Germs of thrones - spontaneous decolonization of Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) in Western Europe: is this myth or reality?

Abstract

BackgroundIn France, Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) are considered as Extensively Drug-Resistant (XDR) bacteria. Their management requires reinforcement of hospital’s hygiene policies, and currently there is few consistent data concerning the spontaneous decolonization in XDR colonized patients. Our aim is to study the natural history of decolonization of XDR carriers over time in a hospital setting in a low prevalence country.Material and methodsRetrospective multicenter study over 2 years (2015–2016) in 2 different tertiary care hospital sites and units having an agreement for permanent cohorting of such XDR carriers. We gathered the type of microorganisms, risk factors for colonization and rectal swabs from patient’s follow-up. We also evaluated patient care considering isolation precautions.ResultsWe included 125 patients, aged 63+/−19y, including 72.8% of CRE (n = 91), 24.8% of VRE (n = 31) and 2.4% (n = 3) co-colonized with CRE and VRE. CRE were mainly E. coli (n = 54), K. pneumoniae (n = 51) and E. cloacae (n = 6). Mechanisms of resistance were mainly OXA-48 (n = 69), NDM-1 (n = 11), OXA-232 (n = 8) and KPC (n = 3).Prior antibiotic therapy was reported in 38.4% (n = 48) of cases. Conversely, 17.6% (n = 22) received antibiotics during follow-up.Spontaneous decolonization occurred within the first 30 days in 16.4% (n = 19/116) of cases and up to 48.2% after day-90 with a median follow-up of 96 days (0–974).We estimated that XDR carriage was associated with a larger care burden in 13.6% (n = 17) of cases, especially due to a prolongation of hospitalization of 32.5 days (15–300).ConclusionsOur study shows that spontaneous decolonization is increasing over time (up to 48.2%). We can regret that only few patients underwent screening after 1 year, emphasizing the need for more monitoring and prospective studies.

Efficacy and safety of fecal microbiota transplantation for decolonization of intestinal multidrug-resistant microorganism carriage: beyond Clostridioides difficile infection

“…Spontaneous clearance of MDRO without treatment is not uncommon [57,65]. In a previous study, spontaneous eradication of VRE and CRE occurred in 48.2% of cases with a median time of 49 days [57]. On some occasions, spontaneous eradication of MDRO, rather than FMT, might have had a greater impact on the MDRO decolonization.…”

“…Most previous studies also showed no difference in the efficacy of FMT for eradication between gram-positive and gram-negative bacteria, and found no evidence for the possibility of any difference. A few studies have also shown similar median duration of spontaneous colonization of 45 to 306 days for VRE and 42 to 387 for CRE, although the results varied widely [52][53][54][55][56][57]. A recently published randomized controlled trial also showed that 29% (5/ 17) of patients in the control group without intervention had no MDRO colonization at the last followup [44].…”

“…Third, no study compared the efficacy of FMT for MDRO eradication with the control group. Spontaneous clearance of MDRO without treatment is not uncommon [57,65]. In a previous study, spontaneous eradication of VRE and CRE occurred in 48.2% of cases with a median time of 49 days [57].…”

“…However, intestinal decolonization strategies with antibiotic regimen before or during FMT in patients with non-CDI can be associated with antimicrobial resistance, subsequent perturbation of intestinal commensal microbes, and disturbance of FMT-administered gut flora [44]. A meta-analysis also showed that the ongoing antibiotic therapy after FMT may slow the clearance of MDRO over time and that antibiotic pretreatment may promote the development of antimicrobial resistance to decolonization antibiotics, considering that antimicrobial agents impact the gut microbiota [57,65,66]. Presently, the frequency of FMT trials did not significantly affect the therapeutic effect of FMT.…”

Prolonged Carriage of Carbapenemase-Producing Enterobacteriaceae: Clinical Risk Factors and the Influence of Carbapenemase and Organism Types

“…Previous data regarding the duration of CPE carriage described mainly KPC CPE cases [ 18 , 23 , 24 , 25 , 26 ]. However, little is known about the duration of carriage of OXA-48-like CPE and NDM CPE [ 27 , 28 , 29 ]. To the best of our knowledge, this is the first study to evaluate the clinical risk factors of prolonged carriage of OXA-48-like CPE with the largest number of cases ( n = 116).…”