Tuesday, August 23, 2016

Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in Healthy Individuals- We May not Want to Know

What do we do with healthy individuals who are fecally colonized with extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae? Recently, it was reported that nearly 15% of healthy patients are ESBL colonized.

Some are already advocating active detection (screening) and isolation of patients who are ESBL colonized.

This is reminiscent of MRSA active detection and isolation argument and of the 'look before you leap' issue, previously articulated by my colleagues Drs. Michael Edmond and Dan Diekema in this article.

Bottom line, there are too many unknown variables regarding ESBL active detection and isolation. What is the real risk of invasive disease in healthy patients with ESBL colonization? What is the risk to others? How long does colonization last? How do we decolonize such patients (and no, fecal transplants for decolonization do not seem feasible)? What sort of cost and labor will screening entail to front line providers and hospital laboratories? What impact will this have on patient throughput?

Last, many of us are reconsidering contact precautions for endemic pathogens, as summarized here. Thus, what incremental benefit, atop a robust horizontal infection control program,  will contact precautions add to the control of ESBL in endemic settings?

Too many questions, too few answers.

We need to be thoughtful and not reactionary with respect to ESBL control in the healthcare setting.