What are the management and treatment options for Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage and gut colonization in patients and healthcare workers?

From the Guidelines

Management of Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage and gut colonization in patients and healthcare workers requires a multifaceted approach focusing on decolonization strategies and infection prevention measures. For decolonization, oral non-absorbable antibiotics are the primary treatment option, with regimens including gentamicin (80 mg four times daily), colistin (2 million units twice daily), or a combination of both for 7-14 days, as supported by recent guidelines 1. Alternative options include oral neomycin (500 mg four times daily) or oral polymyxin E (100 mg four times daily) for similar durations. Fecal microbiota transplantation has shown promise as an emerging therapy for persistent colonization, although its effectiveness is still being studied 1. For healthcare workers who are colonized, the same decolonization protocols apply, though routine screening of staff is not generally recommended unless part of an outbreak investigation. Infection prevention measures are crucial and include:

• Strict contact precautions (gown and gloves when entering patient rooms)
• Dedicated equipment for colonized patients
• Enhanced environmental cleaning with chlorhexidine or hydrogen peroxide-based disinfectants
• Patient isolation in single rooms when possible, as recommended by recent studies 1
• Antibiotic stewardship to reduce selective pressure Follow-up screening is essential, with rectal swabs collected weekly during hospitalization and at 1,3, and 6 months after decolonization therapy to confirm clearance. These approaches are necessary because CRE colonization significantly increases the risk of subsequent infections and contributes to the spread of antimicrobial resistance within healthcare facilities, highlighting the importance of a comprehensive infection control program 1. The most recent and highest quality study 1 supports the implementation of bundle interventions, including contact isolation of CRGNB infected patients/carriers, to prevent CRGNB infections, which is in line with the recommended management and treatment options for CRE fecal carriage and gut colonization.

From the Research

Management and Treatment Options for CRE Fecal Carriage and Gut Colonization

• The management and treatment options for Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage and gut colonization in patients and healthcare workers involve a combination of infection control measures, screening, and treatment with limited antibiotic options 2.
• Screening for CRE carriage is crucial to prevent patient-to-patient transmission, and the ideal population to target for screening, the frequency of testing, and the preferred test method are components of surveillance programs that remain open to debate 3.
• Risk factors for CRE colonization include duration of ICU stay, use of ventilator and aminoglycosides, and prior colonization with CRE 4.
• Treatment options for CRE infections are limited and include combinations of polymyxins, tigecycline, aminoglycosides, or carbapenems, with newer agents with activity against CRE and better safety profiles becoming available 2.
• Gastrointestinal colonization with CRE is a prerequisite for the development of translocated infections, and identifying risk factors for CRE colonization and subsequent infection is crucial to prevent the development of clinical infection 5.

Infection Control Measures

• Infection control measures, such as passive surveillance, rapid and accurate screening of clinical specimens, and contact precautions, are critical for controlling the spread of CRE 6.
• Screening for CRE carriage at ICU admission and follow-up cultures to detect acquisition can help identify patients at risk of developing CRE infections 6.
• Understanding the intestinal flora composition and fecal metabolic profiles in CRE rectal colonization and translocated infection patients can provide insights into the mechanisms of CRE colonization and infection 5.

Antibiotic Treatment Options

• Antibiotic treatment options for CRE infections are limited, and the use of combination therapy, such as polymyxins and tigecycline, may be necessary to treat CRE infections 2.
• Newer agents with activity against CRE, such as meropenem and imipenem, may be effective in treating CRE infections, but their use should be guided by antibiotic susceptibility testing 4.
• The use of aminoglycosides and carbapenems should be avoided in patients with CRE colonization due to the risk of selecting for resistant strains 4.