Can we ever de-isolate CPE carriers?

One of the questions that we often ask ourselves is whether carriers of CPE (and other MDR-GNR) can de-isolated. Most of the guidelines are pretty non-committal on this point due to lack of evidence. Some new guidelines from ESCMID-EUCIC address this issue head on. But, unfortunately, the answer is that de-isolation of CPE carriers, particularly over the course of a single hospitalisation, isn’t going to work because there’s no effective decolonisation method.

The guidelines are based on a systematic review of the literature around efforts to decolonise carriers with MDR-GNR. The outcomes were reported by species/resistance profile and categorised neatly into:

  • microbiological outcomes (carriage and eradication rates)
  • clinical outcomes (attributable and all-cause mortality and infection incidence)
  • epidemiological outcomes (acquisition incidence, transmission and outbreaks), and
  • adverse events of decolonization (including resistance development).

Unfortunately, but not surprisingly, the team concluded that decolonisation of CPE carriers should not be routinely performed. Since we know that CPE colonisation continues at least throughout the course of a single hospitalisation, carriers should remain in isolation for the duration of a hospitalisation. Also, since colonisation often continues through to subsequent hospitalisations, we need to consider a “once positive always positive” stance – although clearly this needs to be balanced against patient experience and operational issues.

It’s a shame that the authors considered the one method that may actually be effective in decolonising carriers of MDR-GNR – faecal microbiota transplantation – as out of scope for this review!

Oh, and by the way, if you’re into acronyms for MDR-GNR, this has the lot: 3GCephRE, CRE, AGRE, CoRGNB, CRAB, CRSM, FQRE, PDRGNB… and XDRPA! My wife has banned the use of acronyms for describing anything to do with my work. Perhaps we should take the same approach with MDR-GNR – sorry, I mean, multidrug resistant Gram-negative bacteria?

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