Abstract
BackgroundMultidrug-resistant Escherichia coli and other enteric bacteria producing extended-spectrum β-lactamases (ESBL) have emerged as an important cause of invasive infection. Targeting the primary (intestinal) niche by decolonization may be a valuable approach to decrease the risk of relapsing infections and to reduce transmission of ESBL-producing enteric pathogens.MethodsIn a retrospective observational study we evaluated the efficacy of intestinal decolonization treatment using orally administered colistin or other non-absorbable agents given for 2 to 4 weeks in adult patients with previous relapsing infection and persistent intestinal colonization with ESBL-positive Enterobacteriaceae (ESBL-E). Eradication success was defined as negative rectal swab or stool culture at the end of treatment and at follow up-2 weeks after treatment discontinuation.ResultsFirst-line decolonization treatment led to eradication of ESBL-E in 19/45 patients (42 %, 7/18 low-dose [4 × 1 million units] colistin, 3/12 high-dose [4 × 2 million units] colistin, 9/15 rifaximin [2 × 400 mg]), and secondary/salvage treatment was successful in 8/13 patients (62 %, 20 treatment episodes). Late follow-up showed that 7/13 patients (54 %) with successful initial or salvage decolonization became recolonized within 3 months after post-treatment assessment while all eight of the patients failing initial or salvage decolonization treatment with late follow-up remained colonized. A narrative review of the literature confirms the limited efficacy of non-absorbable antibiotics including conventional selective digestive tract decolonization (SDD)-like combination regimens for eradicating multidrug-resistant enteric bacteria from the intestinal tract.ConclusionsAt present, there is no clear evidence of a significant decolonization efficacy using single-drug treatment with oral non-absorbable antibiotics. More effective regimens are needed and a better definition of at risk patients is required for planning meaningful randomized controlled studies in this field.
Highlights
Multidrug-resistant Escherichia coli and other enteric bacteria producing extended-spectrum β-lactamases (ESBL) have emerged as an important cause of invasive infection
In the present paper we summarize our experience with intestinal Extended-spectrum β-lactamases (ESBL)-E decolonization regimens in 45 patients given either colistin or rifaximin as first-line regimen and a variety of salvage treatments in case of failure
The patients with a history of at least two invasive ESBL-positive Enterobacteriaceae (ESBL-E) infections [urinary tract infection, bloodstream infection, wound infection, respiratory tract infection or other sites] within the last year were screened for persistent colonization by ESBL-E by culture of rectal swabs and/or fecal samples, urine and other specimens depending on information on previous sites of colonization or infection
Summary
Multidrug-resistant Escherichia coli and other enteric bacteria producing extended-spectrum β-lactamases (ESBL) have emerged as an important cause of invasive infection. Regimens for decolonization of ESBL-E in the intestinal tract have been proposed The experience with such regimes, is limited, and the evidence for their efficacy comes from few studies most of which are observational. It is unknown which regimen is best suited and best tolerated, what is the optimum dose and the minimum treatment duration to ensure sustained eradication and suppression of the ESBLpositive organisms in the gut. On the other hand there is vast experience with and substantial clinical trial data for so-called selective digestive tract decolonization (SDD) regimens in intensive care patients and in neutropenic cancer patients in whom preventive treatment with nonabsorbable drugs like colistin plus tobramycin can decrease the risk of infection due to gram-negative enteric bacteria [6]. Other nonabsorbable drugs like rifaximin have been used successfully for suppression of pathogenic or potentially pathogenic enteric bacteria and thereby may yield clinically beneficial effects in travellers’ diarrhea, hepatic encephalopathy and Crohns disease [7]
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