CARAlert frequently asked questions

The Commission established the National Alert System for Critical Antimicrobial Resistances (CARAlert) to provide system reporting to complement the existing processes for confirming critical antimicrobial resistances (CARs) at an individual patient level. CARAlert provides more timely advice to state and territory health authorities on CARs in their hospitals, and nationally.

While some data on CARs are captured through existing local surveillance programs, CARAlert is the first nationally coordinated system that supports communication of information on confirmed CARs and potential CAR outbreaks, as close as possible to the time of confirmation.

Early advice about potential outbreaks offers the best opportunity to take infection prevention and control measures to minimise patient morbidity.

CARAlert is funded by the Australian Government Department of Health and Aged Care (the Department) as part of the Antimicrobial Use and Resistance in Australia (AURA) Surveillance System. States, territories and private pathology services also contribute funding for CARAlert by meeting the costs of confirmatory testing and data submission processes.

CARAlert is based on routine processes and practices used by pathology laboratories for identifying a potential critically resistant isolate and referring that isolate to a laboratory with the capacity to confirm the CAR.

Public and private pathology laboratories that have the capacity to confirm CARs voluntarily report to CARAlert, via a specially developed secure web portal, following their routine processes.

The confirming laboratory advises the originating laboratory of the result. The originating laboratory notifies the clinician who referred the specimen that a CAR has been confirmed so that they can take appropriate clinical action.

Summary deidentified information on confirmed CARs is also reported to state and territory health authorities and the Department weekly. In addition, designated staff from each state and territory have secure 24/7 access to information on the CARs reported for their jurisdiction.

Information that could be used to identify a patient is not captured by CARAlert.

All health authorities are provided with information about the state or territory where the CAR isolate originated, the confirmation date and whether the patient who had the infection was in hospital, or in the community, at the time the specimen was collected.

State and territory health authorities are able to access their own jurisdictional data for public hospitals where a patient who had the infection was being cared for at the time the specimen was collected. Designated staff have the capacity to access this information at any time. This enables them to monitor the geographic distribution of CARs and to liaise with hospitals, to confirm infection prevention and control action has been taken in the event of an outbreak.

Antimicrobial resistance (AMR) is a serious health threat. The loss of effective antimicrobials through increased AMR will compromise Australia’s ability to fight infectious diseases and manage complications common in vulnerable patients, such as those undergoing cancer treatment, dialysis for renal failure, and surgery. Documenting CARs and providing information about their occurrence, in a timely manner, to states and territories ensures that outbreaks can be contained and the efficacy of last-line antimicrobials is maintained for as long as possible.

The CARs reported to CARAlert are drawn from the Priority Organisms List for national reporting as part of the AURA Surveillance System.

The originating laboratory that performs the initial microbiology test will, in accordance with usual processes, have advised the treating doctor, and infection prevention and control staff where appropriate, of the antimicrobial susceptibility profile of the isolate to enable timely and appropriate treatment to be prescribed for the patient.

Confirmation of a CAR may not occur until after a patient’s infection has been treated and/or they have been discharged from hospital. The occurrence of possible CARs in a patient is communicated to treating clinicians by the originating laboratory before a CAR is confirmed, so that appropriate treatment and/or infection prevention and control measures can be initiated.

The role of CARAlert is to monitor trends in the development of AMR in Australia in near real time, for timely identification of clusters of infections and outbreaks, and for implementation and review of infection prevention and control strategies in the event of an outbreak.

If a CAR is confirmed, the confirming laboratory will notify the originating laboratory and enter data items into the CARAlert web portal – noting that identifiable information is not entered into CARAlert.

The laboratories that provide pathology services to private hospitals issue reports on the confirmation of CARs in the same way as for public hospitals.

Carbapenemase-producing Enterobacterales (CPE), either alone or in combination with ribosomal methyltransferases, has been the most frequently reported CAR to CARAlert.

The majority of CARs have been reported from the three most populous states – New South Wales, Victoria and Queensland.

The IMP-type carbapenemase (mainly IMP-4) is now endemic on the eastern seaboard of Australia in several species of Enterobacterales, particularly Enterobacter cloacae complex. This means that it is difficult to eliminate, and rigorous control measures are essential. There is no evidence that other carbapenemases have become established in Australia to date.

The number of CPE reported, and the endemicity of IMP-type carbapenemase, highlight the importance of implementing actions outlined within the Commission’s Recommendations for the control of carbapenemase-producing Enterobacterales: A guide for acute health facilities.

The frequency of reporting of azithromycin-nonsusceptible Neisseria gonorrhoeae has occurred in the context of a significant increase in notifications of N. gonorrhoeae and there have been sporadic cases of ceftriaxone-nonsusceptible or azithromycin-nonsusceptible (high-level resistance) N. gonorrhoeae.

There was a large increase in the number of reports of multidrug-resistant (MDR) Shigella in 2019. Infections caused by Shigella species are generally food-borne or sexually transmitted and are notifiable nationally. In 2019, New South Wales and Victoria reported increases in MDR Shigella amongst men who have sex with men. In response to the increase, both states issued public health alerts and implemented changes to management recommendations for shigellosis as part of their prevention and control strategies.

The majority of CARs reported from aged care homes since 2019 were daptomycin-nonsusceptible Staphylococcus aureus. Skin and soft tissue infections are commonly caused by S. aureus, which may be spread by contact with contaminated surfaces and hands of healthcare workers, visitors and residents. In group living environments, S. aureus may also be inadvertently spread by sharing personal items such as bed linen, towels or clothing. There is a risk of transmission of this CAR within aged care homes, and in hospitals due to the frequent movement of aged care home residents between these two settings.

CARAlert data undergo regular epidemiological analysis; statistical methods for evaluating temporal and spatial trends will be implemented as the data collection matures.

From March 2016 to January 2023, over 10,000 CARs have been reported to CARAlert.

A number of CAR outbreaks and periodic increases have been identified since the commencement of CARAlert including:

• An outbreak of OXA-48 producing Escherichia coli ST38 in Queensland – 80 cases were reported between May 2017 and July 2017
• A cluster of IMP-producing Enterobacterales in one institution in New South Wales – detected in the 0–4 year age group between late December 2017 and January 2018
• A three-fold increase in NDM-type CPE from South Australia in 2019 compared to 2018
• An increase in NDM- and IMP-type CPE in New South Wales and Victoria in 2019 compared to 2018
• An increase in reports of multidrug-resistant Shigella species in 2019 compared to 2018, with sharp increases in Queensland (up 261%), Victoria (up 246%) and New South Wales (up 142%).

These outbreaks were all responded to locally by the relevant hospital and/or state or territory health authority.

The range of organisations that provide care for patients with CARs includes public and private hospitals, community-based health services and aged care homes.