Abstract
BackgroundExtended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU.MethodsEvery article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy.ResultsAmong 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting.ConclusionCurrent knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.
Highlights
Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU)
We propose here to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in ICU regarding the guidance of hygiene procedures, of empirical antimicrobial therapy for ICU-acquired infections and of selective decontamination strategy
Eligibility criteria Studies were considered suitable for inclusion in this systematic review if (1) they enrolled ICU ESBL-E fecal carriers in a non-outbreak situation, (2) they assess the rate of ESBL-E cross-transmission in ICU, (3) they evaluate the efficacy of contact precautions to limit the spread of ESBL-E, (4) they assess the link or the prognostic value of ESBL-E carriage for subsequent ESBL-E infection, (5) they assess the efficacy of selective decontamination strategy to limit subsequent ESBL-E cross-transmission or infection, (6) all the patients were adults, and (7) they were written in English
Summary
Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). Systematic ESBL-E fecal carriage screening at admission was still considered as a standard of care to reduce guide contact precautions and decrease the incidence of hospital-onset ESBL-E clinical isolates [14, 15]. Despite those precautions, a steady increase of ESBL-E rate has been reported in hospital settings and in the community which can range from 1–6% in Europe and North America to 60% in India [2, 16]. The paradigm of ESBL-E dissemination occurring only in hospital settings by clonal outbreaks has been dramatically changed with the ESBL-E dissemination occurring everywhere, both in community and hospital settings, enhancing the need for further evaluation of contact precautions’ efficacy
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