Are you aware of this terrible bacteria? (Carbapenem-Resistant Enterobacterales - CREs) Let's talk!

You've probably heard that the antibiotics that doctors prescribe for some illnesses sometimes don't work. One such dangerous and concerning condition is the bacterial infection called Carbapenem-Resistant Enterobacterales (CREs). These bacteria may not respond to some of the commonly prescribed antibiotics. So, while this is a serious story, it's important for all of us to be aware of it. Let's simply understand what's going on.

What are `(Carbapenem-Resistant Enterobacterales)` or `(CREs)`?

Simply put, `(Enterobacterales)` is a group of bacteria that are related to each other, like the same family. These bacteria can cause various infections in our bodies. Now, these `(Enterobacterales)` bacteria sometimes show resistance to a special, powerful `(antibiotic)` called `(Carbapenems). Those `(Enterobacterales)` bacteria that are resistant to `(Carbapenems)` are what we call `(Carbapenem-Resistant Enterobacterales)` or `(CREs)`.

Think about it, doctors use `(antibiotics)` to treat bacterial infections. But, these bacteria are very cunning. When they are constantly exposed to `(antibiotics)` (especially in a hospital or nursing home), they find ways to survive and survive against those `(antibiotics). This is what we call `(resistance) . So `(CREs)` are bacteria that have become resistant to the `(Carbapenem)` class of `(antibiotics)`.

There are several other types of drugs that belong to this class of antibiotics called ``Carbapenems'':

• `Ertapenem`
• `Imipenem`
• `Meropenem`

These are powerful antibiotics that are usually given for serious infections. So if a bacteria becomes resistant to these, it means that the infection becomes a little harder to cure.

What are the types of bacteria (Enterobacterales)?

Some people use the abbreviation `(CRE)` to mean `(Carbapenem-resistant Enterobacterales)`, while others use `(Carbapenem-resistant Enterobacteriaceae)`. `(Enterobacterales)` is a large order that contains many different types of bacteria. It has three families, or suborders. One of these suborders is `(Enterobacteriaceae).` This `(Enterobacteriaceae)` group is where the bacteria we often hear about belong:

• `Escherichia` (mostly known to us as `E. coli`)
• `Klebsiella`
• `Salmonella`
• `Shigella`

The most common CREs are antibiotic-resistant strains of Klebsiella pneumoniae and E. coli. It's important to remember that just because you have an infection with Klebsiella or E. coli, it doesn't mean it's antibiotic-resistant.

What are the infections caused by `(CREs)`?

These ``(CREs)`` bacteria can cause infections in many different parts of your body. These infections are most commonly seen in:

• In the blood(Bloodstream infections)
• Urinary tract infection (UTI)
• In the lungs (pneumonia)
• Abdominal (intra-abdominal abscess)

It is in places like these that these sneaky bacteria can easily cause infections.

How common are `(CRE)` infections?

If you look at the statistics of a country like the United States, about 13,000 infections are reported every year due to ``(CREs).`` About 1,100 of them die. Doctors in Sri Lanka are also paying attention to this situation. Because such resistant bacteria are becoming a problem all over the world.

What are the symptoms of `(CRE)` infection?

The symptoms of `(Carbapenem-resistant Enterobacterales)` vary depending on where you have the infection. Some common symptoms may include:

• Fever
• Chills
• Difficulty breathing
• Cough
• Stomach pain
• Pain when urinating
• Redness, swelling, and itching at the site of surgery or a wound

Important: These symptoms are not limited to `(CRE)` infections. Other bacterial infections can also cause these symptoms. Therefore, if you experience any of these symptoms, it is best to see a doctor.

What are the causes of `(CRE)` infections?

Simply put, `(CRE)` infections are caused by bacteria that are resistant to `(antibiotics)` called `(Carbapenem)`. There are various reasons why bacteria develop this `(antibiotic)` resistance. One is the way they have evolved to coexist with other organisms in nature.

In hospitals and other healthcare settings, bacteria are constantly exposed to antibiotics. Especially since powerful antibiotics like carbapenems are used to treat serious infections, bacteria have the opportunity to develop ways to resist them. These bacteria have an amazing ability to pass on their resistance genes to other bacteria . This is called horizontal gene transfer. Like telling a friend a secret, these bacteria share their resistance with others. Otherwise, the bacteria that survive the antibiotics can pass on their resistance genes, creating many more resistant bacteria.

One of the main ways that bacteria become resistant to `(CRE)` is by producing an enzyme called `(Carbapenemase)`. This enzyme breaks down and destroys `(Carbapenem antibiotics)`. This enzyme does a similar job as cutting the medicine with a small pair of scissors. Then the medicine doesn't work.

How are CREs transmitted?

Carbapenem-resistant Enterobacterales bacteria can live on your skin or in your gastrointestinal tract (guts) without making you sick. This is called colonization.CREs can be transmitted from someone who is sick with a CRE infection, or from someone who is asymptomatically colonized with the bacteria.

