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Tejerina-Álvarez EE, de la Cal López MÁ. Selective decontamination of the digestive tract: concept and application. Med Intensiva 2023; 47:603-615. [PMID: 37858367 DOI: 10.1016/j.medine.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/20/2023] [Indexed: 10/21/2023]
Abstract
Selective digestive decontamination (SDD) is a prophylactic strategy aimed at preventing or eradicating bacterial overgrowth in the intestinal flora that precedes the development of most infections in the Intensive Care Unit. SDD prevents serious infections, reduces mortality, is cost-effective, has no adverse effects, and its short- or long-term use is not associated with any significant increase in antimicrobial resistance. SDD is one of the most widely evaluated interventions in critically ill patients, yet its use is not widespread. The present article offers a narrative review of the most relevant evidence and an update of the pathophysiological concepts of infection control supporting the use of SDD.
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Affiliation(s)
- Eva Esther Tejerina-Álvarez
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain.
| | - Miguel Ángel de la Cal López
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Madrid, Spain.
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Mills JP, Marchaim D. Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update. Infect Dis Clin North Am 2021; 35:969-994. [PMID: 34752228 DOI: 10.1016/j.idc.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, University of Michigan Medical School, F4177 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5226, USA.
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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Abstract
Antibiotic resistance is a major global health challenge and, worryingly, several key Gram negative pathogens can become resistant to most currently available antibiotics. Polymyxins have been revived as a last-line therapeutic option for the treatment of infections caused by multidrug-resistant Gram negative bacteria, in particular Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacterales. Polymyxins were first discovered in the late 1940s but were abandoned soon after their approval in the late 1950s as a result of toxicities (e.g., nephrotoxicity) and the availability of "safer" antibiotics approved at that time. Therefore, knowledge on polymyxins had been scarce until recently, when enormous efforts have been made by several research teams around the world to elucidate the chemical, microbiological, pharmacokinetic/pharmacodynamic, and toxicological properties of polymyxins. One of the major achievements is the development of the first scientifically based dosage regimens for colistin that are crucial to ensure its safe and effective use in patients. Although the guideline has not been developed for polymyxin B, a large clinical trial is currently being conducted to optimize its clinical use. Importantly, several novel, safer polymyxin-like lipopeptides are developed to overcome the nephrotoxicity, poor efficacy against pulmonary infections, and narrow therapeutic windows of the currently used polymyxin B and colistin. This review discusses the latest achievements on polymyxins and highlights the major challenges ahead in optimizing their clinical use and discovering new-generation polymyxins. To save lives from the deadly infections caused by Gram negative "superbugs," every effort must be made to improve the clinical utility of the last-line polymyxins. SIGNIFICANCE STATEMENT: Antimicrobial resistance poses a significant threat to global health. The increasing prevalence of multidrug-resistant (MDR) bacterial infections has been highlighted by leading global health organizations and authorities. Polymyxins are a last-line defense against difficult-to-treat MDR Gram negative pathogens. Unfortunately, the pharmacological information on polymyxins was very limited until recently. This review provides a comprehensive overview on the major achievements and challenges in polymyxin pharmacology and clinical use and how the recent findings have been employed to improve clinical practice worldwide.
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Affiliation(s)
- Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Mohammad A K Azad
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Tony Velkov
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Qi Tony Zhou
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
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Hurley JC. Studies of selective digestive decontamination as a natural experiment to evaluate topical antibiotic prophylaxis and cephalosporin use as population-level risk factors for enterococcal bacteraemia among ICU patients. J Antimicrob Chemother 2020; 74:3087-3094. [PMID: 31355880 DOI: 10.1093/jac/dkz300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/28/2019] [Accepted: 06/11/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) regimens appear protective against ICU-acquired overall bacteraemia. These regimens can be factorized as topical antibiotic prophylaxis (TAP) with (SDD) or without (SOD) protocolized parenteral antibiotic prophylaxis (PPAP) using cephalosporins. Both TAP and cephalosporins are risk factors for enterococcal colonization although their impact on enterococcal bacteraemia within studies of SDD/SOD remains unclear. OBJECTIVES To benchmark the enterococcal bacteraemia incidence within component (control and intervention) groups of SDD/SOD studies among ICU patients versus studies without intervention (observational groups). METHODS The literature was searched for SDD/SOD studies reporting enterococcal bacteraemia incidence data. In addition, component groups of studies of various non-antibiotic interventions served to provide additional points of reference. RESULTS The mean incidence per 100 patients (and 95% CI) for enterococcal bacteraemia among 19 SDD/SOD studies was equally increased among concurrent control (2.1; 1.0%-4.7%) and intervention (2.3; 2.0%-2.7%) groups versus the benchmark incidence (0.8; 0.6%-1.2%) derived from 16 observational study groups and also versus 9 component groups from non-antibiotic studies. These higher incidences remained apparent (P < 0.02) in a meta-regression model adjusting for groupwide factors such as PPAP use, mechanical ventilation proportion, group mean length of stay >7 days and publication year. CONCLUSIONS The incidences of enterococcal bacteraemia within both concurrent control and intervention groups of SDD/SOD studies are unusually high compared with the literature-derived benchmark. The impact of parenteral cephalosporin used as PPAP additional to TAP on enterococcal bacteraemia incidence was indeterminate in this analysis.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Internal Medicine Service, Ballarat Health Services, Ballarat, Victoria, Australia
