De novo evolution via chromosomal mutation or mobile genetic elements and cross-transmission of resistant strains
Target Population
Patients in long-term acute care hospitals (LTACHs) with CRKP infections
Care Setting
Long-term acute care hospitals
Key Highlights
Phylogenetic analysis partitions resistance acquisition into de novo evolution and cross-transmission pathways.
Distinct clinical risk factors and antibiotic exposures are associated with each resistance acquisition pathway.
Tailored intervention strategies can be developed based on understanding of resistance emergence and spread mechanisms.
Guideline-Based Recommendations
Diagnosis
Use whole-genome sequencing and susceptibility testing to characterize CRKP isolates.
Apply phylogenetic contextualization to distinguish resistance acquired via de novo evolution versus cross-transmission.
Management
Implement antimicrobial stewardship to reduce selection pressure for de novo resistance emergence.
Apply infection control measures such as patient cohorting, hand hygiene compliance, and contact isolation to minimize cross-transmission.
Monitoring & Follow-up
Monitor antibiotic exposures and patient clinical characteristics to identify risk factors for resistance emergence and spread.
Use phylogenetic-informed regression modeling to track resistance patterns and inform interventions.
Risks
Exposure to specific antibiotics (e.g., trimethoprim-sulfamethoxazole, colistin, beta-lactam/beta-lactamase inhibitors) increases risk of resistance emergence and spread.
Comorbidities (e.g., stage IV decubitus ulcers) and indwelling medical devices (e.g., gastrostomy tubes) are risk factors for resistance spread.
Patient & Prescribing Data
Patients with CRKP infections in LTACHs
Antibiotic exposures correlate with resistance emergence and spread; stewardship and targeted infection control are critical to mitigate resistance.
Clinical Best Practices
Integrate whole-genome sequencing with clinical metadata to inform resistance mechanism identification.
Differentiate resistance acquisition pathways to tailor prevention and control strategies effectively.
Prioritize antimicrobial stewardship and strict infection control protocols in LTACH settings.
