CRAB (Carbapenem-resistant Acinetobacter baumannii) are an urgent threat to public health.¹ These bacteria are typically resistant to many antibiotics; resistance to carbapenems further limits treatment options for patients. Similar to CRE, CRAB can carry mobile genetic elements, known as plasmids, that can move between bacteria and between patients. Based on data from the Antibiotic Resistance Laboratory Network (ARLN), in the Northeastern United States, approximately 66% of Acinetobacter that are resistant to a carbapenem can make an enzyme known as a carbapenemase that breaks down carbapenem antibiotics.² Strains of CRAB that carry the gene that makes one of these carbapenemase enzymes are referred to as carbapenemase-producing (CP). Additionally, CRAB is an important pathogen in healthcare facilities because Acinetobacter can survive for prolonged periods on environmental surfaces. Identifying carbapenemase-producing organisms and containing their spread is an important strategy for protecting patients and preserving the power of antibiotics.³ CT surveillance for CRAB aligns with the case definition of the National Notifiable Diseases Surveillance System (NNDSS).^4-6

When to report CRAB results: Please send lab report by electronic file or OL-15C to DPH and submit bacterial isolate to SPHL accompanied by OL-9B when an isolate is identified with any MIC or zone criteria that indicates possible CRAB, even if this has not yet been confirmed by additional testing. Please include susceptibility testing results and results of any carbapenemase testing performed to DPH and the SPHL.

Clinical laboratory criteria for CRAB reporting and submission of isolate for SPHL testing:

1. Acinetobacter species collected from a normally sterile site*, urine, lower respiratory tract**, or a wound.
  AND one or both of the following:
2. Isolate is resistant to any carbapenem except Ertapenem. Report based on MIC and Zone Diameter, not on interpretation alone.
Note: Ertapenem has little intrinsic activity against Acinetobacter, so Acinetobacter resistant to ertapenem only does not require reporting.
3. The organism displays production of carbapenemase (e.g. KPC, NDM, VIM, IMP, and OXA-48) by PCR regardless of susceptibility results.

Please refer to the full laboratory reporting guidance for additional information.

*Normally sterile sites include: Blood, cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, joint/synovial fluid, bone, internal body site (lymph node, brain, heart, liver spleen, vitreous fluid, kidney, pancreas, or ovary), muscle, deep tissue or other normally sterile site.

**Lower respiratory tract specimens include: Bronchoalveolar lavage, sputum, tracheal aspirate, or other lower respiratory site.

CRE (Carbapenem-resistant Enterobacterales) are an urgent threat to public health.¹ These bacteria are difficult to treat due to increased levels of antibiotic resistance and reduced treatment options for patients. CRE can carry mobile genetic elements, known as plasmids, that can move between bacteria and between patients. Based on data from the Antibiotic Resistance Laboratory Network (ARLN), in the United States, approximately one third of Enterobacterales that are resistant to a carbapenem can make an enzyme known as a carbapenemase that breaks down carbapenem antibiotics.⁷ Strains of CRE that carry a gene for one of these carbapenemase enzymes are referred to as carbapenemase-producing (CP).³ Identifying carbapenemase-producing organisms and containing their spread is an important strategy for protecting patients and preserving the power of antibiotics. CT surveillance for CRE aligns with the case definition of the National Notifiable Diseases Surveillance System (NNDSS).^4-6

When to report CRE results: Please send lab report by electronic file or OL-15C to DPH and submit bacterial isolate to SPHL accompanied by OL-9B when an isolate is identified with any MIC or zone criteria that indicates possible CRE, even if this has not yet been confirmed by additional testing. Please include susceptibility testing results and results of any carbapenemase testing performed (e.g. CarbaR or Carba5) to DPH and the SPHL.

Clinical laboratory criteria for CRE reporting and submission of isolate for SPHL testing:

1. Enterobacterales species collected from a normally sterile site**, urine, or lower respiratory tract***
  AND one or both of the following:
2. Isolate is resistant to any carbapenem. Report based on MIC and Zone Diameter, not on interpretation alone.
Note: Proteus spp., Providencia spp., and Morganella morganii may have elevated Imipenem MICs by mechanisms other than production of carbapenemases; susceptibility results to Imipenem should not be considered for these genera.
3. The organism displays production of carbapenemase (e.g. KPC, NDM, VIM, IMP, and OXA-48) regardless of susceptibility results.

Please refer to the full laboratory reporting guidance for additional information.

*Normally sterile sites include: Blood, cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, joint/synovial fluid, bone, internal body site (lymph node, brain, heart, liver spleen, vitreous fluid, kidney, pancreas, or ovary), muscle, deep tissue or other normally sterile site.