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Buitinck S, Jansen R, Rijkenberg S, Wester JPJ, Bosman RJ, van der Meer NJM, van der Voort PHJ. The ecological effects of selective decontamination of the digestive tract (SDD) on antimicrobial resistance: a 21-year longitudinal single-centre study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:208. [PMID: 31174575 PMCID: PMC6555978 DOI: 10.1186/s13054-019-2480-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/19/2019] [Indexed: 02/03/2023]
Abstract
Background The long-term ecological effects on the emergence of antimicrobial resistance at the ICU level during selective decontamination of the digestive tract (SDD) are unknown. We determined the incidence of newly acquired antimicrobial resistance of aerobic gram-negative potentially pathogenic bacteria (AGNB) during SDD. Methods In a single-centre observational cohort study over a 21-year period, all consecutive patients, treated with or without SDD, admitted to the ICU were included. The antibiotic regime was unchanged over the study period. Incidence rates for ICU-acquired AGNB’s resistance for third-generation cephalosporins, colistin/polymyxin B, tobramycin/gentamicin or ciprofloxacin were calculated per year. Changes over time were tested by negative binomial regression in a generalized linear model. Results Eighty-six percent of 14,015 patients were treated with SDD. Most cultures were taken from the digestive tract (41.9%) and sputum (21.1%). A total of 20,593 isolates of AGNB were identified. The two most often found bacteria were Escherichia coli (N = 6409) and Pseudomonas (N = 5269). The incidence rate per 1000 patient-day for ICU-acquired resistance to cephalosporins was 2.03, for polymyxin B/colistin 0.51, for tobramycin 2.59 and for ciprofloxacin 2.2. The incidence rates for ICU-acquired resistant microbes per year ranged from 0 to 4.94 per 1000 patient-days, and no significant time-trend in incidence rates were found for any of the antimicrobials. The background prevalence rates of resistant strains measured on admission for cephalosporins, polymyxin B/colistin and ciprofloxacin rose over time with 7.9%, 3.5% and 8.0% respectively. Conclusions During more than 21-year SDD, the incidence rates of resistant microbes at the ICU level did not significantly increase over time but the background resistance rates increased. An overall ecological effect of prolonged application of SDD by counting resistant microorganisms in the ICU was not shown in a country with relatively low rates of resistant microorganisms. Electronic supplementary material The online version of this article (10.1186/s13054-019-2480-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie Buitinck
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.,TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Rogier Jansen
- Department of Medical Microbiology, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Saskia Rijkenberg
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Jos P J Wester
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Rob J Bosman
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Nardo J M van der Meer
- TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.,Department of Intensive Care, Amphia Hospital, Molengracht 21, 4814 CK, Breda, The Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands. .,TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
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Marchaim D, Kaye D, Kaye KS. Use of Colistin in Critically Ill Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:155-179. [PMID: 31364078 DOI: 10.1007/978-3-030-16373-0_12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Due to lack of better therapeutic options, colistin use for extensively drug-resistant Gram-negative organisms was revived in the past two decades, including in patients in intensive-care units (ICU). There are multiple knowledge gaps pertaining to the clinical use and utility of colistin in critically-ill patients, but due to lack of options, it is used in these high risk patients. In this chapter, we critically review the various topics pertaining to colistin use in critically-ill patients, while highlighting the (lack of) controlled evidence supporting common current practices pertaining to colistin use by clinicians.
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Affiliation(s)
- Dror Marchaim
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel. .,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Donald Kaye
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
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Sánchez-Ramírez C, Hípola-Escalada S, Cabrera-Santana M, Hernández-Viera MA, Caipe-Balcázar L, Saavedra P, Artiles-Campelo F, Sangil-Monroy N, Lübbe-Vázquez CF, Ruiz-Santana S. Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance. Crit Care 2018; 22:141. [PMID: 29843808 PMCID: PMC5975678 DOI: 10.1186/s13054-018-2057-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin-, tobramycin-, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB). METHODS In this cohort study, which was conducted in a 30-bed medical-surgical ICU, clinical outcomes before (1 year, non-SDD group) and after (4 years) implementation of SDD were compared. ICU patients who were expected to require tracheal intubation for > 48 hours were given a standard prophylactic SDD regimen. Oropharyngeal and rectal swabs were obtained on admission and once weekly thereafter. RESULTS ICU-acquired infections occurred in 110 patients in the non-SDD group and in 258 in the SDD group. A significant (P < 0.001) reduction of infections caused by MDRB (risk ratio [RR], 0.31; 95% CI, 0.23-0.41) was found after SDD and was associated with low rates of colistin- and tobramycin-resistant colonization. Colistin- and tobramycin-acquired increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at admission, was nonsignificant (0.82; 95% CI, 0.56 to 1.95; 1.13; 95% CI, 0.75 to 1.70, respectively). SDD was also a protective factor for ICU-acquired infections caused by MDR gram-negative pathogens and Acinetobacter baumannii in the multivariate analysis. In addition, a significant (P < 0.001) reduction of ventilator-associated pneumonia (VAP) (RR, 0.43; 95% CI, 0.32-0.59) and secondary bloodstream infection (BSI) (RR, 0.35; 95% CI, 0.24-0.52) was found. A decrease in antibiotic consumption was also observed. CONCLUSIONS Treatment with SDD during 4 years was effective in an ICU setting with a high level of resistance, with clinically relevant reductions of infections caused by MDRB, and with low rates of colistin- and tobramycin-resistant colonization with nonsignificant increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at ICU admission. In addition, VAP and secondary BSI rates were significantly lower after SDD. Notably, a decrease in antimicrobial consumption was also observed.
