Table 1.
Studies included in the scoping review
| Study, year | Country (region) | Study period | Study design | Sample | Results (resistance among all bacterial isolates in sample) | Definition of CAI | Conclusions (CRE in community) |
|---|---|---|---|---|---|---|---|
| Tang et al., 2016 [36] | Taiwan (Tainan City) | Jan.– July 2015 | Single-centre, retrospective | N = 78 CRE cases | CR Klebsiella pneumoniae, 42/78 (53.8%) CR Enterobacter cloacae, 24/78 (30.8%) CR Escherichia coli, 11/78 (14.1%) |
HAI if hospitalised >48 h in previous 2 weeks or residence in LTCF; all others CAI | Of the 78 cases of CRE, 23 (29.5%) were CAI; included colonisation |
| Miller and Johnson, 2015 [35] | USA (North Carolina) | Jan. 2012–Dec. 2013 | Single-centre, retrospective case–control | N = 41 CRE cases | CR Enterobacter spp., 20/41 (49%) CR K. pneumoniae, 18/41 (44%) |
‘likely community-acquired’ with no definition given, but variables on medical history collected | Of 41 cases of CRE, 4 (9.8%) were likely CAI; excluded asymptomatic colonisation |
| Guh et al., 2015 [25] | USA (7 metro areas) | Jan. 2012–Dec. 2013 | Population-and laboratory-based active surveillance | N = 599 CRE cases in 481 individuals; 371/569 (65.2%) cases with data available were hospitalised at time of culture or within 30 days of having positive culture | CR K. pneumoniae, 351/599 (58.6%) CR E. coli, 89/599 (14.9%) CR E. cloacae, 75/599 (12.5%) |
‘community-associated’ if no documented relevant healthcare exposure prior to positive culture | Of the 481 individuals with CRE, ca. 8% had no documented preceding healthcare exposure |
| Coccolini et al., 2015 [38] | Worldwide (116 medical institution s across 5 continents) | Jan.– June 2012 Oct. 2012–Mar. 2013 |
Two multicentre prospective cohorts | N = 306 patients with IAIs secondary to acute cholecystitis with microbiological studies performed and 267 bacteria isolated | ESBL E. coli, 12/267 (4.5%) ESBL K. pneumoniae, 4/267 (1.5%) CR K. pneumoniae: 1/267 (0.4%) |
‘community-acquired’ with no definition given | The single case of CRE was not CAI |
| Vlieghe et al., 2015 [42] | Cambodia (Phnom Penh) | 2007–2010 | Single-centre, prospective cohort | BSIs in hospital, 91 Enterobacteriaceae isolates with cefotaxime resistance | ESBL Enterobacteriaceae, 85/91 (93.4%) Colistin-resistant Enterobacter spp., 3/91 (3.3%) |
‘community-acquired’ if infection started before or during first 2 days of hospitalisation | No CRE found in either HAI or CAI sample |
| Lohiya et al., 2015 [40] | India (Haryana) | Nov. 2012–Dec. 2013 | Community surveillance programme | N = 433 healthy individuals providing urine samples; 58/433 (13.4%) positive for Enterobacteriaceae | ESBL E. coli, 20% ESBL K. pneumoniae, 8.7% | No definition given, but entire sample considered ‘community’ because sampled healthy individuals | No CRE found in sample |
| Thaden et al., 2014 [16] | USA (25 community hospitals in North & South Carolina, Virginia and Georgia) | Jan. 2008–Dec. 2012 | Multicentre, prospective cohorts | N = 305 CRE cases; 180 (59%) with symptomatic infection, 125 (41%) asymptomatic colonisation | CR K. pneumoniae, 277/305 (90.8%) | ‘Community acquired’ if infection or colonisation occurring <48 h of patient’s admission and none of the risk factors: previous hospitalisation, surgery, dialysis, or LTCF in past 12 months or presence of invasive device | Of the 305 cases of CRE, 17 (5.6%) were defined as CAI |
| Garrido et al., 2014 [41] | Spain (Zaragoza) | Jan.– June 2010 | Single-centre, prospective surveillance programme | N = 3695 faecal samples from 2508 patients presenting with GI complaint as outpatient or inpatient at hospital; 167 (4.5%) positive for Enterobacteriaceae | ESBL E. coli, 142/167 (85.0%) AmpC E. coli, 16/167 (9.6%) ESBL K. pneumoniae, 12/167 (7.2%) |
