From the Guidelines
Management of Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage and gut colonization requires a comprehensive infection control approach, prioritizing strict contact precautions, active surveillance, and selective digestive decontamination in specific situations, as recommended by the most recent guidelines 1.
Key Components of Management
- Contact Precautions: Placement in a single room, dedicated equipment, and proper hand hygiene with alcohol-based sanitizers or soap and water by all healthcare workers.
- Active Surveillance: Rectal swabs or stool samples for high-risk patients, including those transferred from high-prevalence facilities, roommates of CRE-positive patients, and patients in outbreak settings.
- Selective Digestive Decontamination: Regimens like oral gentamicin (80mg QID), oral colistin (2 million units QID), or oral neomycin combined with polymyxin E for 7-14 days, considered in outbreaks or before major surgeries.
Rationale
The approach is based on the latest guidelines 1, which recommend a bundle intervention scheme including single room or cohorting isolation for patients with CRGNB infections or colonization, with a strong recommendation despite low-quality evidence. This approach aims to balance infection control with antimicrobial stewardship, recognizing the potential for CRE colonization to persist and the risk of promoting further resistance with overuse of decolonization antibiotics.
Considerations for Healthcare Workers
- Standard precautions and hand hygiene compliance are essential.
- Routine screening is not recommended unless implicated in transmission.
Evidence Base
The recommendation is supported by the most recent and highest quality study available 1, which provides a comprehensive approach to managing CRE fecal carriage and gut colonization, emphasizing the importance of infection control measures and selective use of decolonization strategies.
From the Research
Management Approach for CRE Fecal Carriage and Gut Colonization
The management of Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage and gut colonization in patients and healthcare workers is a complex issue that requires a multifaceted approach.
- Risk Factors: Several risk factors have been identified as contributing to CRE fecal carriage, including treatment with carbapenems, transfer from another institution, multi-drug resistant infection, invasive procedures, and sharing a room with a known CRE carrier 2.
- Fecal Microbiota Transplantation (FMT): FMT has been shown to be a safe and effective method for eradicating CRE colonization, with a decolonization rate of 78.7% at 6-12 months after FMT 3.
- Intestinal Dysbiosis: CRE colonization has been associated with intestinal dysbiosis, characterized by a decrease in phylogenetic diversity and an enrichment of Enterobacteriaceae, as well as a depletion of anaerobic commensals 4.
- Clinical Risk Factors: Clinical risk factors for CRE colonization and subsequent infection include enteral feeding, carbapenem exposure, and hematologic malignancy 2, 5.
- Microbiological and Intestinal Characteristics: The intestinal flora composition and fecal metabolic profiles are altered in CRE colonization and translocated infection, with downregulated propionate and butyrate playing a role in regulating immune cell infiltration and inflammatory factor expression 5.
Prevention and Control Measures
Prevention and control measures are crucial to reduce the spread of CRE in healthcare settings.
- Infection Control Programs: Improving infection control programs, including antibiotic stewardship, is essential to prevent nosocomial spread 2.
- Screening and Isolation: Screening for CRE colonization and isolating colonized patients can help prevent transmission 2.
- Personalized FMT: Personalized FMT may be a promising approach for different patients and conditions, according to varied hosts and diseases 6.
Future Directions
Further research is needed to elucidate the complicated mechanisms of CRE colonization and subsequent infection, and to develop effective prevention and control measures.
- Long-term Outcomes of FMT: The long-term outcomes of FMT need to be further studied to monitor clinical efficacy and long-term adverse events 6.
- Intestinal Biomarkers: Identifying intestinal biomarkers for subsequent infections among CRE-colonized patients may help prevent the development of clinical infection 5.