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Affiliation(s)
- Catalina Sánchez-Ramírez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Silvia Hípola-Escalada
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Miriam Cabrera-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - María Adela Hernández-Viera
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Liliana Caipe-Balcázar
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Pedro Saavedra
- Mathematics Department, Universidad de las Palmas de Gran Canaria, Las Palmas, Spain
| | - Fernando Artiles-Campelo
- Microbiology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Nayra Sangil-Monroy
- Pharmacy Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Carlos Federico Lübbe-Vázquez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Sergio Ruiz-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
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Cavalcanti AB, Lisboa T, Gales AC. Is Selective Digestive Decontamination Useful for Critically Ill Patients? Shock 2018; 47:52-57. [PMID: 27488086 DOI: 10.1097/shk.0000000000000711] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this study we review the rationale for using selective digestive decontamination (SDD) in critically ill patients, and its effects on clinical outcomes and rates of infection with antimicrobial-resistant microorganisms. SDD consists of the application of nonabsorbable antibiotics to the oropharynx and through a nasogastric or nasoenteral tube, in association with a 4-day course of an intravenous third-generation cephalosporin. The enteral component aims at preventing oral and rectal colonization with potentially pathogenic nosocomial aerobic gram-negative bacilli and yeasts while preserving normal protective anaerobic enteral flora. The short-course systemic component aims at eradicating oral endogenous gram-positive bacteria. SDD decreases the risk of nosocomial infections, and reduces by one-quarter the mortality of patients on mechanical ventilation in settings with low prevalence of antibiotic resistance. Evidence from randomized trials suggests that SDD does not increase rates of antimicrobial-resistant microorganisms, and may reduce resistance rates to some antibiotics. However, several limitations decrease our confidence on these data, particularly for settings with high baseline rates of antimicrobial-resistant microorganisms. Although SDD has a clear potential to improve clinical outcomes of critically patients, its long-term ecologic effects on rates of antimicrobial resistant require appropriate assessment by large multinational cluster randomized trials. Before these results are available, the use of SDD cannot be recommended in most parts of the world, except in settings with very low baseline prevalence of antibiotic resistance.
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Affiliation(s)
- Alexandre Biasi Cavalcanti
- *Research Institute HCor, Hospital do Coração, São Paulo, Brazil †Institutional Network for Research and Inovation in Intensive care (RIPIMI), Complexo Hospitalar Santa Casa, Porto Alegre/Critical Care Department and Infection Control Committee, Clinics Hospital, Porto Alegre, Brazil ‡Infectious Disease Division, Department of Internal Medicine, Escola Paulista de Medicina/ São Paulo Federal University, São Paulo, Brazil
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Bonten MJ. Controlling Transmission of Antibiotic-Resistant Bacteria in ICU Settings. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Adler A, Friedman ND, Marchaim D. Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications. Infect Dis Clin North Am 2016; 30:967-997. [PMID: 27660090 DOI: 10.1016/j.idc.2016.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Dror Marchaim
- Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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Silvestri L, van Saene HKF, Sarginson RE, Gullo A. Selective Decontamination of the Digestive Tract and Ventilator-Associated Pneumonia: We Cannot Let Misinformation Go Uncorrected. J Intensive Care Med 2016; 22:181-2; author reply 183. [PMID: 17562740 DOI: 10.1177/0885066607299773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Plantinga NL, Wittekamp BHJ, van Duijn PJ, Bonten MJM. Fighting antibiotic resistance in the intensive care unit using antibiotics. Future Microbiol 2016; 10:391-406. [PMID: 25812462 DOI: 10.2217/fmb.14.146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Antibiotic resistance is a global and increasing problem that is not counterbalanced by the development of new therapeutic agents. The prevalence of antibiotic resistance is especially high in intensive care units with frequently reported outbreaks of multidrug-resistant organisms. In addition to classical infection prevention protocols and surveillance programs, counterintuitive interventions, such as selective decontamination with antibiotics and antibiotic rotation have been applied and investigated to control the emergence of antibiotic resistance. This review provides an overview of selective oropharyngeal and digestive tract decontamination, decolonization of methicillin-resistant Staphylococcus aureus and antibiotic rotation as strategies to modulate antibiotic resistance in the intensive care unit.
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Affiliation(s)
- Nienke L Plantinga
- Julius Center for Epidemiology of Infectious Disease, University Medical Center Utrecht, Utrecht, The Netherlands
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14
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Plantinga NL, Bonten MJM. Selective decontamination and antibiotic resistance in ICUs. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:259. [PMID: 26104045 PMCID: PMC4479224 DOI: 10.1186/s13054-015-0967-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) have been associated with reduced mortality and lower ICU-acquired bacteremia and ventilator-associated pneumonia rates in areas with low levels of antibiotic resistance. However, the effect of selective decontamination (SDD/SOD) in areas where multidrug-resistant Gram-negative bacteria are endemic is less clear. It will be important to determine whether SDD/SOD improves patient outcome in such settings and how these measures affect the epidemiology of multidrug-resistant Gram-negative bacteria. Here we review the current evidence on the effects of SDD/SOD on antibiotic resistance development in individual ICU patients as well as the effect on ICU ecology, the latter including both ICU-level antibiotic resistance and antibiotic resistance development during long-term use of SDD/SOD.
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Affiliation(s)
- Nienke L Plantinga
- University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Marc J M Bonten
- University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands
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Selective digestive tract decontamination and spread of colistin resistance: antibiotic prophylaxis is not a substitute for hygiene. Antimicrob Agents Chemother 2015; 58:3574-5. [PMID: 24829389 DOI: 10.1128/aac.02313-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wittekamp BHJ, Oostdijk EAN, de Smet AMGA, Bonten MJM. Colistin and tobramycin resistance during long- term use of selective decontamination strategies in the intensive care unit: a post hoc analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:113. [PMID: 25880968 PMCID: PMC4373110 DOI: 10.1186/s13054-015-0838-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/23/2015] [Indexed: 11/10/2022]
Abstract
Introduction Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) have been shown to improve intensive care unit (ICU) patients’ outcomes. The aim of this study was to determine the effects of long-term use of SDD and SOD on colistin and tobramycin resistance among gram-negative bacteria. Methods We performed a post hoc analysis of two consecutive multicentre cluster-randomised trials with crossover of interventions. SDD and SOD were alternately but continuously used during 7 years in five Dutch ICUs participating in two consecutive cluster-randomised trials. In both trials, to measure colistin and tobramycin resistance among gram-negative bacteria, rectal and respiratory samples were obtained monthly from all patients present in the ICU. Results The prevalence of tobramycin resistance in respiratory and rectal samples decreased significantly during long-term use of SOD and SDD. (rectal samples risk ratio (RR) 0.35 (0.23 to 0.53); respiratory samples RR 0.48 (0.32 to 0.73), SDD compared to standard care). Colistin resistance in rectal and respiratory samples did not change (rectal samples RR 0.63 (0.29 to 1.38); respiratory samples RR 1.26 (0.35 to 4.57), SDD compared to standard care). Conclusions In this study, in a setting with low antimicrobial resistance rates, the prevalence of resistance against colistin and tobramycin among gram-negative isolates did not increase during a mean of 7 years of SDD or SOD use. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0838-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bastiaan H J Wittekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Anne Marie G A de Smet
- CAPE, Critical Care, Anesthesiology, Peri-operative and Emergency Medicine Research Program, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Houben AJM, Oostdijk EAN, van der Voort PHJ, Monen JCM, Bonten MJM, van der Bij AK, Vlaspolder F, Stuart JWTC, van Hees BC, Vijfhuizen J, Wintermans RGF, der Kuil WAV, Alblas J, van der Bij AK, Frentz D, Leenstra T, Monen JC, Muilwijk J, Notermans DW, de Greeff SC, van Keulen PHJ, Kluytmans JAJW, Mattsson EE, Sebens FW, Frenay HME, Maraha B, Heilmann FGC, Halaby T, Versteeg D, Hendrix R, Schellekens JFP, Diederen BMW, de Brauwer EIGB, Stals FS, Bakker LJ, Dorigo-Zetsma JW, van Zeijl JH, Bernards AT, de Jongh BM, Vlaminckx BJM, Horrevorts A, Kuipers S, Wintermans RGF, Moffie B, Brimicombe RW, Jansen CL, Renders NHM, Hendrickx BGA, Buiting AGM, Kaan JA, Thijsen SFT, Deege MPD, Ekkelenkamp MB, Tjhie HT, van Zwet AA, Voorn GP, Ruijs GJHM, Wolfhagen MJHM. Selective decontamination of the oropharynx and the digestive tract, and antimicrobial resistance: a 4 year ecological study in 38 intensive care units in the Netherlands. J Antimicrob Chemother 2013; 69:797-804. [DOI: 10.1093/jac/dkt416] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Selective decontamination in European intensive care patients. Intensive Care Med 2013; 38:533-8. [PMID: 22293777 PMCID: PMC3308002 DOI: 10.1007/s00134-012-2488-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 12/12/2011] [Indexed: 12/23/2022]
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Daneman N, Sarwar S, Fowler RA, Cuthbertson BH. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2013; 13:328-41. [PMID: 23352693 DOI: 10.1016/s1473-3099(12)70322-5] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many meta-analyses have shown reductions in infection rates and mortality associated with the use of selective digestive decontamination (SDD) or selective oropharyngeal decontamination (SOD) in intensive care units (ICUs). These interventions have not been widely implemented because of concerns that their use could lead to the development of antimicrobial resistance in pathogens. We aimed to assess the effect of SDD and SOD on antimicrobial resistance rates in patients in ICUs. METHODS We did a systematic review of the effect of SDD and SOD on the rates of colonisation or infection with antimicrobial-resistant pathogens in patients who were critically ill. We searched for studies using Medline, Embase, and Cochrane databases, with no limits by language, date of publication, study design, or study quality. We included all studies of selective decontamination that involved prophylactic application of topical non-absorbable antimicrobials to the stomach or oropharynx of patients in ICUs, with or without additional systemic antimicrobials. We excluded studies of interventions that used only antiseptic or biocide agents such as chlorhexidine, unless antimicrobials were also included in the regimen. We used the Mantel-Haenszel model with random effects to calculate pooled odds ratios. FINDINGS We analysed 64 unique studies of SDD and SOD in ICUs, of which 47 were randomised controlled trials and 35 included data for the detection of antimicrobial resistance. When comparing data for patients in intervention groups (those who received SDD or SOD) versus data for those in control groups (who received no intervention), we identified no difference in the prevalence of colonisation or infection with Gram-positive antimicrobial-resistant pathogens of interest, including meticillin-resistant Staphylococcus aureus (odds ratio 1·46, 95% CI 0·90-2·37) and vancomycin-resistant enterococci (0·63, 0·39-1·02). Among Gram-negative bacilli, we detected no difference in aminoglycoside-resistance (0·73, 0·51-1·05) or fluoroquinolone-resistance (0·52, 0·16-1·68), but we did detect a reduction in polymyxin-resistant Gram-negative bacilli (0·58, 0·46-0·72) and third-generation cephalosporin-resistant Gram-negative bacilli (0·33, 0·20-0·52) in recipients of selective decontamination compared with those who received no intervention. INTERPRETATION We detected no relation between the use of SDD or SOD and the development of antimicrobial-resistance in pathogens in patients in the ICU, suggesting that the perceived risk of long-term harm related to selective decontamination cannot be justified by available data. However, our study indicates that the effect of decontamination on ICU-level antimicrobial resistance rates is understudied. We recommend that future research includes a non-crossover, cluster randomised controlled trial to assess long-term ICU-level changes in resistance rates. FUNDING None.
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Affiliation(s)
- Nick Daneman
- Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada.
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20
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Silvestri L, van Saene HKF, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother 2012; 13:1113-29. [PMID: 22533385 DOI: 10.1517/14656566.2012.681778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) has been proposed to prevent endogenous and exogenous infections and to reduce mortality in critically ill patients. Although the efficacy of SDD has been confirmed by randomized controlled trials (RCTs) and systematic reviews, SDD has been the subject of intense controversy, based mainly on an insufficient evidence of efficacy and on concerns about resistance. AREAS COVERED This article reviews the philosophy, the current evidence on the efficacy of SDD and the issue of emergence of resistance. All SDD RCTs were searched using Embase and Medline, with no restriction of language, gender or age. Personal archives were also explored, including abstracts from major scientific meetings; references in papers and published meta-analyses on SDD were crosschecked. Up-to-date evidence of the impact of SDD on carriage, infections and mortality is presented, and the efficacy of SDD in selected patient groups was investigated, along with the problem of the emergence of resistance. EXPERT OPINION SDD significantly reduces the number of infections of the lower respiratory tract and bloodstream, multiple organ failure and mortality. It also controls resistance, particularly when the full protocol of parenteral and enteral antimicrobials is used.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170 Gorizia, Italy.
