ESCMID-EUCIC clinical guidelines on decolonization of multidrug-resistant Gram-negative bacteria carriers

SCOPE

The aim of these guidelines is to provide recommendations for decolonizing regimens targeting multidrug-resistant Gram-negative bacteria (MDR-GNB) carriers in all settings.

METHODS

These evidence-based guidelines were produced after a systematic review of published studies on decolonization interventions targeting the following MDR-GNB: third-generation cephalosporin-resistant Enterobacteriaceae (3GCephRE), carbapenem-resistant Enterobacteriaceae (CRE), aminoglycoside-resistant Enterobacteriaceae (AGRE), fluoroquinolone-resistant Enterobacteriaceae (FQRE), extremely drug-resistant Pseudomonas aeruginosa (XDRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), cotrimoxazole-resistant Stenotrophomonas maltophilia (CRSM), colistin-resistant Gram-negative organisms (CoRGNB), and pan-drug-resistant Gram-negative organisms (PDRGNB). The recommendations are grouped by MDR-GNB species. Faecal microbiota transplantation has been discussed separately. Four types of outcomes were evaluated for each target MDR-GNB:(a) microbiological outcomes (carriage and eradication rates) at treatment end and at specific post-treatment time-points; (b) clinical outcomes (attributable and all-cause mortality and infection incidence) at the same time-points and length of hospital stay; (c) epidemiological outcomes (acquisition incidence, transmission and outbreaks); and (d) adverse events of decolonization (including resistance development). The level of evidence for and strength of each recommendation were defined according to the GRADE approach. Consensus of a multidisciplinary expert panel was reached through a nominal-group technique for the final list of recommendations.

RECOMMENDATIONS

The panel does not recommend routine decolonization of 3GCephRE and CRE carriers. Evidence is currently insufficient to provide recommendations for or against any intervention in patients colonized with AGRE, CoRGNB, CRAB, CRSM, FQRE, PDRGNB and XDRPA. On the basis of the limited evidence of increased risk of CRE infections in immunocompromised carriers, the panel suggests designing high-quality prospective clinical studies to assess the risk of CRE infections in immunocompromised patients. These trials should include monitoring of development of resistance to decolonizing agents during treatment using stool cultures and antimicrobial susceptibility results according to the EUCAST clinical breakpoints.

Natural history and decolonization strategies for ESBL/carbapenem-resistant Enterobacteriaceae carriage: systematic review and meta-analysis

BACKGROUND

ESBL-producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae (CRE) are rapidly spreading worldwide. Their natural reservoir is intestinal.

METHODS

We carried out a systematic review and meta-analysis to estimate CRE and ESBL carriage duration and to evaluate the effect of decolonization therapy. We included cohort and comparative studies examining the natural history of CRE/ESBL colonization, examining rates of carriage following decolonization or comparing decolonization and no decolonization conducted in the healthcare setting or in the community. A comprehensive search was conducted until November 2015. We compiled carriage rates at 1, 3, 6 and 12 months with and without decolonization therapy and assessed the effect of decolonization.

RESULTS

Thirty-seven studies fulfilled inclusion criteria. In healthcare settings, pooled ESBL/CRE colonization rates decreased without intervention from 76.7% (95% CI = 69.3%-82.8%) at 1 month to 35.2% (95% CI = 28.2%-42.9%) at 12 months of follow-up. Following decolonization, the rate was 37.1% (95% CI = 27.5%-47.7%) at end of therapy and 57.9% (95% CI = 43.1%-71.4%) at 1 month. In two randomized trials, carriage was significantly reduced at end of therapy (risk ratio = 0.42, 95% CI = 0.25-0.65), but the effect was not significant after 1 month (risk ratio = 0.72, 95% CI = 0.48-1.05), with no longer follow-up. Heterogeneity was explained by surveillance methodology, with no differences observed between ESBLs and CREs. Among community dwellers, ESBL colonization decreased from 52.3% (95% CI = 29.5%-74.2%) at 1 month to 19.2% (95% CI = 9.7%-34.4%) at 6 months.

CONCLUSIONS

A significant proportion of ESBL and CRE carriers remain colonized up to 1 year in the healthcare setting. While short-term decolonization therapy reduces carriage during therapy, its longer-term effects are unclear.

Decolonization and decontamination: what's their role in infection control?

PURPOSE OF REVIEW

Hospital-acquired infections cause up to 19% of infections in paediatric patients contributing to the spread of antimicrobial resistance. This review evaluates the effect of decolonization and decontamination in hospitalized children and neonates as an adjunct to standard infection control measures.

RECENT FINDINGS

Few studies on decolonization and decontamination are available in children. The evidence about the effectiveness of daily chlorhexidine washcloths on bacteraemia in paediatric patients relies on a single randomized controlled trial, in neonates with central venous access in a single retrospective observational study. It is uncertain whether nasal mupirocin reduces methicillin-resistant Staphylococcus aureus carriage and infections in neonates, whereas oral chlorhexidine mouthwashes have not proven effective in children in intensive care settings. Scanty evidence demonstrates a reduction in the rate of ventilation-acquired pneumonia with digestive tract decontamination in paediatric patients and no studies are available in neonates. These strategies have not been extensively tested in resource-poor countries.

SUMMARY

Strong evidence about the efficacy of decolonization and decontamination interventions exists in adult medicine but not in paediatric patients. There is an urgent need to understand how these interventions could be adapted to neonates and resource-poor settings in which the prevalence of hospital-acquired infections is higher.