Rising Carbapenemase-Producing Enterobacterales: What Hospitals Need to Know About Emerging Resistance Risks

Carbapenemase-producing Enterobacterales (CPE) represent one of the most urgent antimicrobial resistance threats facing health care today. Once limited to sporadic outbreaks, these organisms are now spreading more broadly across the US, with newer resistance mechanisms emerging that compromise even last-line antibiotics.

In this Q&A with Infection Control Today^®(ICT^®), Lucas Schulz, PharmD, discusses how the epidemiology of CPE is shifting, why New Delhi metallo-β-lactamase-(NDM-) producing strains pose unique clinical and operational challenges, and what rising resistance means for hospitals that rely on effective antibiotics to support modern care. Schulz also explores how rapid diagnostics and diagnostic-driven antimicrobial stewardship can improve patient outcomes, limit unnecessary antibiotic exposure, and help infection prevention teams contain transmission before resistance escalates further.

ICT: What trends are you seeing in CPE, and what should hospitals understand about the associated risks?

Lucas Schulz, PharmD: CPE rates are rising nationwide, with recent state and federal reports documenting significant year–over–year increases—70% or more in some instances—including rapid growth in NDM‑producing strains.

Beyond the volume, the epidemiology is shifting from predominantly KPC‑type carbapenemases to NDM‑type enzymes, which are far harder to treat and can undermine even last‑line agents. Global travel, medical tourism, and antimicrobial pressure (both human and veterinary) accelerate this spread.

Clinically, these infections increase the likelihood of delayed effective therapy, leading to higher mortality, prolonged hospitalization, and greater risk of treatment failure.

Operationally, plasmid‑mediated resistance enables easy patient‑to‑patient transmission, making rigorous infection control and rapid detection essential to prevent downstream outbreaks and future difficult‑to‑treat infections.

ICT: What happens when resistance emerges to last‑resort agents, and what are the real‑world consequences?

LS: When CPE develops resistance to last-line antibiotics, leaving treatment options extremely limited, relying on older, more toxic drugs with narrow therapeutic windows. Some patients fail all available therapies, and mortality is high. Clinicians may attempt complex combinations or experimental approaches such as phagotherapy, but these are not widely accessible and have limited evidence.

For health care systems, the implications are profound: modern medicine, from chemotherapy to major surgery, depends on reliable antibiotics. As more organisms develop resistance, the safety of routine care is jeopardized, and costs rise through longer stays, more interventions, and greater resource utilization.

ICT: How does rapid, accurate identification of resistant organisms improve clinical decision‑making and preserve antibiotic effectiveness?

LS: Rapid diagnostic shortens the time to identify both the organism and its resistance mechanisms, enabling clinicians to select the right drug earlier and avoid unnecessary broad‑spectrum exposure. Accurate early results support antimicrobial stewardship’s “5 rights”: right drug, dose, time, patient, and duration.

Effective stewardship requires engaging all clinicians, not only infectious disease specialists but also intensive care unit teams, oncologists, surgeons, and infection preventionists. When everyone operates from a stewardship mindset, patients receive appropriate therapy sooner, outcomes improve, unnecessary antimicrobial pressure is reduced, and, thus, resistance is reduced. Rapid diagnostics strengthen infection prevention by identifying colonized patients early enough to prevent onward transmission.

ICT: How can diagnostic‑driven stewardship shift care away from broad-empiric therapy toward more targeted, responsible use?

LS: Diagnostic‑driven stewardship narrows the window during which clinicians must rely on broad-spectrum empiric therapy. By revealing the causative pathogen and its resistance profile earlier, hospitals can transition patients to targeted therapy faster, reduce unnecessary exposure, and better tailor treatment duration.

Early identification also improves operational outcomes: It lowers transmission risk, informs isolation decisions, supports safer patient placement, and reduces health care‑associated infections. When combined with antimicrobial stewardship, diagnostic stewardship ensures patients receive the right therapy at the right time while reducing the selective pressure that drives resistance.