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Antimicrobial Resistance

Key CDC Webpages and Resources on AR

Antimicrobial Resistance

Antimicrobial resistance (AR) occurs when germs, such as bacteria and fungi, have the ability to survive and withstand the effects of drugs that are intended to kill the germs and treat the infection. Mechanisms of antimicrobial resistance can be inherent or acquired, and some methods of resistance develop as a result of exposure to certain antimicrobial agents. Antimicrobial resistant infections can be very difficult for healthcare providers to effectively treat. Overuse and misuse of antimicrobials contribute to the growing problem of antimicrobial resistance.

Microorganisms that become resistant to multiple classes of antimicrobials are known as multidrug-resistant organisms (MDROs). Some pathogens have become resistant or non-susceptible to all available forms of treatment (i.e., pan-resistant or pan-non-susceptible infections), further complicating treatment options. MDROs continue to spread across the globe and pose a serious risk to public health, particularly among patients admitted to healthcare facilities.

Some of the most prevalent MDROs in New Jersey include:

Carbapenem-resistant Enterobacterales (CRE), such as KPC-producing Klebsiella pneumoniae and KPC-producing Escherichia coli

Carbapenem-resistant Acinetobacter baumannii (CRAB)

Carbapenem-resistant Pseudomonas aeruginosa (CRPA)

Candida auris

What to Report to CDS

NJDOH CDS asks for cases of the following MDROs to be reported upon identification:

Candida auris, colonization and infection cases

Carbapenemase-producing organisms (CPOs), colonization and infection cases

Pan-non-susceptible and pan-resistant organisms

Carbapenem-resistant Enterobacterales (CRE), Carbapenem-resistant Pseudomonas aeruginosa (CRPA), and Carbapenem-resistant Acinetobacter baumannii (CRAB) identified in the pediatric patient population

Extensively drug-resistant* Carbapenem-resistant Enterobacterales (CRE)

Extensively drug-resistant* Carbapenem-resistant Pseudomonas aeruginosa (CRPA)

Extensively drug-resistant* Carbapenem-resistant Acinetobacter baumannii (CRAB)

Outbreaks of any pathogens within healthcare facilities

* Extensively drug resistant (XDR) is defined as nonsusceptibility to at least one agent in all but two or fewer antimicrobial categories (i.e., bacterial isolates that remain susceptible to only one or two antimicrobial categories)

Carbapenem-resistant Enterobacterales (CRE)

Enterobacterales are a large order of different gram-negative bacteria (i.e., Klebsiella spp., Escherichia spp., Proteus spp., Morganella spp., Providencia spp., Serratia spp., etc.) that can cause a variety of infections in healthcare settings, including bloodstream infections, wound infections, surgical site infections, pneumonia, and urinary tract infections. Many Enterobacterales species are opportunistic plumbing pathogens that can form biofilms in plumbing systems, sinks and drains, and can create environmental reservoirs in other wet areas. When Enterobacterales are resistant to the class of antibiotics called carbapenems, which are often the last line of defense against resistant infections caused by gram-negative bacteria, they are referred to as carbapenem-resistant Enterobacterales (CRE). Carbapenem-resistant Enterobacterales that carry carbapenemase genes are referred to as carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE), a type of carbapenemase-producing organism.

Carbapenem-resistant Pseudomonas aeruginosa (CRPA)

Pseudomonas aeruginosa is a species of gram-negative bacteria that frequently cause infections within healthcare settings, such as pneumonia, urinary tract infections, bloodstream infections, and surgical site infections. Pseudomonas aeruginosa poses the greatest threat to patients with chronic respiratory diseases and weakened immune systems. As a water-loving pathogen, Pseudomonas aeruginosa can form biofilms in plumbing systems, sinks and drains, and can create environmental reservoirs in other wet areas. In New Jersey, Pseudomonas aeruginosa frequently exhibits resistance to the class of antibiotics called carbapenems, which are often the last line of defense against resistant infections caused by gram-negative bacteria, referred to as carbapenem-resistant Pseudomonas aeruginosa (CRPA). However, despite the notable burden of CRPA in New Jersey, only a small portion of CRPA produce carbapenemases, the enzymes that breakdown and inactivate carbapenems and other β-lactam antibiotics. Carbapenem-resistant Pseudomonas aeruginosa that carry carbapenemase genes are referred to as carbapenemase-producing carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA), a type of carbapenemase-producing organism.

Carbapenem-resistant Acinetobacter baumannii (CRAB)

Acinetobacter baumannii is a species of gram-negative bacteria that can cause infections in the blood, lungs, wounds, or urinary tract, and can colonize individuals without causing signs or symptoms. As a very environmentally hardy pathogen, Acinetobacter baumannii can survive on dust particles, form biofilms in plumbing systems, and is capable of persisting in the environment for months. Acinetobacter baumannii is often multidrug-resistant, which limits available treatment options. When Acinetobacter baumannii are resistant to the class of antibiotics called carbapenems, which are often the last line of defense against resistant infections caused by gram-negative bacteria, they are referred to as carbapenem-resistant Acinetobacter baumannii (CRAB). Carbapenem-resistant Acinetobacter baumannii that carry carbapenemase genes are referred to as carbapenemase-producing carbapenem-resistant Acinetobacter baumannii (CP-CRAB), a type of carbapenemase-producing organism.

Carbapenemase-Producing Organisms (CPOs)

Carbapenemase-producing organisms (CPOs) are bacteria that carry genes that allow them to produce enzymes, called carbapenemases, which breakdown carbapenems and render carbapenem and other β-lactam antibiotics ineffective. Resistance genes, including but not limited to blaKPC, blaNDM, blaVIM, blaIMP, blaOXA-48, blaOXA-23, and blaOXA-24/40, encode for the production of carbapenemases and are often located on mobile genetic elements called plasmids. Plasmid-mediated resistance enables these AR genes to be easily spread between different types of bacteria through horizontal gene transfer.

CPOs can cause a variety of infections (e.g., wound, respiratory, bloodstream), but do not always cause clinical infections. CPOs can also colonize individuals, living on their skin and in their bodies, without causing signs or symptoms. Individuals colonized with CPOs are still capable of contributing to transmission and are at risk for progression from colonization to clinical infection. CPOs are spread directly (from direct contact, often through the provision of patient care) and indirectly (from contaminated objects and the environment). Individuals who are infected or colonized with a CPO require strict adherence to infection prevention and control measures in order to prevent the spread of CPOs to others.

Candida auris (C. auris)

Candida auris (or C. auris) is a fungus that is causing serious infections in patients in the United States, including New Jersey. C. auris is primarily found in healthcare settings, particularly in long-term acute care hospitals and nursing homes that take care of patients on ventilators. Patients can carry C. auris on their body, even if it is not making them sick. This is called colonization. When people in hospitals and nursing homes are colonized, C. auris can spread from their bodies and can get on other people or nearby objects, allowing the fungus to spread to people around them. In some patients, this fungus can enter the bloodstream and spread throughout the body, causing serious invasive infections. This fungus often does not respond to commonly used antifungal drugs, making infections difficult to treat.

VISA/VRSA

Staphylococcus aureus is a pathogen that frequently colonizes the skin and most frequently causes skin and soft tissue infections. It is incredibly rare for Staphylococcus aureus bacteria to be resistant to the drug vancomycin. Vancomycin-intermediate Staphylococcus aureus (VISA) and vancomycin-resistant Staphylococcus aureus (VRSA) are specific types of Staphylococcus aureus bacteria with antimicrobial resistance. Staphylococcus aureus with intermediate-level resistance to vancomycin (VISA) have a vancomycin minimum inhibitory concentration (MIC) ranging from 4-8 ug/ml; Staphylococcus aureus with high-level resistance to vancomycin (VRSA) have a vancomycin minimum inhibitory concentration (MIC) >= 16 ug/ml. Susceptibility levels are defined according to Clinical and Laboratory Standards Institute's Performance Standards for Antimicrobial Susceptibility Testing; Seventeenth Informational Supplement (M100-S17). Suspected and confirmed cases of VRSA must be reported to the state and local health departments within 24 hours of diagnosis.

MRSA

Methicillin-resistant Staphylococcus aureus (MRSA) reporting into NHSN is currently required for all acute care hospitals in New Jersey. At a minimum, each facility must be monitoring MRSA LabID Event BSIs at the facility-wide level and conducting MRSA Admission AST to and the adherence rate in at least one high-risk patient care area (i.e., a patient care area where patients have an increased likelihood of acquiring MRSA and/or developing severe clinical outcomes resulting from a MRSA infection).

Clostridioides difficile (C. difficile)

Clostridioides difficile (C. difficile) is a bacterium that causes diarrhea and inflammation of the colon. Other signs and symptoms include fever, loss of appetite, nausea and abdominal pain. Infection with C. difficile can be life threatening. Risk factors for C. difficile infection include prior infection with C. difficile, recent hospitalization or nursing home admission, recent exposure to antibiotics, older age, and a weakened immune system.

Educational Materials for Patients and Family Members

Resources for Patients, Family and Household Members