Gastrointestinal carriage of carbepenemase resistance Enterobacteriaceae- Decolonization?

CRE Map 2012; Source CDC

Can gastrointestinal carriage of carbepenemase resistance Enterobacteriaceae (CRE) be eliminated? Here is a recent publication in the American Journal of Infection Control that suggests that GI eradication of CRE is feasible.

In this cohort,  patients whose rectal isolates were gentamicin sensitive but colistin resistant were treated with gentamicin. Patients whose isolates were colistin sensitive but gentamicin resistant were treated with colistin. Patients whose isolates were sensitive to both drugs were randomized to 3 groups of oral antibiotic treatment: gentamicin, colistin, or both. Patients whose isolates were resistant to both drugs, and those who did not consent, were followed for spontaneous eradication.

A total of 152 patients were included; 102 were followed for spontaneous eradication for a median duration of 140 days (controls), and 50 received 1 of the 3 drug regimens: gentamicin, 26; colistin, 16; both drugs, 8, followed for a median duration of 33 days. Eradication rates in the 3 treatment groups were 42%, 50%, and 37.5%, respectively, each significantly higher than the 7% spontaneous eradication rate in the control group (P < .001, P < .001, and P = .004, respectively) with no difference between the regimens.CRE eradication with non-absorbable antibiotics is better than spontaenous eradication. However, the efficacy of eradication was less than superb and the results were by no means overwhelmingly positive.  Of note, no significant adverse effects were observed.

How is this applicable? Many unanswered questions remain such as what are the optimal CRE decolonization strategies? Who should be targeted? Should CRE eradication be limited to endemic settings, high risk patients (neuropenic patients) or in outbreak settings? We are far from having an optimal approach for CRE detection, isolation and eradication.