Strategies for the eradication of extended-spectrum beta-lactamase or carbapenemase-producing Enterobacteriaceae intestinal carriage

ABSTRACT

Introduction: Among the multidrug resistant pathogens, extended-spectrum beta-lactamase (ESBL-E) or carbapenemase-producing Enterobacteriaceae (CPE) are currently considered the main threat due to the scarcity of therapeutic options and their rapid spread around the globe. In addition to developing new antibiotics and stopping transmission, recent research has focused on ‘decolonization’ strategies to eradicate the carriage of ESBL-E/CPE before infection occurs.

Areas covered: In this narrative review, we aim to describe the current evidence of decolonization strategies for ESBL-E or CPE intestinal carriage. We first define decolonization and highlight the issues related to the lack of standardized definitions, then we summarize the available data on the natural history of colonization. Finally, we review the strategies assessed over the past 10 years for ESBL and CPE decolonization: oral antibiotics, probiotics and more recently fecal microbiota transplantation. We conclude by presenting the risks and uncertainties associated with these strategies.

Expert opinion: The evidence available today is too low to recommend decolonization strategies for ESBL-E or CPE in routine clinical practice. The potential increase of resistance and the impact of microbiome manipulation should not be underestimated. Some of these decolonization strategies may nevertheless be effective, at least in temporarily suppressing colonization, which could be useful for specific populations such as high-risk patients. Effectiveness and long-term effects must be properly assessed through well-designed randomized controlled trials.

KEYWORDS:

• Decolonization
• Enterobacteriaceae
• fecal microbiota transplantation
• carbapenemase
• extended-spectrum beta-lactamase

Article highlights

• Today, the evidence is too limited to recommend ESBL-E and CPE decolonization in routine practice, even among high-risk patient populations.

• Attempts to suppress (and possibly eradicate) intestinal colonization in selected populations such as heavily immunosuppressed patients or patients undergoing certain high-risk interventions may be worthwhile.

• Some of the decolonization strategies may be effective in temporary suppressing colonization.

• Effectiveness and long-term effects (including impact on the microbiome) must be properly assessed.

• Emergence of resistance to the agents used in the decolonization regimens is a potential concern that should be taken seriously, particularly if last-resort drugs such as polymyxins are used in the regimen.

Declaration of interest

B Huttner was supported in the past in the context of the European R-GNOSIS ‘Resistance in Gram-Negative Organisms: Studying Intervention Strategies’ collaborative research project funded by the European Commission under the Seventh Framework Programme (FP7/2007) for Research and technology (Grant Agreement no. 282512). G Catho is partially supported by the Swiss National Science Foundation in the context of the National Research Plan (NRP) 72 ‘Antimicrobial Resistance’ (No. 407240_167079). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

G Catho is partially supported by the Swiss National Science Foundation in the context of the National Research Plan (NRP) 72 ‘Antimicrobial Resistance’ (Number. 407240_167079).