What are the management and decolonization strategies for Carbapenem-Resistant Enterobacteriaceae (CRE) gut colonization in patients and healthcare workers?

From the Guidelines

Management of Carbapenem-Resistant Enterobacteriaceae (CRE) gut colonization in patients and healthcare workers requires a multifaceted approach focusing on infection control measures, including strict contact precautions and isolation, rather than routine decolonization. For colonized patients, placement in single rooms or cohorting isolation is recommended, as well as dedicated equipment use and proper hand hygiene with alcohol-based sanitizers or soap and water 1. Healthcare workers should adhere to standard precautions and use personal protective equipment when caring for colonized patients.

Key Considerations

• Isolation or cohorting of colonized/infected patients is a cornerstone of infection prevention and control (IPC) to prevent the transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and healthcare workers (HCWs) 1.
• Active screening for CRE using rectal surveillance cultures has been shown to be highly effective, when part of a comprehensive infection control program, in halting the spread of CRE in healthcare facilities 1.
• Environmental cleaning with hospital-grade disinfectants effective against gram-negative bacteria is crucial, particularly for high-touch surfaces.

Decolonization Strategies

• Unlike MRSA, there are no widely accepted decolonization protocols for CRE.
• Selective digestive decontamination using oral antibiotics such as gentamicin, colistin, or neomycin has shown limited success in some studies, but is not routinely recommended due to concerns about promoting further resistance.
• Fecal microbiota transplantation has emerged as a potential decolonization strategy in research settings but remains investigational.

Healthcare Worker Screening

• Routine screening of healthcare workers is not recommended unless implicated in transmission.
• Healthcare workers should adhere to standard precautions and use personal protective equipment when caring for colonized patients.

Challenges

• CRE colonization management is challenging because these organisms can persist in the gut for months to years, and the primary goal is preventing transmission rather than eradication, as decolonization attempts often lead to recolonization and may increase resistance.
• The evidence currently available is derived from observational studies, and the quality of the evidence for critical outcomes is low 1.

From the Research

Management and Decolonization Strategies for CRE Gut Colonization

• The management and decolonization of Carbapenem-Resistant Enterobacteriaceae (CRE) gut colonization in patients and healthcare workers is crucial to prevent the spread of infection and reduce mortality rates 2, 3.
• Studies have shown that CRE colonization is a significant risk factor for the development of systemic CRE infection, particularly in critically ill patients 3.
• The use of antibiotic stewardship and device-related infection control measures can help prevent CRE infections in hospitalized patients 2.

Decolonization Strategies

• Fecal microbiota transplantation (FMT) has been explored as a potential decolonization strategy for CRE colonization, with studies showing promising results 4.
• A systematic review of FMT for CRE decolonization found that it was safe and effective in eradicating CRE colonization in infected individuals, with a decolonization rate of 78.7% at the end of the study follow-up 4.
• However, more studies, especially randomized trials, are needed to validate the safety and clinical utility of FMT for CRE eradication 4.

Clinical Significance and Burden of CRE Colonization

• CRE colonization has been associated with increased risk of clinical infections and longer hospital stays, but not necessarily with increased mortality rates 5.
• A study found that CRE colonized patients had 1.7 times the odds of clinical infection of any cause and increased length of hospital stay compared to non-colonized controls 5.
• Infection prevention and antimicrobial stewardship are essential to prevent acquisition and infections in colonized patients 5.

Fecal Microbiota Transplantation (FMT)

• FMT is a method to directly change the recipient's gut microbiota to normalize the composition and gain a therapeutic benefit 6.
• The use of FMT has been approved by the United States Food and Drug Administration for treating recurrent and refractory Clostridium difficile infection, and its applications have been extended to other gastrointestinal and extra-gastrointestinal diseases 6.
• However, the long-term outcomes of FMT have not been completely elucidated, and establishing periodicity and length of regular follow-up after FMT is essential to monitor the clinical efficacy and long-term adverse events 6.