**Lower respiratory tract specimens include: Bronchoalveolar lavage, sputum, tracheal aspirate, or other lower respiratory site.

CRPA (Carbapenem-resistant Pseudomonas aeruginosa) are a serious threat to public health.¹ These bacteria are typically resistant to many antibiotics; resistance to carbapenems further limits treatment options for patients. CRPA can carry mobile genetic elements, known as plasmids, that can move between bacteria and between patients. Approximately 2-3% of Pseudomonas that are resistant to a carbapenem can make an enzyme known as a carbapenemase that breaks down carbapenem antibiotics.⁷ Strains of CRPA that carry the gene that makes one of these carbapenemase enzymes are referred to as carbapenemase-producing organisms (CPO).⁴ CRPA isolates can be resistant to most if not all antibiotics and can cause significant clinical disease, resulting in worsened patient morbidity and mortality. Identifying carbapenemase-producing organisms and containing their spread is an important strategy for protecting patients and preserving the power of antibiotics.² CT surveillance for CRPA aligns with the case definition of the National Notifiable Diseases Surveillance System (NNDSS). ^4-6

When to report CRPA results: Please send lab report by electronic file or OL-15C to DPH and submit bacterial isolate to SPHL accompanied by OL-9B when an isolate is identified with any MIC or zone criteria that indicates resistance to a carbapenem antibiotic, doripenem, imipenem, or meropenem. Please include susceptibility testing results and results of any carbapenemase testing performed (e.g. CarbaR or Carba5) to DPH and the SPHL.

Clinical laboratory criteria for CRPA reporting and submission of isolate for SPHL testing:

1. Pseudomonas aeruginosa collected from a normally sterile site*, urine, lower respiratory tract**, or a wound.
  AND one of the following:
2. Isolate is resistant to doripenem, imipenem, or meropenem. Report based on MIC and Zone Diameter, not on interpretation alone.
3. The organism displays production of carbapenemase (e.g. KPC, NDM, VIM, IMP, and OXA-48) by PCR regardless of susceptibility results.

Please refer to the full laboratory reporting guidance for additional information.

*Normally sterile sites include: Blood, cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, joint/synovial fluid, bone, internal body site (lymph node, brain, heart, liver spleen, vitreous fluid, kidney, pancreas, or ovary), muscle, deep tissue or other normally sterile site.

**Lower respiratory tract specimens include: Bronchoalveolar lavage, sputum, tracheal aspirate, or other lower respiratory site.

Invasive Escherichia coli (iEC) disease is responsible for significant morbidity and mortality in the United States, accounting for 27% of documented episodes of bacteremia.⁸ Mortality related to iEC disease ranges from 12–22%.^8,9 Invasive E. coli infections are also a significant cause of morbidity and mortality among neonates, in particular premature infants

Identification of E. coli in a sterile body site from an infant less than 1 year of age has been added as a Category 2 disease and as a reportable laboratory finding. Laboratories should submit infant iEC isolates to the State Public Health Laboratory (SPHL) for subsequent typing and susceptibility testing.

Beginning July 1, 2024, statewide laboratory reporting of E. coli isolated from normally sterile body sites expanded to all ages and iEC isolate submission for individuals ≥1 year of age became required at a subset of laboratories as determined by DPH. Laboratories statewide should continue to submit iEC isolates from infants (<1 year of age) to the State Public Health Laboratory. Laboratories not participating in iEC isolate submission for individuals ≥1 year of age should continue to submit only carbapenem resistant E. coli (CRE) isolates.

iEC remains healthcare provider reportable only for infants <1 year of age. Healthcare provider case reporting (via PD-23 or electronic reporting through CTEDSS) is not required for cases of iEC in individuals ≥1 year of age.

Candida auris is a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities. C. auris can cause a range of infections from superficial (skin) infections to more severe, life-threatening infections, such as bloodstream infections. C. auris is often resistant to antifungal medications, meaning the fungus develops the ability to defeat the drugs designed to kill it. That means the germs are not killed and continue to grow. Resistant infections can be difficult, and sometimes impossible, to treat.¹⁰

Submit first isolate/specimen from any source. Submit upon first identification of colonization and first identification of clinical infection. Submit additional isolates once every 30 days; additional susceptibility testing for clinical management may be requested. For clinical laboratories performing in-house PCR colonization testing, please submit residual clinical material.

Candida auris infection or colonization from all sites and any potential C. auris misidentifications should be reported to the DPH HAI-AR Program.

Laboratories should submit all Candida spp. blood isolates to the State Public Health Laboratory for speciation and antifungal susceptibility testing.