Hidden Toll of CRE Colonization: Tripled Three-Year Mortality Risk and Increased Bloodstream Infection Burden After
Yuan Zhang1, Rong Wang1, Guoqing Lyu1,2,3
1Department of Hematology, the First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan Province, 453100, People's Republic of China.
Insights
Pre-transplant Carbapenem-resistant Enterobacteriaceae (CRE) colonization significantly worsens allogeneic stem cell transplant outcomes, increasing bloodstream infections and mortality. Early screening and decolonization are crucial for improving patient survival.
Area of Science:
- Infectious Diseases
- Hematology
- Transplantation Medicine
Background:
- Carbapenem-resistant Enterobacteriaceae (CRE) colonization is a significant risk factor for allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients.
- Limited data exists on the long-term consequences of CRE colonization and the efficacy of decolonization strategies in this vulnerable population.
Purpose of the Study:
- To evaluate the long-term impact of pre-transplant CRE colonization on allo-HSCT outcomes.
- To assess the incidence of CRE bloodstream infections (BSI) and associated mortality in colonized versus non-colonized patients.
- To investigate the effect of CRE colonization on engraftment, graft-versus-host disease (GVHD), and overall survival (OS).
Main Methods:
- A prospective study of 240 allo-HSCT recipients screened for pre-transplant rectal CRE colonization.
- Inverse probability of treatment weighting (IPTW) was used for covariate balancing.
- Kaplan-Meier curves and Cox proportional hazards models analyzed outcomes including CRE BSI, engraftment, GVHD, and 3-year OS.
Main Results:
- CRE BSI occurred primarily in colonized patients (26.6%) with high strain and enzyme concordance (81.0% and 77.8%) between colonizing and infecting isolates.
- Colonized patients experienced delayed engraftment and earlier chronic GVHD onset.
- 3-year OS was significantly lower in colonized patients (58% vs 83%) with a 3.49-fold increased mortality risk.
Conclusions:
- Pre-transplant CRE colonization is a strong predictor of adverse allo-HSCT outcomes, including increased CRE BSI, mortality, delayed engraftment, and accelerated GVHD.
- CRE colonization represents a modifiable risk factor, underscoring the need for routine screening and targeted decolonization protocols.
- Implementing effective decolonization strategies is essential to improve survival rates in allo-HSCT recipients.
Purpose:
Carbapenem-resistant Enterobacteriaceae (CRE) colonization poses a major threat to the success of allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, evidence on its long-term impact and the role of decolonization strategies remains limited.
Methods:
This study included 240 allo-HSCT recipients prospectively screened for pre-transplant rectal CRE colonization (colonized n=80; non-colonized n=160; 1:2 matching). Inverse probability of treatment weighting (IPTW) was applied to achieve covariate balance (standardized mean difference <0.10). Key outcomes included CRE bloodstream infection (BSI) incidence, hematopoietic engraftment time, graft-versus-host disease (GVHD) onset, and 3-year overall survival (OS), analyzed using Kaplan-Meier curves and Cox proportional hazards models. Strain and carbapenemase enzyme concordance between colonizing and infecting isolates were evaluated in BSI cases.
Results:
CRE BSI occurred almost exclusively in colonized patients (26.6%, 21/79), with 81.0% strain concordance (predominantly Escherichia coli and Klebsiella pneumoniae) and 77.8% enzyme profile concordance (mainly metallo-β-lactamase/NDM) between pre-transplant colonizing and post-transplant infecting isolates. An 81.0% concordance rate was observed between CRE strain types isolated from perianal colonization samples and those from bloodstream infections. BSI-attributable 100-day mortality was 34.8% (8/23). Colonized patients exhibited delayed engraftment (neutrophils: 14 vs 13 days, P=0.044; platelets: 15 vs 14 days, P=0.014) and earlier chronic GVHD onset (150 vs 235 days, P=0.004), with comparable GVHD incidence. Both unweighted and IPTW-adjusted 3-year OS were markedly lower in colonized patients (62.5%/58% vs 85.0%/83%; HR 3.49, 95% CI 1.91-6.38, P<0.001).
Conclusion:
Pre-transplant CRE colonization is strongly associated with poorer allo-HSCT outcomes, including increased CRE BSI incidence and 100-day mortality, delayed engraftment, accelerated cGVHD onset, and approximately threefold higher 3-year mortality risk. These findings position CRE colonization as a potentially modifiable driver of both early and long-term morbidity, highlighting the critical need for routine screening and targeted decolonization strategies to improve survival in this high-risk population.
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