ESCMID-EUCIC clinical guidelines on decolonisation of multidrug-resistant Gram-negative bacteria carriers

SCOPE: The aim of these guidelines is to provide recommendations for decolonising regimens targeting multidrug-resistant Gram-negative bacteria (MDR-GNB) carriers in all settings. METHODS: These evidence-based guidelines were produced after a systematic review of published studies on decolonisation interventions targeting the following MDR-GNB: third-generation cephalosporin-resistant Enterobacteriaceae (3GCephRE), carbapenem-resistant Enterobacteriaceae (CRE), aminoglycoside-resistant Enterobacteriaceae (AGRE), fluoroquinolone-resistant Enterobacteriaceae (FQRE), extremely drug-resistant Pseudomonas aeruginosa (XDRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), cotrimoxazole-resistant Stenotrophomonas maltophilia (CRSM), colistin-resistant Gram-negative organisms (CoRGNB), pan-drug-resistant Gram-negative organisms (PDRGNB). The recommendations are grouped by MDR-GNB species. Faecal microbiota transplantation has been discussed separately. Four types of outcomes were evaluated for each target MDR-GNB: 1) microbiological outcomes (carriage and eradication rates) at treatment end and at specific post-treatment time points; 2) clinical outcomes (attributable and all-cause mortality and infection incidence) at the same time points and length of hospital stay; 3) epidemiological outcomes (acquisition incidence, transmission and outbreaks); and 4) adverse events of decolonisation (including resistance development). The level of evidence for and strength of each recommendation were defined according to the GRADE approach. Consensus of a multidisciplinary expert panel was reached through a nominal-group technique for the final list of recommendations. RECOMMENDATIONS: The panel does not recommend routine decolonisation of 3GCephRE and CRE carriers. Evidence is currently insufficient to provide recommendations for or against any intervention in patients colonised with AGRE, CoRGNB, CRAB, CRSM, FQRE, PDRGNB, and XDRPA. On the basis of the limited evidence of increased risk of CRE infections in immunocompromised carriers, the panel suggests designing high quality prospective clinical studies to assess the risk of CRE infections in immunocompromised patients. These trials should include monitoring of development of resistance to decolonising agents during treatment using stool cultures and antimicrobial susceptibility results according to the EUCAST clinical breakpoints.