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Wittekamp BHJ, Bonten MJM. Antibiotic prophylaxis in the era of multidrug-resistant bacteria. Expert Opin Investig Drugs 2012; 21:767-72. [DOI: 10.1517/13543784.2012.681642] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Selective digestive decontamination and antibiotic resistance. THE LANCET. INFECTIOUS DISEASES 2012; 12:181; author reply 181-2. [PMID: 22361428 DOI: 10.1016/s1473-3099(11)70276-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: a 5-year prospective cohort study. Intensive Care Med 2011; 37:1458-65. [DOI: 10.1007/s00134-011-2307-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 06/27/2011] [Indexed: 10/18/2022]
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Pileggi C, Bianco A, Flotta D, Nobile CGA, Pavia M. Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R155. [PMID: 21702946 PMCID: PMC3219029 DOI: 10.1186/cc10285] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 04/27/2011] [Accepted: 06/24/2011] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Given the high morbidity and mortality attributable to ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, prevention plays a key role in the management of patients undergoing mechanical ventilation. One of the candidate preventive interventions is the selective decontamination of the digestive or respiratory tract (SDRD) by topical antiseptic or antimicrobial agents. We performed a meta-analysis to investigate the effect of topical digestive or respiratory tract decontamination with antiseptics or antibiotics in the prevention of VAP, of mortality and of all ICU-acquired infections in mechanically ventilated ICU patients. METHODS A meta-analysis of randomised controlled trials was performed. The U.S. National Library of Medicine's MEDLINE database, Embase, and Cochrane Library computerized bibliographic databases, and reference lists of selected studies were used. Selection criteria for inclusion were: randomised controlled trials (RCTs); primary studies; examining the reduction of VAP and/or mortality and/or all ICU-acquired infections in ICU patients by prophylactic use of one or more of following topical treatments: 1) oropharyngeal decontamination using antiseptics or antibiotics, 2) gastrointestinal tract decontamination using antibiotics, 3) oropharyngeal plus gastrointestinal tract decontamination using antibiotics and 4) respiratory tract decontamination using antibiotics; reported enough data to estimate the odds ratio (OR) or risk ratio (RR) and their variance; English language; published through June 2010. RESULTS A total of 28 articles met all inclusion criteria and were included in the meta-analysis. The overall estimate of efficacy of topical SDRD in the prevention of VAP was 27% (95% CI of efficacy = 16% to 37%) for antiseptics and 36% (95% CI of efficacy = 18% to 50%) for antibiotics, whereas in none of the meta-analyses conducted on mortality was a significant effect found. The effect of topical SDRD in the prevention of all ICU-acquired infections was statistically significant (efficacy = 29%; 95% CI of efficacy = 14% to 41%) for antibiotics whereas the use of antiseptics did not show a significant beneficial effect. CONCLUSIONS Topical SDRD using antiseptics or antimicrobial agents is effective in reducing the frequency of VAP in ICU. Unlike antiseptics, the use of topical antibiotics seems to be effective also in preventing all ICU-acquired infections, while the effectiveness on mortality of these two approaches needs to be investigated in further research.
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Affiliation(s)
- Claudia Pileggi
- Department of Clinical and Experimental Medicine, Medical School, University of Catanzaro Magna Græcia, via Tommaso Campanella, 88100 Catanzaro Italy.
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Abecasis F, Sarginson RE, Kerr S, Taylor N, van Saene HK. Is Selective Digestive Decontamination Useful in Controlling Aerobic Gram-Negative Bacilli Producing Extended Spectrum Beta-Lactamases? Microb Drug Resist 2011; 17:17-23. [DOI: 10.1089/mdr.2010.0060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Francisco Abecasis
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Richard E. Sarginson
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Steve Kerr
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Nia Taylor
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
| | - Hendrik K.F. van Saene
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
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Schultz MJ, Haas LE. Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review. Crit Care 2011; 15:R18. [PMID: 21232110 PMCID: PMC3222052 DOI: 10.1186/cc9963] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 11/08/2010] [Accepted: 01/13/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction Mechanically ventilated critically ill patients frequently develop ventilator-associated pneumonia (VAP), a life-threatening complication. Proposed preventive measures against VAP include, but are not restricted to, selective decontamination of the digestive tract (SDD), selective oropharyngeal decontamination (SOD) and the use of probiotics. Probiotics are live bacteria that could have beneficial effects on the host by altering gastrointestinal flora. Similar to SDD and SOD, a prescription of probiotics aims at the prevention of secondary colonization of the upper and/or lower digestive tract. Methods We performed a literature review to describe the differences and similarities between SDD/SOD and probiotic preventive strategies, focusing on (a) efficacy, (b) risks, and (c) the routing of these strategies. Results Reductions in the incidence of VAP have been achieved with SDD and SOD. Two large randomized controlled trials even showed reduced mortality with these preventive strategies. Randomized controlled trials of probiotic strategies also showed a reduction of the incidence of VAP, but trials were too small to draw firm conclusions. Preventive strategies with antibiotics and probiotics may be limited due to the risk of emerging resistance to the locally applied antibiotics and the risk of probiotic-related infections, respectively. The majority of trials of SDD and SOD did not exhaustively address the issue of emerging resistance. Likewise, trials of probiotic strategies did not adequately address the risk of colonization with probiotics and probiotic-related infection. In studies of SDD and SOD the preventive strategy aimed at decontamination of the oral cavity, throat, stomach and intestines, and the oral cavity and throat, respectively. In the vast majority of studies of probiotic therapy the preventive strategy aimed at decontamination of the stomach and intestines. Conclusions Prophylactic use of antibiotics in critically ill patients is effective in reducing the incidence of VAP. Probiotic strategies deserve consideration in future well-powered trials. Future studies are needed to determine if preventive antibiotic and probiotic strategies are safe with regard to development of antibiotic resistance and probiotic infections. It should be determined whether the efficacy of probiotics improves when these agents are provided to the mouth and the intestines simultaneously.
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Affiliation(s)
- Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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[Prevention and follow-up care of sepsis. 1st revision of S2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V., DSG) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin, DIVI)]. Internist (Berl) 2010; 51:925-32. [PMID: 20652527 DOI: 10.1007/s00108-010-2663-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The 1st revision of the S2k guideline on the prevention and follow-up care of sepsis, provided by the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information on the effective and appropriate medical care of critically ill patients with severe sepsis or septic shock. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.
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Selective decontamination of the digestive tract reduces pneumonia and mortality. Crit Care Res Pract 2010; 2010:501031. [PMID: 20981328 PMCID: PMC2958652 DOI: 10.1155/2010/501031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 09/20/2010] [Indexed: 11/20/2022] Open
Abstract
Selective decontamination of the digestive tract (SDD) has been subject of numerous randomized controlled trials in critically ill patients. Almost all clinical trials showed SDD to prevent pneumonia. Nevertheless, SDD has remained a controversial strategy. One reason for why clinicians remained reluctant to implement SDD into daily practice could be that mortality was reduced in only 2 trials. Another reason could be the heterogeneity of trials of SDD. Indeed, many different prophylactic antimicrobial regimes were tested, and dissimilar diagnostic criteria for pneumonia were applied amongst the trials. This heterogeneity impeded interpretation and comparison of trial results. Two other hampering factors for implementation of SDD have been concerns over the risk of antimicrobial resistance and fear for escalation of costs associated with the use of prophylactic antimicrobials. This paper describes the concept of SDD, summarizes the results of published trials of SDD in mixed medical-surgical intensive care units, and rationalizes the risk of antimicrobial resistance and rise of costs associated with this potentially life-saving preventive strategy.
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Respuesta de los autores. Enferm Infecc Microbiol Clin 2010. [DOI: 10.1016/j.eimc.2010.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Oudhuis GJ, Bergmans DC, Dormans T, Zwaveling JH, Kessels A, Prins MH, Stobberingh EE, Verbon A. Probiotics versus antibiotic decontamination of the digestive tract: infection and mortality. Intensive Care Med 2010; 37:110-7. [PMID: 20721536 PMCID: PMC3020315 DOI: 10.1007/s00134-010-2002-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 06/15/2010] [Indexed: 12/28/2022]
Abstract
PURPOSE Selective decontamination of the digestive tract (SDD) has been shown to decrease the infection rate and mortality in intensive care units (ICUs); Lactobacillus plantarum 299/299v plus fibre (LAB) has been used for infection prevention and does not harbour the potential disadvantages of antibiotics. The objective was to assess whether LAB is not inferior to SDD in infection prevention. METHODS Two hundred fifty-four consecutive ICU patients with expected mechanical ventilation ≥ 48 h and/or expected ICU stay ≥ 72 h were assigned to receive SDD: four times daily an oral paste (polymyxin E, gentamicin, amphotericin B), enteral solution (same antibiotics), intravenous cefotaxime (first 4 days) or LAB: two times daily L. plantarum 299/299v with rose-hip. RESULTS The primary endpoint was infection rate. A difference <12% between both groups indicated non-inferiority of LAB. The trial was prematurely stopped after a study reporting increased mortality in critically ill pancreatitis patients receiving probiotics. No significant difference in infection rate [31% in the LAB group, 24% in the SDD group (OR 1.68, 95% CI 0.91-3.08; p = 0.10)] was found. ICU mortality was 26% and not significantly different between the LAB and SDD groups. Gram-positive cocci and Pseudomonas aeruginosa were significantly more frequently isolated from surveillance cultures in the SDD group compared to the LAB group (for sputum: 18 vs. 10% and 33 vs. 14%). Significantly more Enterobacteriaceae were found in the LAB group (23 vs. 50%). No increase in antibiotic resistance was found during and after SDD or LAB use. CONCLUSIONS The trial could not demonstrate the non-inferiority of LAB compared with SDD in infection prevention. Results suggest no increased ICU mortality risk in the LAB group.
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Affiliation(s)
- Guy J Oudhuis
- Department of Medical Microbiology, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, PO Box 5800, 6202 AZ Maastricht, The Netherlands
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Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T. [Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI)]. Anaesthesist 2010; 59:347-70. [PMID: 20414762 DOI: 10.1007/s00101-010-1719-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- K Reinhart
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena der Friedrich-Schiller-Universität Jena, Erlanger Allee 101, 07747 Jena.
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Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T. Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI)). GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc14. [PMID: 20628653 PMCID: PMC2899863 DOI: 10.3205/000103] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Indexed: 12/16/2022]
Abstract
Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.
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Affiliation(s)
- K Reinhart
- University Hospital Jena, Clinic for Anaesthesiology and Intensive Care Therapy, Jena, Germany
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Palencia Herrejón E, Rico Cepeda P. [Decontamination. A treatment without indications]. Med Intensiva 2010; 34:334-44. [PMID: 20488583 DOI: 10.1016/j.medin.2010.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 04/12/2010] [Accepted: 04/12/2010] [Indexed: 11/30/2022]
Abstract
The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown.
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van Ruler O, Schultz MJ, Reitsma JB, Gouma DJ, Boermeester MA. Has mortality from sepsis improved and what to expect from new treatment modalities: review of current insights. Surg Infect (Larchmt) 2009; 10:339-48. [PMID: 19673598 DOI: 10.1089/sur.2008.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The incidence of sepsis is increasing continuously, making mortality rate reduction through improved intensive care unit (ICU) care and new treatment modalities a pressing issue. This study aimed to provide insight into the effects of modern ICU care on mortality trends from severe sepsis and to provide a quantitative review of the relative effectiveness of new treatment modalities in reducing deaths. METHODS Mortality data from severe sepsis were extracted from the control arms of several large randomized trials of sepsis treatment published within the last two decades. The effectiveness of recent treatment strategies was expressed as the number of patients it is necessary to treat by that method to save one life (number needed to treat: NNT). RESULTS Death from severe sepsis showed a decline from 44% to 35% between 1990 and 2000. The two most effective strategies in critically ill patients are early appropriate antibiotics (NNT 3; 95% confidence interval [CI] 2, 4) and early goal-directed therapy (NNT 6; 95% CI 4, 24). Infusion of recombinant human activated protein C is the most effective anticoagulant therapy (NNT 15; 95% CI 10, 27). Intensive insulin therapy is only moderately effective (NNT 27; 95% CI 15, 124). CONCLUSIONS The mortality rate from severe sepsis has decreased significantly with modernization of ICU care. New therapeutic strategies may reduce further the mortality rate. However, focused implementation of these new strategies in accordance with their relative effectiveness is needed before we can expect to see their true effect on mortality rates.
