From the Guidelines
Decolonization and control practices for Carbapenem-Resistant Enterobacteriaceae (CRE) should primarily focus on infection prevention through strict infection control measures, including contact precautions, patient isolation, and active surveillance, rather than decolonization therapy. The cornerstone of CRE control involves implementing a comprehensive program that includes prompt identification of cases, contact tracing, and facility-wide protocols. According to the most recent and highest quality study 1, bundle interventions including contact isolation of CRGNB infected patients/carriers are recommended to prevent CRGNB infections. This includes single room or cohorting isolation for patients with CRGNB infections or colonization in hospital settings, with priority given to those with fecal or urinary incontinence, using invasive devices, or having continuous wound secretion.
Key components of a CRE control program include:
- Contact precautions for all patients colonized or infected with CRE
- Active surveillance through rectal swabs or stool cultures for high-risk patients
- Dedicated equipment and hand hygiene compliance
- Environmental cleaning and antimicrobial stewardship
- Nursing staff cohorting to prevent cross-transmission
- No caregivers permitted to stay in the ward to care for isolated patients
While some experimental decolonization approaches have been studied, including oral non-absorbable antibiotics like gentamicin, colistin, or combination regimens, these are not routinely recommended due to limited efficacy and concerns about further resistance development 1. Fecal microbiota transplantation has shown promise in small studies but remains investigational. The lack of effective decolonization strategies highlights the importance of preventing CRE transmission in the first place through rigorous infection control practices and limiting unnecessary antibiotic use that can select for resistant organisms. As recommended by the most recent study 1, healthcare facilities should adopt a bundle intervention scheme including single room or cohorting isolation for patients with CRGNB infections or colonization to reduce the rate of CRGNB infection or colonization in hospitalized patients.
From the Research
Decolonization Practices for CRE
- A comprehensive, multisystem, mechanical decolonization protocol for CRE has been proposed, which includes mechanical evacuation using a glycerin enema, replacement of normal gut flora using daily lactobacillus ingestion, skin hygiene cleansing using chlorhexidine, and environmental cleansing by changing bed sheets and clothing every day 2.
- This protocol has been shown to be effective in decolonizing CRE, with a success rate of 62.5% in one study 2.
- Another approach to decolonization is the use of nonabsorbable oral antibiotics, such as gentamicin and colistin, which have been shown to be effective in eradicating CRE colonization in some patients 3.
Control Practices for CRE
- Hand hygiene is an effective intervention to reduce the spread of CRE, and improving hand hygiene compliance has been shown to decrease the rate of healthcare-associated CRE colonization 4.
- Contact precautions, active surveillance cultures, monitoring, audit and feedback of measures, patient isolation or cohorting, and environmental cleaning are also important components of a multimodal approach to controlling CRE 5.
- The use of a targeted solution tool, such as the Hand Hygiene Targeted Solution Tool, can help to improve hand hygiene compliance and reduce the spread of CRE 4.
- A systematic review and reanalysis of quasi-experimental studies found that IPC measures, including contact precautions, active surveillance cultures, and environmental cleaning, were effective in reducing the spread of CRE, CRAB, and CRPsA in healthcare facilities 5.
Key Considerations
- Decolonization and control practices for CRE should be tailored to the individual patient and healthcare facility, taking into account factors such as the patient's underlying health conditions and the facility's resources and infrastructure.
- A comprehensive approach to decolonization and control, including multiple interventions and strategies, is likely to be more effective than a single intervention or strategy 2, 5.
- Further research is needed to fully understand the effectiveness of different decolonization and control practices for CRE, and to develop evidence-based guidelines for healthcare facilities 6, 5.