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Barsuk AL, Nekaeva ES, Lovtsova LV, Urakov AL. Selective Intestinal Decontamination as a Method for Preventing Infectious Complications (Review). Sovrem Tekhnologii Med 2021; 12:86-95. [PMID: 34796022 PMCID: PMC8596238 DOI: 10.17691/stm2020.12.6.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 11/14/2022] Open
Abstract
Infectious complications are the most common cause of death in patients with severe burns. To date, there is no generally accepted method for preventing such complications in burn injury. One of the possible prevention options is selective intestinal decontamination (SID). This method is based on the enteral administration of non-absorbable antimicrobial agents. The preventive effect of SID involves inhibition of intestinal microflora translocation through the mucous membranes, inasmuch as studies demonstrate that endogenous opportunistic microorganisms are a common cause of infectious complications in various critical conditions. The SID method was originally developed in the Netherlands for patients suffering from mechanical injury. Antimicrobial drugs were selected based on their high activity in relation to the main endogenous opportunistic pathogens and minimal activity against normal intestinal microflora components. The combination of polymyxin (B or E), tobramycin, and amphotericin B with intravenous cefotaxime was chosen as the first SID regimen. Other regimens were proposed afterwards, and the application field of the method was expanded. In particular, it became the method of choice for prevention of infectious complications in patients with severe burn injury. Clinical studies demonstrate efficacy of some SID regimens for preventing infectious complications in patients with thermal injury. Concomitant administration of SID and systemic preventive antibiotics and addition of oropharyngeal decontamination increases the method efficacy. SID is generally well-tolerated, but some studies show an increased risk of diarrhea with this preventive option. In addition, SID increases the risk of developing antibiotic resistance like any other antibiotic regimens.
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Affiliation(s)
- A L Barsuk
- Associate Professor, Department of General and Clinical Pharmacology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - E S Nekaeva
- Head of Admission and Consultation Department, Clinical Pharmacologist, University Clinic; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - L V Lovtsova
- Associate Professor, Head of the Department of General and Clinical Pharmacology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A L Urakov
- Professor, Head of the Department of General and Clinical Pharmacology; Izhevsk State Medical Academy, 281 Kommunarov St., Izhevsk, 426034, Udmurt Republic, Russia; Leading Researcher, Department of Modeling and Synthesis of Technological Processes Udmurt Federal Research Center, Ural Branch of the Russian Academy of Sciences, 34 Tatyany Baramzinoy St., Izhevsk, 426067, Udmurt Republic, Russia
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Elderman JH, Ong DSY, van der Voort PHJ, Wils EJ. Anti-infectious decontamination strategies in Dutch intensive care units: A survey study on contemporary practice and heterogeneity. J Crit Care 2021; 64:262-269. [PMID: 34052572 DOI: 10.1016/j.jcrc.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite increasing evidence and updated national guidelines, practice of anti-infectious strategies appears to vary in the Netherlands. This study aimed to determine the variation of current practices of anti-infectious strategies in Dutch ICUs. MATERIALS AND METHODS In 2018 and 2019 an online survey of all Dutch ICUs was conducted with detailed questions on their anti-infectious strategies. RESULTS 89% (63 of 71) of the Dutch ICUs responded to the online survey. The remaining ICUs were contacted by telephone. 47 (66%) of the Dutch ICUs used SDD, 14 (20%) used SOD and 10 (14%) used neither SDD nor SOD. Within these strategies considerable heterogeneity was observed in the start criteria of SDD/SOD, the regimen adjustments based on microbiological surveillance and the monitoring of the interventions. CONCLUSIONS The proportion of Dutch ICUs applying SDD or SOD increased over time. Considerable heterogeneity in the regimens was reported. The impact of the observed differences within SDD and SOD practices on clinical outcome remains to be explored.
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Affiliation(s)
- J H Elderman
- Department of Intensive Care, IJsselland Hospital, Capelle aan den IJssel, the Netherlands; Department of Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - D S Y Ong
- Department of Medical Microbiology and Infection Control, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, the Netherlands; Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P H J van der Voort
- Department of Critical Care, University Medical Center Groningen, Groningen, the Netherlands
| | - E-J Wils
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Intensive Care, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, the Netherlands
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Frencken JF, Wittekamp BHJ, Plantinga NL, Spitoni C, van de Groep K, Cremer OL, Bonten MJM. Associations Between Enteral Colonization With Gram-Negative Bacteria and Intensive Care Unit-Acquired Infections and Colonization of the Respiratory Tract. Clin Infect Dis 2019; 66:497-503. [PMID: 29186403 DOI: 10.1093/cid/cix824] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/14/2017] [Indexed: 01/25/2023] Open
Abstract
Background Enteral and respiratory tract colonization with gram-negative bacteria may lead to subsequent infections in critically ill patients. We aimed to clarify the interdependence between gut and respiratory tract colonization and their associations with intensive care unit (ICU)-acquired infections in patients receiving selective digestive tract decontamination (SDD). Methods Colonization status of the rectum and respiratory tract was determined using twice-weekly microbiological surveillance in mechanically ventilated subjects receiving SDD between May 2011 and June 2015 in a tertiary medical-surgical ICU in the Netherlands. Acquisition of infections was monitored daily by dedicated observers. Marginal structural models were used to determine the associations between gram-negative rectal colonization and respiratory tract colonization, ICU-acquired gram-negative infection, and ICU-acquired gram-negative bacteremia. Results Among 2066 ICU admissions, 1157 (56.0%) ever had documented gram-negative carriage in the rectum during ICU stay. Cumulative incidences of ICU-acquired gram-negative infection and bacteremia were 6.0% (n = 124) and 2.1% (n = 44), respectively. Rectal colonization was an independent risk factor for both respiratory tract colonization (cause-specific hazard ratio [CSHR], 2.93 [95% confidence interval {CI}, 2.02-4.23]) and new gram-negative infection in the ICU (CSHR, 3.04 [95% CI, 1.99-4.65]). Both rectal and respiratory tract colonization were associated with bacteremia (CSHR, 7.37 [95% CI, 3.25-16.68] and 2.56 [95% CI, 1.09-6.03], respectively). Similar associations were observed when Enterobacteriaceae and glucose nonfermenting gram-negative bacteria were analyzed separately. Conclusions Gram-negative rectal colonization tends to be stronger associated with subsequent ICU-acquired gram-negative infections than gram-negative respiratory tract colonization. Gram-negative rectal colonization seems hardly associated with subsequent ICU-acquired gram-negative respiratory tract colonization.
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Affiliation(s)
- Jos F Frencken
- Julius Center for Health Sciences and Primary Care
- Department of Intensive Care Medicine, University Medical Center Utrecht
| | | | | | | | - Kirsten van de Groep
- Julius Center for Health Sciences and Primary Care
- Department of Intensive Care Medicine, University Medical Center Utrecht
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands
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Möhlmann JE, van Luin M, Mascini EM, van Leeuwen HJ, de Maat MR. Monitoring of tobramycin serum concentrations in selected critically ill patients receiving selective decontamination of the digestive tract: a retrospective evaluation. Eur J Clin Pharmacol 2019; 75:831-836. [PMID: 30778624 DOI: 10.1007/s00228-019-02644-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/04/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) is a strategy in mechanically ventilated patients to reduce mortality. Treatment consists of enterally administered non-absorbable antibiotics, i.e., tobramycin. However, most intensive care unit (ICU) patients with SDD appear to have detectable tobramycin serum concentrations. The Rijnstate Hospital implemented a protocol for therapeutic drug monitoring (TDM) of tobramycin in patients at risk. The aim of this study was to evaluate the necessity of TDM in these patients and to optimize the current protocol. METHODS This retrospective observational study included ICU patients with SDD treatment for ≥ 7 days and renal failure. These patients were considered eligible for monitoring of tobramycin. Tobramycin serum concentrations, relevant laboratory parameters (i.e., renal function, lactate), and patient data were extracted from the National Intensive Care Evaluation database and the hospital electronic patient data system. RESULTS In 23 subjects, a total of 43 tobramycin serum concentrations was determined. The median tobramycin serum concentration was 0.33 (IQR 0.17-0.49) mg/L of which 12 (27.9%) samples had concentrations < 0.2 mg/L, 30 (69.8%) had concentrations 0.2-1.0 mg/L and 1 (2.3%) had a toxic concentration > 1.0 mg/L. In 3 (7.0%) cases, an intervention was conducted based on the tobramycin serum concentration. CONCLUSION The majority (83.7%) of samples had detectable tobramycin serum concentrations. Monitoring of tobramycin serum concentrations can be considered necessary in patients at risk. However, the current protocol should be optimized to intercept patients more precise.
