From the Guidelines
Patients with Carbapenem-Resistant Enterobacteriaceae (CRE) gut colonization should be managed with a comprehensive approach focusing on infection prevention and antimicrobial stewardship, prioritizing strict contact precautions with single-room isolation when possible, as recommended by the most recent guidelines 1. The primary strategies for managing CRE gut colonization include:
- Strict contact precautions with single-room isolation when possible, using gloves and gowns for all patient interactions
- Implementing rigorous hand hygiene with alcohol-based sanitizers or soap and water
- Enhancing environmental cleaning, with particular attention to high-touch surfaces using hospital-grade disinfectants effective against these organisms
- Conducting active surveillance through rectal swabs or stool samples for high-risk patients, including those previously colonized, transferred from high-prevalence facilities, or with recent healthcare exposure in endemic regions
- Implementing antimicrobial stewardship to limit unnecessary antibiotic use that may promote CRE proliferation
- Considering decolonization therapy on an individual case basis, although the current evidence is insufficient to support or refute its use 1 Healthcare facilities should implement cohort nursing when multiple patients are colonized, and dedicated equipment should be used for each patient. Patient education about their colonization status is important, though reassurance should be provided that colonization itself doesn't require treatment unless infection develops. These measures are essential because CRE colonization significantly increases the risk of subsequent infections with mortality rates of 40-50% in invasive cases, and these organisms can persist in the gut for months to years, serving as a reservoir for transmission to other patients. The most recent guidelines recommend a bundle intervention scheme including single room or cohorting isolation for patients with CRGNB infections or colonization in hospital settings 1.
From the Research
Management Strategies for CRE Gut Colonization
The management of patients with Carbapenem-Resistant Enterobacteriaceae (CRE) gut colonization is crucial to prevent the development of infections and reduce the risk of transmission. The following strategies can be employed:
- Infection prevention and control measures, such as proper hand hygiene, use of personal protective equipment, and environmental cleaning, to prevent the spread of CRE 2
- Antimicrobial stewardship programs to optimize the use of antibiotics and reduce the risk of resistance development 2, 3
- Screening of patients for CRE colonization, particularly those at high risk, such as those with recent hospitalization or antibiotic use 2
- Use of contact precautions for patients with CRE colonization to prevent transmission to others 2
Treatment Options for CRE Infections
In the event of a CRE infection, treatment options are limited, but several antibiotics have shown effectiveness:
- Ceftazidime-avibactam has been shown to be effective in treating CRE bacteremia, with a lower risk of 14-day mortality compared to colistin 4
- Colistin, although associated with a higher risk of mortality, can still be used as an alternative therapy for CRE infections, particularly in combination with other antibiotics 3, 5
- Combination therapy with colistin and other antibiotics, such as linezolid, rifampin, azithromycin, and fusidic acid, has shown synergistic activity against colistin-resistant Enterobacteriaceae 5
Role of Gut Microbiota in Colonization Resistance
The gut microbiota plays a critical role in providing colonization resistance against exogenous microorganisms, including CRE: