Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase–producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies

Abstract

The rising burden of intensive care unit (ICU)-acquired infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) strengthens the requirement for efficient prevention strategies. The detection of intestinal carriage of ESBL-E through active surveillance cultures (ASC) and the implementation of contact precautions (CP) in carriers are currently advocated in most high-income countries, to prevent cross-transmission and subsequent ESBL-E infections in critically-ill patients. Yet, recent studies have challenged the benefit of ASC and CP in controlling the spread of ESBL-E in ICUs with high compliance to standard hygiene precautions and no ongoing outbreak of ESBL-producing Klebsiella pneumoniae or Enterobacter spp. Besides, given their debated performance to positively predict which patients are at risk of ESBL-E infections, ASC results appear of limited value to rationalize the empirical use of carbapenems in the ICU, emphasizing the urgent need for novel anticipatory and diagnostic approaches. This Viewpoint article summarizes the available evidence on these issues.

Semi-quantitative cultures of throat and rectal swabs are efficient tests to predict ESBL-Enterobacterales ventilator-associated pneumonia in mechanically ventilated ESBL carriers

“…The worldwide spreading of extended spectrum beta-lactamase producing Enterobacterales (ESBL-E) represents a major problem encountered at an increasing frequency in ICU [2,3]. Among ICU patients, between 5 and 25% are ESBL-E carriers [4][5][6]. Whereas a previous carriage is the major risk factor associated with VAP related to ESBL-E [7,8], only 5-20% of the ESBL-E carriers will develop a VAP related to ESBL-E [9,10].…”

Risk factors for acquisition of carbapenem-resistance during treatment with carbapenem in the intensive care unit: a prospective study

“…Indeed, the emergence and spread of new beta-lactamases, the principal mechanism involved in bacterial resistance of gram-negative bacteria, closely paralleled the sequential introduction of different beta lactams [1]. Over the last decade, the prevalence of gram-negative bacterial pathogens resistant to multiple antibiotics has dramatically increased [2] and extended-spectrum beta lactamases (ESBLs) are now common in intensive care units.…”

Spontaneous decolonization during hospitalization in intensive care unit patients colonized by extended-spectrum beta-lactamase-producing Enterobacterales

“…From both infection control and antimicrobial stewardship standpoints, the usefulness of systematic screening for intestinal carriage of ESBL-E is currently challenged in the literature 7 . One of the potential benefits of identifying ESBL-E carriers is to limit their spread by implementing additional hygiene precautions.…”