Different screening frequencies of carbapenem-resistant Enterobacteriaceae in patients undergoing hematopoietic stem cell transplantation: which one is better?

Abstract

Background A consensus has been reached that carbapenem-resistant Enterobacteriaceae (CRE) screening in immunosuppressed individuals can reduce the incidence of CRE bloodstream infection (BSI). Methods We retrospectively studied the clinical data of 395 consecutive HSCT patients from September 2017 to April 2019. From September 2017 to June 2018 (period 1), 200 patients received single CRE screening before transplantation. From July 2018 to April 2019 (period 2), 195 patients received continuous weekly CRE screening after admission. For patients colonized with CRE, targeted managements were received: (1) contact precautions and (2) preemptive CRE-targeted treatment if necessary. Results During period 1, 3 patients with CRE colonization were detected (1.5%). The CRE BSI rate was 2.0% (4 patients), and the related 30-day mortality was 50.0% (2 out of 4 patients). During period 2, 21 patients with CRE colonization were detected, and the detection rate was significantly higher than that in period 1 (P<0.001). Of the 21 colonized patients, 4 (19.0%) patients were identified as positive for CRE at the first screening, 5 (23.8%) were identified at the second screening, and the remaining 12 (57.1%) were identified at the third or later screening. The CRE BSI rate decreased to 0.5% (1/195), and there were no CRE-related death. Fifteen colonized patients developed neutropenic fever. Thirteen colonizers were preemptively treated with tigecycline within 24 hours of fever onset, and they achieved rapid temperature control. One colonizer received tigecycline later than 48 hours after fever onset and ultimately survived due to the addition of polymyxin. The other received tigecycline later than 72 hours after fever onset and died of septic shock. Conclusion The increase in screening frequency contributed to the detection of patients with CRE colonization. Targeted managements for these colonized patients may contribute to reducing the incidence and mortality of CRE BSI, therefore improving the prognosis of patients.

Prevention and management of carbapenem-resistant Enterobacteriaceae in haematopoietic cell transplantation

“…21 The incidence of CRE infection in HCT recipients ranges from 1.6% to 3.4%. [22][23][24] Prior colonisation by CRE dramatically increases the CRE BSI rates in the post-HCT period. 3,16,25 While Klebsiella pneumoniae carbapenemase (KPC) is the most common CRE subtype isolated from bacteraemic HCT recipients, oxacillinase (OXA-48) and New Delhi metallo-β-lactamase (NDM) producing CREs are increasingly being reported.…”

“…A regular and continuous screening strategy via faecal culture has been found to be more effective for detection for CRE carriage compared with onetime screening strategy. 24 Forcina et al 23 reported substantial reduction in mortality due to carbapenem-resistant Klebsiella pneumoniae (CRKp) BSI at 1 year post-HCT when weekly surveillance cultures strategy was employed, with contact precautions, in carriers and early targeted therapy was initiated in febrile neutropenic carriers. The 2015 Italian multidisciplinary consensus statement on CRKp infection management in HCT recipients recommended monitoring for CRE colonisation before hospital admission for HCT, weekly post-HCT monitoring in the event of CRKp isolation from other patients in the same BMT unit and in patients who present with post-HCT intestinal complications, in particular GVHD.…”