You are most at risk of getting a `(CRE)` infection in a hospital or other healthcare setting. This is because bacteria that naturally live on our skin and in our bodies can become resistant to antibiotics by being exposed to them. You can get a `(CRE)` infection in the following ways:

• By touching someone who has the bacteria on their skin (for example, if that person has not washed their hands properly).
• From dirty surfaces , especially sinks and toilets.
• From dirty medical equipment and medical devices inserted into your body (e.g., a central venous line, a breathing tube).

Who is most at risk for `(CRE)` infections?

You may be at higher risk of developing a `(CRE)` infection if you:

• If you have a central venous line (a tube inserted into a main vein), breathing tube, feeding tube, or other tube or device inserted into your body, CREs can enter your body from outside through these.
• If you have been taking antibiotics for a long time or if you take them regularly, it is possible that bacteria will develop resistance to them over time. This can kill off the "good" (non-harmful) bacteria in our gut, allowing other bacteria to grow out of control and cause infections.
• If you have an underlying health condition that weakens your immune system . For example, if you have HIV, blood cancers, diabetes, or have had an organ transplant or stem cell transplant, you are at higher risk. This is because it is harder for the body to fight off infections under these conditions.
• If you need help with daily activities, such as bathing and using the toilet , you may be at greater risk of coming into contact with feces (and bacteria from the gastrointestinal tract), which can spread CREs.
• If you have been hospitalized for a long time , especially if you have been in a hospital outside the United States within the past six months. Although CREs are increasing in the United States, they are more common outside the country.

What are the possible complications of `(CREs)`?

If doctors can't control a bacterial infection with antibiotics, it can spread throughout the body and cause fatal complications like organ failure. This is the biggest danger of CRE infections.

How to recognize a `(CRE)` infection?

If you have symptoms of a bacterial infection and it doesn't go away with antibiotics, your doctor may think you have a CRE infection. They will then take samples from your body to check for the bacteria. These samples may include:

• Blood
• Urine
• Stool
• Fluid or tissue from a wound

A laboratory can determine whether the bacteria in these samples are ``CREs''. Don't forget to tell your doctor about any medical devices you have implanted in your body or if you have recently been hospitalized.

How are CREs treated?

Treating CREs can be tricky because the antibiotics you usually use don't work. So, your doctor may give you a different antibiotic. Or, they may give you a carbapenem antibiotic along with another drug that inhibits the bacteria's carbapenemase enzyme. Laboratories can test different drugs to see which ones work on CREs.

Types of `(Antibiotics)` used to treat `(CREs)`

Here are some types of antibiotics that doctors use – either alone or in combination – to treat CREs:

• `Polymyxin/Colistin`
• `Tigecycline`
• `Fosfomycin`
• Aminoglycosides (e.g. gentamicin or tobramycin)
• `Rifampin`
• `Carbapenem` (with an inhibitor)

These medications are selected based on the patient's condition, the nature of the infection, and the resistance pattern of the bacteria.

How serious is a `(CRE)` infection?

CREs can cause serious, difficult-to-treat illnesses. Some people develop life-threatening infections. If you develop a CRE infection, you will be treated in a hospital where medical staff can monitor you closely.

What is the recovery rate from `(CRE)`?

Studies show that the mortality rate for CREs varies depending on where the infection occurs. For example, the mortality rate for urinary tract infections (UTIs) caused by CREs is about 13%, while the mortality rate for bloodstream infections caused by CREs can be 50% or higher. Looking at these statistics, you can see how serious this can be, right?

Can CREs be prevented?

Healthcare providers, such as doctors and nurses, follow special safety and sterilization rules to prevent ``healthcare-acquired infections`` such as ``CREs.`` These include:

• Wash your hands often.
• Disinfecting surfaces.
• Ensure that antibiotics are only given to people with bacterial infections. (Antibiotics are not helpful for viral infections.)
• Sterilization of medical equipment.

You can also help prevent CRE infections by:

• Wash your hands often and thoroughly. This is especially important if you are caring for someone with a weakened immune system or someone who needs help bathing or using the toilet.
• If you have had to use medical devices that are inserted into your body, such as catheters , ask your doctor how long they should be kept in place and what you should do to prevent infections while the device is in place.

When should I see my doctor?

If you have an implanted medical device or if your immune system is weak, ask your doctor what signs of infection you should look out for. If you have any suspicious symptoms, see a doctor.

Even when you're in the hospital, it's important to maintain good communication with your medical team. If you experience any signs of infection, such as pain, a rapid heartbeat, weakness, or fever, tell them right away.

When should I go to the emergency room (ER)?

If you have symptoms of a serious illness, go to an emergency room. Symptoms include:

• Fever over 103 degrees Fahrenheit (40 degrees Celsius).
• Severe pain.
• Seizures.
• Confusion or disorientation.
• Sudden drop in blood pressure (symptoms: weakness, dizziness, fainting).

What questions should I ask my doctor?

It may be helpful to ask your doctor questions like these:

• What treatment options do I have?
• When can I expect to get well?
• How did I get this infection?
• What can I do to prevent this type of infection in the future?

Finally, things to remember (Take-Home Message)

Carbapenem-resistant Enterobacterales (CREs) are a type of bacteria that can cause serious infections that are difficult to treat. That's why your healthcare providers are working so hard to keep hospitals and long-term care facilities clean and safe. Doctors and health officials in Sri Lanka are also on high alert for this situation.