ArticleInfection and drug resistance2026
Hidden Toll of CRE Colonization: Tripled Three-Year Mortality Risk and Increased Bloodstream Infection Burden After Allo-HSCT-A Propensity-Adjusted Study.
Article in Infection and drug resistance, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
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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