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Affiliation(s)
- Oddeke van Ruler
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Olaechea PM. [Bacterial infections in critically ill patients: review of studies published between 2006 and 2008]. Med Intensiva 2009; 33:196-206. [PMID: 19558941 DOI: 10.1016/s0210-5691(09)71216-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A systematic revision of medical publications between 2006 and 2008 regarding bacterial infections that affect the critical patients was performed. Four subjects were selected: Community-acquired pneumonia, ventilator-associated pneumonia, catheter-related bloodstream infection and new antimicrobial treatments. When dealing with community-acquired pneumonia and due to the absence of completely reliable standards, it is necessary to follow the locally adapted guidelines of clinical practice, to identify patients related to the health-care system and admit patients to the ICU in accordance with the criteria. Regarding the etiological diagnosis of ventilator-associated pneumonia, any microbiological information available must be used. Due to the risk of multidrug bacteria, combined empiric therapy should be initiated immediately and then mono-therapy adjusted to the antibiogram should be established. Already established measures for mechanical ventilation associated pneumonia and catheter-related bacteriemias, which have been effective, should be implemented. The empirical treatment of catheter-related bacteremia must be directed towards the most probable pathogens according to the puncture site. The most recently sold antibiotics are basically directed towards multidrug gram positive resistant bacteria. However, for the treatment of gram negative resistant bacilli, the use of the new antimicrobials must be combined with a new evaluation of the antibiotics that have been used for years and the possibility of choosing different administration forms.
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Affiliation(s)
- Pedro M Olaechea
- Unidad de Cuidados Intensivos, Hospital de Galdakao-Usansolo, Galdakao, Vizcaya, Spain.
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García-San Vicente B, Canut A, Labora A, Otazua M, Corral E. [Selective decontamination of the digestive tract: repercussions on microbiology laboratory workload and costs, and antibiotic resistance trends]. Enferm Infecc Microbiol Clin 2009; 28:75-81. [PMID: 19632746 DOI: 10.1016/j.eimc.2009.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 03/05/2009] [Accepted: 03/11/2009] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study determines the workload and cost of implementing selective digestive decontamination in the microbiology laboratory, and reports the impact on microbial flora and bacterial resistance trends in the intensive care unit (ICU). METHODS The total microbiological workload and cost were quantified, as well as the part charged to the petitioning service, in the year before and the year after introducing the procedure. Changes in microbial flora were evaluated and bacterial resistance trends were analyzed over 12 years in 21 sentinel antimicrobial/microorganism combinations. RESULTS The workload ascribed to the ICU increased by 10% and cost increased by 1.8% in the period after introduction of the procedure (non-significant differences). The increased workload resulting from epidemiological surveillance cultures was compensated by significant reductions in quantitative endotracheal aspirate cultures, blood cultures, exudate cultures, identification tests with antibiograms, and serologies. The procedure has been associated with a significant decrease in Acinetobacter isolates and a significant increase in Enterococcus. Three significant trends of increased resistance were detected, all of them in Pseudomonas aeruginosa (imipenem, tobramycin, and ciprofloxacin). CONCLUSIONS In our hospital, implementation of selective digestive decontamination did not cause a significant increase in the workload or costs in the microbiology laboratory. Selective digestive decontamination was associated with a significant decrease in Acinetobacter, an increase in Enterococcus, and higher resistance to imipenem, tobramycin and ciprofloxacin in P. aeruginosa.
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Affiliation(s)
- Blanca García-San Vicente
- Servicio de Laboratorio, Hospital Santiago Apóstol, Osakidetza-Servicio Vasco de Salud, Vitoria, Alava, Spain
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Wilhelm J, Ebelt H, Buerke M, Schlitt A. Selective decontamination of the digestive tract and oropharynx: new findings for an old approach still under discussion. Expert Rev Anti Infect Ther 2009; 7:399-402. [DOI: 10.1586/eri.09.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bastin AJ, Ryanna KB. Use of selective decontamination of the digestive tract in United Kingdom intensive care units*. Anaesthesia 2009; 64:46-9. [PMID: 19087006 DOI: 10.1111/j.1365-2044.2008.05676.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- A J Bastin
- Adult Intensive Care Unit, Royal Brompton Hospital, London SW36NP, UK.
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de Smet AMGA, Kluytmans JAJW, Cooper BS, Mascini EM, Benus RFJ, van der Werf TS, van der Hoeven JG, Pickkers P, Bogaers-Hofman D, van der Meer NJM, Bernards AT, Kuijper EJ, Joore JCA, Leverstein-van Hall MA, Bindels AJGH, Jansz AR, Wesselink RMJ, de Jongh BM, Dennesen PJW, van Asselt GJ, te Velde LF, Frenay IHME, Kaasjager K, Bosch FH, van Iterson M, Thijsen SFT, Kluge GH, Pauw W, de Vries JW, Kaan JA, Arends JP, Aarts LPHJ, Sturm PDJ, Harinck HIJ, Voss A, Uijtendaal EV, Blok HEM, Thieme Groen ES, Pouw ME, Kalkman CJ, Bonten MJM. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360:20-31. [PMID: 19118302 DOI: 10.1056/nejmoa0800394] [Citation(s) in RCA: 497] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)
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Affiliation(s)
- A M G A de Smet
- Division of Perioperative and Emergency Care, University Medical Center, Utrecht, The Netherlands.