Infections of the ‘community’ were from all outpatients | No CRE found in HAI or CO sample |
| Rai et al., 2014 [45] | India (East Delhi) | 2011 | Single-centre, prospective surveillance programme | N = 242 stool samples positive for Enterobacteriaceae from 123 outpatients undergoing GI surgery | CRE, 24/242 (9.9%) | No definition given, but entire sample considered ‘community’ because attending an outpatient clinic | Since entire sample was from community, all 9.9% of isolates were CO-CRE carriage |
| Brennan et al., 2014 [37] | USA (Michigan) | Sept. 2012–Feb. 2013 | Multicentre surveillance programme | N = 102 cases of CRE | CR K. pneumoniae, 89/102 (87%) CR E. coli, 13/102 (13%) |
‘community onset’ if specimen was collected ≤3 days after admission, but still considered HAI if exposure to healthcare in past 90 days | Of the 102 cases of CRE, 66 (64.7%) were deemed CO, but only 11 (10.8%) had no documented exposure to healthcare in past 90 days and could be classified as CAI |
| Turnidge et al., 2013 [43] | Australia (all six states) | 2012 | Multicentre surveillance programme | N = 2802 UTI isolates from patients presenting to outpatient clinic, emergency departments or community practitioners | ESBL E. coli, 91/2802 (3.2%) ESBL K. pneumoniae, 21/2802 (0.7%) CR E. cloacae, 1/2802 (0.04%) |
No definition given, but entire sample considered ‘community-onset’ because presenting as outpatients | Since entire sample was from community, the single CRE case (0.04%) was considered CO |
| Villar et al., 2013 [29] | Argentina (Buenos Aires) | Mar.– July 2012 | Single-centre surveillance programme | N = 164 non-hospitalised patients presenting faecal samples at clinic with GI complaints | ESBL-producing Enterobacteriaceae, 31/164 (18.9%) CRE, 8/164 (4.9%) |
‘community-acquired’ defined by no hospitalisation in past 2 months or antibiotic use in past 7 days | Since entire sample was from community, all 4.9% were community CRE carriage |
| Sheng et al., 2013 [44] | Asia-Pacific region (11 countries) | 2008–2009 | Multicentre prospective cohort | N = 5585 IAIs positive for Enterobacteriaceae; 699 (12.5%) positive for β-lactamase gene | CRE, 197/699 (28.2%) | Presumed ‘community-acquired’ if organisms isolated <48 h of hospitalisation | Of the 197 CRE cases, 42 (21.3%) were CAI |
| Alexopoulou et al., 2013 [39] | Greece (Athens) | 2008–May 2011 | Single-centre retrospective | N = 156 cirrhotic patients with spontaneous bacterial peritonitis, 47 with positive ascetic fluid culture included in sample | ESBL E. coli, 3/47 (6.4%) CR K. pneumoniae KPC, 4/47 (8.5%) |
Community-acquired if present on admission or developed within first 48 h after hospitalisation | Of the 4 cases of CRE, none were CO |
| Gijón et al., 2012 [46] | Spain (Madrid) | Jan.– Apr. 2006 July 2009–Jan. 2010 |
Two prospective cohorts | N = 1100 faecal samples randomly selected from laboratory from 1043 patients | CRE VIM, 11/1043 (1.1%) | Patients from community setting defined by samples from non-hospitalised patients, with no hospitalisation in past 3 months | Of the 11 CRE cases, 2 (18.2%) were among non-hospitalised patients with no previous admission and considered community CRE carriage |
CAI, community-associated infection; CRE, carbapenem-resistant Enterobacteriaceae; CR, carbapenem-resistant; HAI, healthcare-associated infection; LTCF, long-term care facility; IAI, intra-abdominal infection; ESBL, extended-spectrum β-lactamase; BSI, bloodstream infection; GI, gastrointestinal; CO, community-onset; UTI, urinary tract infection.