against Carbapenem-resistant Enterobacterales (CRE); however, further clinical trials should be performed to corroborate our initial findings. Keywords: Carbapenem-resistant Enterobacterales (CRE), activity of Manuka honey, antimicrobial resistance

Background Colistin-carbapenem combination therapy is frequently used for carbapenem-resistant Gram-negative infections, but its impact on subsequent acquisition of carbapenem-resistant Enterobacterales (CRE) requires further investigation. We evaluated the incidence of CRE acquisition and performed molecular characterization of recovered isolates following treatment with colistin–meropenem versus colistin monotherapy. Methods This analysis addressed a pre-specified secondary aim of the AIDA multicenter randomized controlled trial, which compared colistin monotherapy to colistin–meropenem combination therapy for carbapenem-resistant Gram-negative infections at six hospitals in Israel, Greece, and Italy. Rectal swabs were obtained at enrollment and weekly until day 28 or discharge. Swabs were processed centrally by plating onto MacConkey agar supplemented with imipenem to selectively isolate CRE. Recovered colonies were identified using MALDI-TOF mass spectrometry, and meropenem minimum inhibitory concentrations (MICs) were determined by broth microdilution. Clinical cultures were obtained as indicated and processed locally, and CRE isolates were sent to the central laboratory for confirmation and characterization. Whole-genome sequencing was used to determine sequence types and resistance genes. Patients were excluded if they had CRE detected at baseline, either by rectal culture or as the index clinical isolate, or if no follow-up rectal cultures were available. Results Among 197 eligible patients (99 colistin; 98 colistin–meropenem), CRE acquisition occurred in 6 (3.0%): 1/99 (1.0%, 95% CI 0.03–5.5%) in the monotherapy arm and 5/98 (5.1%, 95% CI 1.7–11.5%) in the combination arm ( p  = 0.12). Two patients in the combination arm developed clinical infections caused by CRE (bacteremia and pneumonia); none occurred in the monotherapy arm. Carbapenemase genes were detected in four of the six acquired CRE isolates: one in the monotherapy arm ( bla VIM ) and three in the combination arm (all bla KPC ). Identified species included Klebsiella pneumoniae and Escherichia coli belonging to established and emerging high-risk, multidrug-resistant clones. Conclusions Patients treated with colistin-meropenem had a higher, though not statistically significant, rate of CRE acquisition. Early detection of high-risk CRE clones highlights the need to weigh potential unintended consequences when selecting combination regimens for multidrug-resistant infections. Trial Registration AIDA trial was registered with ClinicalTrials.gov, number NCT01732250 (submitted 19-11-2012).

The carbapenem-resistant Enterobacterales (CRE) pose a pressing public health concern. Here, we investigated the frequency of CRE bacteria, carbapenemase-encoding genes, and the molecular epidemiology of carbapenemase-resistant Escherichia coli in wastewater resources and healthy carriers in Iran. Out of 617 Enterobacterales bacteria, 24% were carbapenem-resistant. The prevalence of CRE bacteria in livestock and poultry wastewater at 34% and hospital wastewater at 33% was significantly higher (P ≤ 0.05) than those in healthy carriers and municipal wastewater at 22 and 17%, respectively. The overall colonization rate of CRE in healthy individuals was 22%. Regarding individual Enterobacterales species, the following percentages of isolates were found to be CRE: E. coli (18%), Citrobacter spp. (24%), Klebsiella pneumoniae (28%), Proteus spp. (40%), Enterobacter spp. (25%), Yersinia spp. (17%), Hafnia spp. (31%), Providencia spp. (21%), and Serratia spp. (36%). The blaOXA-48 gene was detected in 97% of CRE isolates, while the blaNDM and blaVIM genes were detected in 24 and 3% of isolates, respectively. The B2 phylogroup was the most prominent group identified in carbapenem-resistant E. coli isolates, accounting for 80% of isolates. High prevalence of CRE with transmissible carbapenemase genes among healthy people and wastewater in Iran underscores the need for assertive measures to prevent further dissemination.

The aim of this work was to investigate the activity of ceftazidime-avibactam (CZA) and aztreonam-avibactam (AZA) against bloodstream infections caused by carbapenem-resistant organisms (CROs). Non-duplicate CROs, including 56 carbapenem-resistant (CR-Eco), 318 carbapenem-resistant (CR-Kpn), and 65 carbapenem-resistant (CR-Pae), were collected using the Blood Bacterial Resistant Investigation Collaborative System (BRICS) program in China. The minimum inhibitory concentrations (MICs) of 24 antibiotics were tested. Carbapenemase genes were amplified for CZA-resistant CROs by PCR. The MICs of CZA and AZA were further determined with avibactam at 8 and 16 mg/L, respectively. The resistance rate of polymyxin B against CROs was less than 5%. Only one CR-Kpn was resistant to tigecycline. The resistance rates of CZA against CR-Eco, CR-Kpn, and CR-Pae were 75.0%, 12.6%, and 18.5%, respectively. The MIC values of AZA against CR-Eco, CR-Kpn, and CR-Pae were 2/4, 1/4, and 64/4 mg/L, respectively. Among the CZA-resistant CROs, 42 (100%) CR-Eco, 24 (60%) CR-Kpn, and 1 (8.3%) CR-Pae isolates harbored metallo-β-lactamase genes. The increase of avibactam concentration enhanced the susceptibility of CZA and AZA against CROs, especially for CR-Eco and CR-Kpn. The activity of AZA was superior to that of CZA against CR-Eco and CR-Kpn, whereas CZA showed better effect against CR-Pae.

Introduction: The spread of Carbapenemase-producing Enterobacterales (CPEs) has become a significant concern in Algeria, with limited data available on their presence in community settings. This research investigated the resistance mechanisms of carbapenem-resistant Enterobacterales (CREs) collected from hospitals and the community in Skikda city, Algeria, between December 2020 and June 2022. Methodology: The study collected Enterobacterales strains resistant to ertapenem from inpatient and outpatient populations. An automated system was used for identification and antibiotic susceptibility testing. β-lactamase production was evaluated through phenotypic tests and confirmed by standard PCR. Lastly, the carbapenemase genes were sequenced using the Sanger method. Results: 17 CRE were isolated, with 9 from inpatients and 8 from outpatients. These isolates belonged to four species: Klebsiella pneumoniae (n = 8), Escherichia coli (n = 6), Enterobacter cloacae (n = 1), and Proteus mirabilis (n = 1). Of 15 CPEs, 11 were extended-spectrum β-lactamases (ESBLs) positive, 5 were plasmid-mediated cephalosporinase (AmpC) positive, and 1 harbored all three β-lactamases. All metallo-β-lactamase-producing strains carried the New Delhi metallo-beta-lactamase gene (blaNDM), including 5 NDM-1 and 7 NDM-5 variants. The presence of blaOXA-48 and blaOXA-244 was observed in one outpatient strain each. NDM was associated with Cefotaximase Munich (CTX-M) ESBL in 8 isolates, while Cephamycinase (CMY) was detected in 3 NDM-5-producing E. coli. Conclusions: This research highlights the rising prevalence of carbapenemases NDM-1 and NDM-5 among inpatients and outpatients and supports the notion that OXA-48 is becoming increasingly widespread beyond Algerian hospitals.