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The Complex Epidemiology of Carbapenem-Resistant Enterobacter Infections: A Multicenter Descriptive Analysis

  • Tsilia Lazarovitch (a1), Keren Amity (a2), Joseph R. Coyle (a3), Benjamin Ackerman (a4), Ruthy Tal-Jasper (a5), Hadas Ofer-Friedman (a3), Kayoko Hayakawa (a6), Christopher Bogan (a6), Paul R. Lephart (a6), Tamir Kaplansky (a4), Moran Maskit (a4), Tal Azouri (a4), Ronit Zaidenstein (a2) (a4), Federico Perez (a7) (a8), Robert A. Bonomo (a7) (a8) (a9) (a10) (a11), Keith S. Kaye (a6) and Dror Marchaim (a4) (a5)...

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.


To conduct an extensive epidemiologic analysis of carbapenem-resistant Enterobacter spp. (CREn) from 2 endemic and geographically distinct centers.


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.


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.


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.

Infect. Control Hosp. Epidemiol. 2015;36(11):1283–1291

Corresponding author
Address correspondence to Dror Marchaim, MD, Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel (
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T. L. and K. A. contributed equally to this article.

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