Document Type



Doctor of Philosophy (PhD)


Public Health

First Advisor's Name

Mary Jo Trepka

First Advisor's Committee Title

Committee chair

Second Advisor's Name

Kristopher Fennie

Second Advisor's Committee Title

Committee member

Third Advisor's Name

Silvia Munoz-Price

Third Advisor's Committee Title

Committee member

Fourth Advisor's Name

Boubakari Ibrahimou

Fourth Advisor's Committee Title

Committee member

Fifth Advisor's Name

Vukosava Pekovic

Fifth Advisor's Committee Title

Committee member

Sixth Advisor's Name

Kalai Mathee

Sixth Advisor's Committee Title

Committee member


Infection Control, Carbapenem-resistant, Multidrug-resistant bacteria, Carbapenemase, Enterobacteriaceae, Carrier State, Patient Isolation, Antimicrobial Stewardship, Hospital associated infections, Miami

Date of Defense



Carbapenem-resistant Enterobacteriaceae (CRE) are multidrug-resistant organisms (MDRO) considered by the CDC as an urgent public health threat that is spreading globally. Little is known about the epidemiology of CRE in Miami, FL. The purpose of this dissertation was to 1) Evaluate trends in the epidemiology of CRE among patients admitted to the acute care facilities of the largest healthcare system in Miami, FL between 2012 and 2016, 2) Identify factors associated with progressing to infection among patients colonized with carbapenemase-producing Enterobacteriaceae (CPE), and 3) Determine the duration of CPE carriage and factors associated with long-term carriage in our cohort.

A total of 371 CRE cases were identified retrospectively. The overall prevalence was 0.077 per 100 patient-admissions; the admission prevalence was 0.019 per 100 patient-admissions, and the incidence density was 1.46 cases per 10,000 patient-days. Rates increased during the first three years of the study and declined in the last two.

Of 54 patients colonized with CPE, 16 (30%) of them developed CPE infections. The mean time for infection development was 63 days. Cox regression analysis identified the use of an indwelling urinary catheter (HR 4.4; P-value=0.034), exposure to intravenous colistin (HR 3.2; P-value=0.037), and transfer from overseas facilities (HR 9.8; P-value=0.021) as variables associated with the development of infection. Additionally, out of 75 eligible patients, 25 (33%) were cleared from CPE-carrier status. Immunocompromised patients, those that had mechanical ventilation exposure, or exposure to carbapenems had a lower probability of being cleared from CPE-carrier status (HR 0.34; 0.34, and 0.14 respectively (P-value 1 anatomical body site was associated with a 5.3 times higher probability of being cleared from CPE-carrier status (P-value

In conclusion, the use of MDRO registries and active surveillance testing contribute to control increasing rates of CRE. Furthermore, infection prevention and antimicrobial stewardship interventions aimed to decrease unnecessary use of medical devices and rapid selection of effective treatment are key factors to prevent the development of CPE-related infections among CPE colonized patients as well as to prevent long-term CPE carriage.




Previously Published In

Jimenez A, Trepka MJ, Munoz-Price LS, et al. Epidemiology of carbapenem-resistant Enterobacteriaceae in hospitals of a large healthcare system in Miami, Florida from 2012 to 2016: Five years of experience with an internal registry [published online ahead of print, 2020 Apr 23]. Am J Infect Control. 2020;S0196-6553(20)30239-X

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