From the Guidelines
Management of patients with fecal carriage of colistin and carbapenem-resistant Gram-negative bacteria (GNBs) should prioritize a comprehensive approach focusing on infection prevention, surveillance, and targeted interventions, with contact precautions and patient isolation in a single room being the cornerstone of management. This approach is based on the most recent evidence from 2023, which emphasizes the importance of bundle interventions, including contact isolation, to prevent the spread of these highly resistant organisms 1.
Key components of this approach include:
- Contact precautions, including patient isolation in a single room, dedicated medical equipment, and strict hand hygiene protocols with alcohol-based sanitizers or soap and water
- Healthcare workers using personal protective equipment, including gloves and gowns, when providing care
- Environmental cleaning with hospital-grade disinfectants effective against these resistant organisms, particularly for high-touch surfaces
- Active surveillance through rectal swabs or stool cultures to monitor colonization status, with screening of roommates or close contacts when new cases are identified
- Antibiotic stewardship to prevent further resistance development, with careful restriction of broad-spectrum antibiotics, especially carbapenems and colistin
For decolonization, although no universally effective regimen exists, options may include selective digestive decontamination with non-absorbable antibiotics like oral gentamicin (80mg four times daily), oral colistin (2 million units three times daily), or combination regimens for 5-7 days in specific clinical scenarios, as suggested by guidelines from 2019 1. Fecal microbiota transplantation has shown promise in some studies but remains investigational. Patient education about hand hygiene, bathroom cleaning, and infection control measures is essential to prevent household transmission.
It is also important to consider the potential risks and benefits of different management strategies, including the risk of psychological discomfort and increased consumption of health resources associated with isolation, as well as the potential benefits of preventing the spread of these highly resistant organisms 1. Overall, a comprehensive and multifaceted approach is necessary to effectively manage patients with fecal carriage of colistin and carbapenem-resistant GNBs.
From the Research
Management Strategies for Fecal Carriage of Colistin and Carbapenem-Resistant GNBs
The management of patients with fecal carriage of colistin and carbapenem-resistant Gram-Negative Bacteria (GNBs) is crucial to prevent the spread of these resistant bacteria. Some key strategies include:
- Infection control measures: Implementing strict infection control measures, such as isolation cohorts, is essential to limit the spread of resistant GNBs 2.
- Antibiotic stewardship: The implementation of antibiotic stewardship programs can help reduce the misuse of antibiotics, which is a major driver of antibiotic resistance 2, 3.
- Screening and surveillance: Regular screening and surveillance of patients for fecal carriage of resistant GNBs can help identify potential carriers and inform infection control measures 4, 5, 3.
- Treatment options: Several treatment options are available for infections caused by carbapenem-resistant GNBs, including ceftazidime-avibactam, ceftolozane-tazobactam, and tigecycline 2.
Risk Factors for Fecal Carriage
Several risk factors have been identified for fecal carriage of colistin and carbapenem-resistant GNBs, including:
- Prior antimicrobial use: Prior use of antimicrobials is a significant risk factor for fecal carriage of ESBL-producing and carbapenem-resistant EcKp strains 3.
- Length of hospital stay: Longer lengths of hospital stay increase the risk of fecal carriage of resistant GNBs 3.
- Use of indwelling devices: The use of indwelling devices, such as nasogastric tubes, is a risk factor for acquiring gut colonization with carbapenem-resistant Enterobacteriaceae (CRE) 5.
- Receipt of total parenteral nutrition: Receipt of total parenteral nutrition in the last 6 months is a risk factor for fecal carriage of ESBL-producing and/or carbapenem-resistant EcKp strains 3.
Prevention and Control
Prevention and control of the spread of colistin and carbapenem-resistant GNBs require a multifaceted approach, including:
- Strict implementation of infection control measures: This includes isolation cohorts, proper hand hygiene, and use of personal protective equipment 2.
- Improved antibiotic stewardship: This includes responsible use of antibiotics, monitoring of antibiotic resistance, and development of antibiotic stewardship programs 2, 3.
- Enhanced screening and surveillance: Regular screening and surveillance of patients for fecal carriage of resistant GNBs can help identify potential carriers and inform infection control measures 4, 5, 3.