# Carbapenem-resistant Enterobacterales bacteraemia at a tertiary hospital: A five-year review

## TL;DR

This study examines CRE bloodstream infections in South Africa, finding high mortality and poor treatment access in a regional hospital.

## Contribution

First outcome-focused study on CRE bacteraemia in this under-represented region.

## Key findings

- In-hospital mortality for CRE bacteraemia was 56.8%, higher than global averages.
- Only 13.8% of OXA-48-positive cases received recommended first-line antibiotics.
- Klebsiella pneumoniae was the most common CRE isolate, with OXA-48 the dominant carbapenemase gene.

## Abstract

Carbapenem-resistant Enterobacterales (CRE) pose a critical threat to public health, marked by limited therapeutic options, high mortality rates and significant pressure on healthcare systems. Despite the growing global burden, our region remains under-represented in national surveillance efforts, with a notable absence of local data.

This study aims to describe the epidemiological, clinical and microbiological characteristics, as well as patient outcomes, of CRE bacteraemia at Universitas Academic Hospital in Bloemfontein, South Africa, over a 5-year period.

A retrospective file review was performed for all adult in-patients with confirmed CRE bacteraemia admitted between 2019 and 2023. Data collected included patient demographics, comorbidities and clinical data pertaining to admission, microbial characteristics and clinical outcomes.

Ninety-four episodes of CRE bacteraemia were identified in 88 patients. Prior antibiotic exposure was present in 90.9%, while 79.5% had comorbidities and 61.4% acute renal impairment. Klebsiella pneumoniae (84%) and Enterobacter cloacae (9.6%) were the predominant organisms cultured, with oxacillinase-48 (OXA-48) (78.4%) and New Delhi metallo-β-lactamase (NDM) (6.7%) being the most common carbapenemase genes detected. Only 13.8% of OXA-48-positive episodes received recommended first-line antibiotics. In-hospital mortality reached 56.8%, with immunosuppressive therapy significantly associated with death (p = 0.0165).

Mortality in our setting was substantially higher than national and international reports. Suboptimal treatment and limited access to effective antimicrobials likely contributed to these poor outcomes.

This is the first outcome-focused CRE study in this region, highlighting an urgent need for improved diagnostic capacity, antimicrobial access and targeted intervention strategies in under-resourced healthcare settings.