Is systematic fecal carriage screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae still useful in intensive care unit: a systematic review

Abstract

Background 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). 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. Methods Every 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. Results Among 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. Conclusion Current 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. Electronic supplementary material The online version of this article (10.1186/s13054-019-2460-3) contains supplementary material, which is available to authorized users.

Prior Carriage Predicts Intensive Care Unit Infections Caused by Extended-Spectrum Beta-Lactamase–Producing Enterobacteriaceae

“…However, the efficacy of screening for ESBL-PE colonization in the ICU is questioned when its prevalence is low. 9,10 ICUs present a specific setting in which HAIs are acquired at a higher rate and exhibit higher mortality. In a systematic review, the pooled incidence of ICU-acquired sepsis was 44.8 cases per 1,000 ICU patients with a mortality rate accounting for 44.7%.…”

Effects of Discontinuing Contact Precaution on Control of Extended-Spectrum β-lactamase-producing Enterobacteriaceae Nosocomial Acquisition: An Interrupted Time Series Analysis

“…Finally, several studies have questioned the rectal screening's relevance in non-epidemic situations which is in line with our study and the wide dissemination in the community. (27) The systematic ESBLE screening could not be adequate anymore to guide contact precautions since the HCWs have just to apply the SP.…”

Rückkehr aus den Tropen und Subtropen: Risiko der Kolonisation mit ESBL-Bildnern

“…Eine chinesische Studie berichtet über eine Rate von 0,5 % (62 von 9015) Blutstrominfektionen mit ESBL-Bildnern unter entsprechend besiedelten Intensivpatienten [21]. Daher wird auch ein Screening auf diese Erreger bei Krankenhauseinweisung kritisch diskutiert [22] und von der Kommission für Krankenhaushygiene und PR A XIS Tipp Auch diese Daten der finnischen Studie belegen sehr klar, dass eine erhöhte Vigilanz hinsichtlich importierter MRE erforderlich ist [14].…”