A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae

Abstract

Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.

Keywords: Enterobacteriaceae; carbapenem; meta-analysis; resistance; risk factors; systematic review.

FIG 1

Flow diagram of study selection for the systematic review of studies on carbapenem-resistant Enterobacteriaceae.

FIG 2

Forest plots of random-effects meta-analyses of antibiotic exposure as a risk factor and/or protective factor for the acquisition of carbapenem-resistant Enterobacteriaceae. (A) Carbapenem use; (B) cephalosporin use; (C) quinolone use; (D) β-lactam use; (E) glycopeptide use. *, nonsignificant confidence interval (Orsi et al. were contacted multiple times to receive the correct numbers; unfortunately, the authors did not respond).

FIG 3

Forest plots of random-effects meta-analyses of other risk factors and/or protective factors for the acquisition of carbapenem-resistant Enterobacteriaceae. (A) Underlying disease or condition; (B) invasive procedures; (C) medical devices; (D) ICU admission; (E) demographic patient characteristics; (F) exposure to hospital care; (G) mechanical ventilation; (H) CRE exposure.

FIG 3

Forest plots of random-effects meta-analyses of other risk factors and/or protective factors for the acquisition of carbapenem-resistant Enterobacteriaceae. (A) Underlying disease or condition; (B) invasive procedures; (C) medical devices; (D) ICU admission; (E) demographic patient characteristics; (F) exposure to hospital care; (G) mechanical ventilation; (H) CRE exposure.