Effectiveness and safety of oral antibiotics as a decolonization strategy for carbapenem-resistant Enterobacteriaceae: A systematic review of randomized and non-randomized studies

Introduction: Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with increased mortality
and higher healthcare costs in hospitalized patients, making it reasonable to explore the effectiveness of strategies
for decolonization of intestinal carriage.
Objective: To evaluate the effectiveness and safety of oral and/or intravenous antibiotics in adults colonized by
CRE.
Methods: We conducted a systematic review of randomized clinical trials and nonrandomized studies comparing
oral and/or intravenous antibiotic therapy versus no treatment or placebo in adults colonized by CRE. Outcomes
assessed included eradication, infection rate, mortality, length of hospital stay, and adverse events. Searches
were performed in the Embase, MEDLINE (PubMed), and Cochrane Library. Quality assessment was conducted
using the ROB1 or ROBINS-I tool. Meta-analysis was performed using a random effects model in Review Manager,
and the certainty of evidence was evaluated using the GRADE methodology.
Results: Seven studies comprising 728 participants were included. Decolonization therapy was significantly
associated with intestinal carriage eradication (OR: 2.66; 95% CI: 1.55–4.55; I2: 0%). There was a trend toward a
reduced infection rate (OR: 0.66; 95% CI: 0.26–1.65; I2: 4%). Data on mortality and adverse events were limited
and insufficient to draw conclusions about differences between groups. The certainty of evidence ranged from
moderate to very low.
Conclusion: This study suggests that decolonization therapy may be effective in eradicating CRE intestinal carriage
state, but current evidence is insufficient to determine its impact on infection rates, mortality, or adverse
events. Larger, high-quality randomized clinical trials are necessary to generate robust evidence supporting its
clinical use.