• Kalisvar Marimuthu, Indumathi Venkatachalam, Wei Xin Khong, Tse Hsien Koh, Benjamin Pei Zhi Cherng, My Van La, Partha Pratim De, Prabha Unny Krishnan, Thean Yen Tan, Raymond Fong Kok Choon, Surinder Kaur Pada, Choong Weng Lam, Say Tat Ooi, Rama Narayana Deepak, Nares Smitasin, Eng Lee Tan, Jia Jun Lee, Asok Kurup, Barnaby Young, Nancy Tee Wen Sim, Koh Cheng Thoon, Dale Fisher, Moi Lin Ling, Brenda Ang Sze Peng, Yik-Ying Teo, Li Yang Hsu, Lin Raymond Tzer Pin RTP National Public Health Laboratory, Ministry of Health of Singapore. Department , Rick Twee-Hee Ong, Jeanette Teo, Oon Tek Ng, and Carbapenemase-Producing Enterobacteriaceae in Singapore (CaPES) Study Group.
• Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.
• Clin. Infect. Dis. 2017 May 15; 64 (suppl_2): S68-S75.

BackgroundSince 2010, the incidence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing in Singapore. We analyzed the clinical and molecular epidemiology of CRE among adult inpatients in Singapore.MethodsQuarterly incidence of unique subjects (per 100000 patient-days) with positive clinical and surveillance cultures for CRE were estimated based on mandatory data submitted to the National Public Health Laboratory by public hospitals between 2010 and 2015. CRE-positive adult inpatients were prospectively recruited from 6 public sector hospitals between December 2013 and April 2015. Subjects answered a standardized epidemiologic questionnaire and provided samples for this study. Further clinical information was extracted from subjects' electronic medical records. Whole-genome sequencing was performed on study isolates to determine transmission clusters.ResultsIncidence of CRE clinical cultures among adult inpatients plateaued from 2013 (range: 7.73 to 10.32 per 100000 patient-days) following an initial increase between 2010 and end-2012. We prospectively recruited 249 subjects. Their median age was 65 years, 108 (43%) were female, and 161 (64.7%) had carbapenemase-producing Enterobacteriaceae (CPE). On multivariate analysis, prior carbapenem exposure (OR: 3.23; 95% CI: 1.67-6.25) and hematological malignancies (OR: 2.85; 95% CI: 1.10-7.41) were associated with non-carbapenemase-producing CRE (NCPE) (n = 88) compared with CPE (n = 161) subjects. Among 430 CRE isolates from the 249 subjects, 307(71.3%) were CPE, of which 154(50.2%) were blaKPC-positive, 97(31.6%) blaNDM-positive, and 42 (13.7%) blaOXA-positive. Klebsiella pneumoniae (n = 180, 41.9%), Escherichia coli (n = 129, 30.0%) and Enterobacter cloacae (n = 62, 14.4%) were the main Enterobacteriaceae species. WGS (n = 206) revealed diverse bacterial strain type (STs). The predominant blaKPC-positive plasmid was pHS102707 (n = 62, 55.4%) and the predominant blaNDM-positive plasmid was pNDM-ECS01 (n = 46, 48.9%). Five transmission clusters involving 13 subjects were detected.ConclusionsClinical CRE trend among adult inpatients showed stabilization following a rapid rise since introduction in 2010 potentially due to infection prevention measures and antimicrobial stewardship. More work is needed on understanding CPE transmission dynamics.© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

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