From the Guidelines
Management of Carbapenem-Resistant Enterobacteriaceae (CRE) fecal carriage and gut colonization in patients and healthcare workers requires a comprehensive approach focusing on infection control measures, including strict contact precautions and environmental cleaning, rather than routine decolonization. The primary management strategy involves placing colonized patients in single rooms with dedicated equipment, proper hand hygiene with alcohol-based sanitizers, and use of personal protective equipment by healthcare workers, as recommended by the guidelines for the diagnosis, treatment, prevention, and control of infections caused by carbapenem-resistant gram-negative bacilli 1. Key considerations include:
- Single room isolation is preferred, and separate toilet should be provided for those infected/colonized with CRGNB.
- Nursing staffs designated to care for patients with CRGNB infections or colonization should not participate in caring for other patients.
- It is recommended that no caregivers be permitted to stay in the ward to care for the isolated patients. Unlike some other resistant organisms, routine decolonization therapy is not generally recommended for CRE carriers due to limited evidence of effectiveness and concerns about further resistance development, as noted in the escmid/eucic clinical practice guidelines on perioperative antibiotic prophylaxis in patients colonized by multidrug-resistant gram-negative bacteria before surgery 1. In specific high-risk scenarios such as before major surgery or in outbreak situations, selective oral decontamination regimens may be considered, which might include combinations of non-absorbable antibiotics like gentamicin, colistin, and neomycin, though protocols vary by institution. Active surveillance through rectal swabs or stool samples is recommended for high-risk patients, including those transferred from high-prevalence facilities or with recent healthcare exposure in endemic regions, as suggested by the escmid-eucic clinical guidelines on decolonization of multidrug-resistant gram-negative bacteria carriers 1. Healthcare workers rarely require screening unless implicated in transmission. This approach is necessary because CRE organisms harbor mobile genetic elements that confer resistance to nearly all available antibiotics, making infections extremely difficult to treat and prevention of transmission paramount.
From the Research
CRE Fecal Carriage and Gut Colonization
- Carbapenem-resistant Enterobacteriaceae (CRE) fecal carriage is a significant concern in patients and healthcare workers, as it can lead to the development of translocated infections 2.
- The prevalence of CRE fecal carriage has been reported to be around 3.6% in outpatient children in Shanghai, China, with Klebsiella pneumoniae and Escherichia coli being the most common strains 3.
- In a Chinese university hospital, the prevalence of CRE fecal carriage was found to be 6.6%, with hospital readmissions, sickbed changes, invasive procedures, and vancomycin use being independently associated with CRE colonization 4.
Risk Factors for CRE Colonization
- Enteral feeding and carbapenem exposure have been identified as risk factors for subsequent pneumonia caused by CRE in patients with fecal colonization 2.
- Hospital readmissions, sickbed changes, invasive procedures, and vancomycin use have also been associated with an increased risk of CRE colonization 4.
- The use of broad-spectrum antibiotics, such as carbapenems, can select for CRE and increase the risk of colonization and infection 5.
Management of CRE Fecal Carriage and Gut Colonization
- Effective infection control measures, such as hand hygiene, contact precautions, and environmental cleaning, are crucial in preventing the transmission of CRE in healthcare facilities 4, 5.
- The use of antimicrobial stewardship programs can help reduce the selective pressure for CRE and other resistant organisms 5.
- Treatment options for CRE infections are limited, but may include combinations of polymyxins, tigecycline, aminoglycosides, or carbapenems, as well as newer agents with activity against CRE 6, 5.