ESCMID-EUCIC clinical guidelines on decolonization of multidrug-resistant Gram-negative bacteria carriers

E Tacconelli; F Mazzaferri; A M de Smet; D Bragantini; P Eggimann; B D Huttner; E J Kuijper; J-C Lucet; N T Mutters; M Sanguinetti; M J Schwaber; M Souli; J Torre-Cisneros; J R Price; J Rodríguez-Baño

doi:10.1016/j.cmi.2019.01.005

ESCMID-EUCIC clinical guidelines on decolonization of multidrug-resistant Gram-negative bacteria carriers

Clin Microbiol Infect. 2019 Jul;25(7):807-817. doi: 10.1016/j.cmi.2019.01.005. Epub 2019 Jan 29.

Authors

E Tacconelli¹, F Mazzaferri², A M de Smet³, D Bragantini², P Eggimann⁴, B D Huttner⁵, E J Kuijper⁶, J-C Lucet⁷, N T Mutters⁸, M Sanguinetti⁹, M J Schwaber¹⁰, M Souli¹¹, J Torre-Cisneros¹², J R Price¹³, J Rodríguez-Baño¹⁴

Affiliations

¹ Division of Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Germany; Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy. Electronic address: [email protected].
² Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy.
³ University of Groningen, University Medical Centre Groningen, Department of Critical Care, Groningen, the Netherlands.
⁴ Adult Critical Care Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
⁵ Division of Infectious Diseases and Infection Control Programme, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
⁶ Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands.
⁷ Infection Control Unit, Bichat-Claude Bernard Hospital, AP-HP, Paris, France; IAME, UMR 1137, DeSCID team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
⁸ European Committee on Infection Control (EUCIC), Basel, Switzerland; Institute for Infection Prevention and Hospital Epidemiology, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
⁹ Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy.
¹⁰ National Centre for Infection Control, Israel Ministry of Health, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
¹¹ Duke Clinical Research Institute, Duke University, Durham, NC, USA; Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
¹² Infectious Diseases Service, Reina Sofía University Hospital, Maimonides Institute for Biomedical Research (IMIBIC), Department of Medicine, University of Córdoba, Córdoba, Spain.
¹³ Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK.
¹⁴ Division of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena / Department of Medicine, University of Seville / Biomedicine Institute of Seville (IBiS), Seville, Spain.

PMID: 30708122
DOI: 10.1016/j.cmi.2019.01.005

Abstract

Scope: The aim of these guidelines is to provide recommendations for decolonizing regimens targeting multidrug-resistant Gram-negative bacteria (MDR-GNB) carriers in all settings.

Methods: These evidence-based guidelines were produced after a systematic review of published studies on decolonization interventions targeting the following MDR-GNB: third-generation cephalosporin-resistant Enterobacteriaceae (3GCephRE), carbapenem-resistant Enterobacteriaceae (CRE), aminoglycoside-resistant Enterobacteriaceae (AGRE), fluoroquinolone-resistant Enterobacteriaceae (FQRE), extremely drug-resistant Pseudomonas aeruginosa (XDRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), cotrimoxazole-resistant Stenotrophomonas maltophilia (CRSM), colistin-resistant Gram-negative organisms (CoRGNB), and pan-drug-resistant Gram-negative organisms (PDRGNB). The recommendations are grouped by MDR-GNB species. Faecal microbiota transplantation has been discussed separately. Four types of outcomes were evaluated for each target MDR-GNB:(a) microbiological outcomes (carriage and eradication rates) at treatment end and at specific post-treatment time-points; (b) clinical outcomes (attributable and all-cause mortality and infection incidence) at the same time-points and length of hospital stay; (c) epidemiological outcomes (acquisition incidence, transmission and outbreaks); and (d) adverse events of decolonization (including resistance development). The level of evidence for and strength of each recommendation were defined according to the GRADE approach. Consensus of a multidisciplinary expert panel was reached through a nominal-group technique for the final list of recommendations.

Recommendations: The panel does not recommend routine decolonization of 3GCephRE and CRE carriers. Evidence is currently insufficient to provide recommendations for or against any intervention in patients colonized with AGRE, CoRGNB, CRAB, CRSM, FQRE, PDRGNB and XDRPA. On the basis of the limited evidence of increased risk of CRE infections in immunocompromised carriers, the panel suggests designing high-quality prospective clinical studies to assess the risk of CRE infections in immunocompromised patients. These trials should include monitoring of development of resistance to decolonizing agents during treatment using stool cultures and antimicrobial susceptibility results according to the EUCAST clinical breakpoints.

Keywords: Acinetobacter; Carbapenemase; Decolonization; Enterobacteriaceae; Extended-spectrum β-lactamase; Guideline; Multidrug-resistant Gram-negative; Pseudomonas; Stenotrophomonas.

Publication types

Practice Guideline
Systematic Review

MeSH terms

Acinetobacter baumannii / drug effects
Anti-Bacterial Agents / pharmacology*
Cross Infection / drug therapy
Drug Resistance, Multiple, Bacterial*
Europe
Gram-Negative Bacteria / drug effects*
Gram-Negative Bacterial Infections / drug therapy*
Humans
Immunocompromised Host
Pseudomonas aeruginosa / drug effects
Stenotrophomonas maltophilia / drug effects

Substances

Anti-Bacterial Agents