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Silvestri L, Van Saene HKF, Casarin A, Berlot G, Gullo A. Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials. Anaesth Intensive Care 2008; 36:324-38. [PMID: 18564793 DOI: 10.1177/0310057x0803600304] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Meta-analyses of randomised controlled trials of selective digestive decontamination have clinical outcome measures, mainly pneumonia and mortality. This meta-analysis has a microbiological endpoint and explores the impact of selective digestive decontamination on Gram-negative and Gram-positive carriage and severe infections. We searched electronic databases, Cochrane Register of Controlled Trials, previous meta-analyses and conference proceedings with no language restrictions. We included randomised controlled trials which compared the selective digestive decontamination protocol with no treatment or placebo. Three reviewers independently applied selection criteria, performed the quality assessment and extracted the data. The outcome measures were carriage and severe infection due to Gram-negative and Gram-positive bacteria. Odds ratios were pooled with the random effect model. Fifty-four randomised controlled trials comprising 9473 patients were included; 4672 patients received selective digestive decontamination and 4801 were controls. Selective digestive decontamination significantly reduced oropharyngeal carriage (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.07 to 0.23), rectal carriage (OR 0.15, 95% CI 0.07 to 0.31), overall infection (OR 0.17, 95% CI 0.10 to 0.28), lower respiratory tract infection (OR 0.11, 95% CI 0.06 to 0.20) and bloodstream infection (OR 0.35, 95% CI 0.21 to 0.67) due to Gram-negative bacteria. Reduction in Gram-positive carriage was not significant. Gram-positive lower airway infections were significantly reduced (OR 0.52, 95% CI 0.34 to 0.78). Gram-positive bloodstream infections were not significantly increased (OR 1.03, 95% CI 0.75 to 1.41). The association of parenteral and enteral antimicrobials was superior to enteral antimicrobials in reducing carriage and severe infections due to Gram-negative bacteria. This meta-analysis confirms that selective digestive decontamination mainly targets Gram-negative bacteria; it does not show a significant increase in Gram-positive infection.
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Affiliation(s)
- L. Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
| | - H. K. F. Van Saene
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Medical Microbiology, University of Liverpool and Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - A. Casarin
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Critical Care, St. Michael's Hospital, Toronto, Ontario, Canada
| | - G. Berlot
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anesthesia, Intensive Care and Pain Therapy, University Hospital, Trieste, Italy
| | - A. Gullo
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anaesthesia and Intensive Care, Policlinico University Hospital, Catania, Italy
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van Till JO, van Ruler O, Lamme B, Weber RJP, Reitsma JB, Boermeester MA. Single-drug therapy or selective decontamination of the digestive tract as antifungal prophylaxis in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R126. [PMID: 18067657 PMCID: PMC2246222 DOI: 10.1186/cc6191] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 08/16/2007] [Indexed: 11/19/2022]
Abstract
Introduction The objective of this study was to determine and compare the effectiveness of different prophylactic antifungal therapies in critically ill patients on the incidence of yeast colonisation, infection, candidemia, and hospital mortality. Methods A systematic review was conducted of prospective trials including adult non-neutropenic patients, comparing single-drug antifungal prophylaxis (SAP) or selective decontamination of the digestive tract (SDD) with controls and with each other. Results Thirty-three studies were included (11 SAP and 22 SDD; 5,529 patients). Compared with control groups, both SAP and SDD reduced the incidence of yeast colonisation (SAP: odds ratio [OR] 0.38, 95% confidence interval [CI] 0.20 to 0.70; SDD: OR 0.12, 95% CI 0.05 to 0.29) and infection (SAP: OR 0.54, 95% CI 0.39 to 0.75; SDD: OR 0.29, 95% CI 0.18 to 0.45). Treatment effects were significantly larger in SDD trials than in SAP trials. The incidence of candidemia was reduced by SAP (OR 0.32, 95% CI 0.12 to 0.82) but not by SDD (OR 0.59, 95% CI 0.25 to 1.40). In-hospital mortality was reduced predominantly by SDD (OR 0.73, 95% CI 0.59 to 0.93, numbers needed to treat 15; SAP: OR 0.80, 95% CI 0.64 to 1.00). Effectiveness of prophylaxis reduced with an increased proportion of included surgical patients. Conclusion Antifungal prophylaxis (SAP or SDD) is effective in reducing yeast colonisation and infections across a range of critically ill patients. Indirect comparisons suggest that SDD is more effective in reducing yeast-related outcomes, except for candidemia.
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Affiliation(s)
- Jw Olivier van Till
- Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands
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Update on infections in ICU patients. Enferm Infecc Microbiol Clin 2008. [DOI: 10.1016/s0213-005x(08)76380-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Milbrandt EB, Ishizaka A, Angus DC. Update in critical care 2006. Am J Respir Crit Care Med 2007; 175:638-48. [PMID: 17384325 DOI: 10.1164/rccm.200701-0123up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Eric B Milbrandt
- The CRISMA Laboratory, Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, De Backer D, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Macrae D, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C. Year in review in Intensive Care Medicine, 2006. II. Infections and sepsis, haemodynamics, elderly, invasive and noninvasive mechanical ventilation, weaning, ARDS. Intensive Care Med 2007; 33:214-29. [PMID: 17221187 PMCID: PMC7079976 DOI: 10.1007/s00134-006-0512-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 12/18/2006] [Indexed: 01/04/2023]
Affiliation(s)
- Peter Andrews
- Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK
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Zandstra DF, van Saene HK. Chris Stoutenbeek and selective digestive decontamination. Intensive Care Med 2006; 33:207-8. [PMID: 17146634 DOI: 10.1007/s00134-006-0456-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 10/17/2006] [Indexed: 10/23/2022]
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Schröder F, Krueger WA. Infektion – Inflammation – Sepsis: Aktueller Stand und Zukunftsperspektiven. Anaesthesist 2006; 55:797-802. [PMID: 16680441 DOI: 10.1007/s00101-006-1030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- F Schröder
- Universitätsklinik für Anaesthesiologie und Intensivmedizin, Universität, Hoppe-Seyler-Str. 3, 72076, Tübingen
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