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Affiliation(s)
- J E Möhlmann
- Department of Clinical Pharmacy, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
| | - M van Luin
- Department of Clinical Pharmacy, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - E M Mascini
- Department of Medical Microbiology and Immunology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - H J van Leeuwen
- Department of Intensive Care, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | - M R de Maat
- Department of Clinical Pharmacy, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
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Oral Tobramycin Prophylaxis Prior to Colorectal Surgery Is Not Associated with Systemic Uptake. Antimicrob Agents Chemother 2017; 62:AAC.01723-17. [PMID: 29061755 DOI: 10.1128/aac.01723-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/17/2017] [Indexed: 11/20/2022] Open
Abstract
Preoperative oral prophylaxis with nonabsorbable antibiotics has been reported to reduce the risk of surgical site infections after colorectal surgery. This prospective study was conducted to evaluate the risk of toxic side effects by measuring postoperative serum tobramycin levels in patients who received a 3-day prophylaxis with tobramycin and colistin prior to colorectal surgery. In all patients, serum tobramycin concentrations were below the detection limit (0.3 mg/liter), implying a low risk of toxicity.
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Oami T, Hattori N, Matsumura Y, Watanabe E, Abe R, Oshima T, Takahashi W, Yamazaki S, Suzuki T, Oda S. The Effects of Fasting and Massive Diarrhea on Absorption of Enteral Vancomycin in Critically Ill Patients: A Retrospective Observational Study. Front Med (Lausanne) 2017. [PMID: 28642864 PMCID: PMC5462912 DOI: 10.3389/fmed.2017.00070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Although vancomycin (VCM) is not absorbed from healthy intestinal mucosa, elevations in the serum VCM concentrations have been reported in some cases. The aims of this study are to evaluate the necessity of therapeutic drug monitoring (TDM) during enteral VCM administration in critically ill patients. Materials and methods In this retrospective study, we enrolled 19 patients admitted to our intensive care unit who were treated with enteral VCM from December 2006 to January 2014. Clinical factors were compared between two groups: Group E whose serum concentrations were detectable, and Group N whose concentrations were below the detection limit of the VCM assay. Results Group E comprises 7 patients, and Group N comprises 12 patients. The fasting duration in Group E was significantly longer compared with that in Group N (17 vs. 8 days, p = 0.023). Furthermore, there was a significant correlation between the serum VCM concentrations and the fasting duration (r = 0.79, p < 0.0001), and the amount of diarrhea (r = 0.46, p = 0.046). No difference was observed in the amount of diarrhea at the time of TDM (Group E; 1,850 mL vs. Group N; 210 mL, p = 0.055) and in the Sequential Organ Failure Assessment subscore for the renal system at the time of TDM (Group E; 4.0 vs. Group N; 1.5, p = 0.068). Conclusion Long durations of fasting and massive diarrhea were associated with elevations in the serum VCM concentrations, which suggested that TDM might be necessary during enteral VCM administration in critically ill patients. Trial registration UMIN Clinical Trials Registry identifier UMIN000016955.
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Affiliation(s)
- Takehiko Oami
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Noriyuki Hattori
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Eizo Watanabe
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ryuzo Abe
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Waka Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Tatsuya Suzuki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Roquilly A, Marret E, Abraham E, Asehnoune K. Pneumonia Prevention to Decrease Mortality in Intensive Care Unit: A Systematic Review and Meta-analysis. Clin Infect Dis 2014; 60:64-75. [DOI: 10.1093/cid/ciu740] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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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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Oudemans-van Straaten HM, Endeman H, Bosman RJ, Attema-de Jonge ME, van Ogtrop ML, Zandstra DF, Franssen EJF. Presence of tobramycin in blood and urine during selective decontamination of the digestive tract in critically ill patients, a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R240. [PMID: 22004661 PMCID: PMC3334791 DOI: 10.1186/cc10489] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 09/05/2011] [Accepted: 10/17/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Tobramycin is one of the components used for selective decontamination of the digestive tract (SDD), applied to prevent colonization and subsequent infections in critically ill patients. Tobramycin is administered in the oropharynx and gastrointestinal tract and is normally not absorbed. However, critical illness may convey gut barrier failure. The aim of the study was to assess the prevalence and amount of tobramycin leakage from the gut into the blood, to quantify tobramycin excretion in urine, and to determine the association of tobramycin leakage with markers of circulation, kidney function and other organ failure. METHODS This was a prospective observational cohort study. The setting was the 20-bed closed format-mixed ICU of a teaching hospital. The study population was critically ill patients with an expected stay of more than two days, receiving SDD with tobramycin, polymyxin-E and amphotericin-B four times daily in the oropharynx and stomach. Tobramycin concentration was measured in serum (sensitive high performance liquid chromatography - mass spectrometry/mass spectrometry (HLPC-MS/MS) assay) and 24-hour urine (conventional immunoassay), in 34 patients, 24 hours after ICU admission, and in 71 patients, once daily for 7 days. Tobramycin leakage was defined as tobramycin detected in serum at least once (> 0.05 mg/L). Ototoxicity was not monitored. RESULTS Of the 100 patients with available blood samples, 83 had tobramycin leakage. Median highest serum concentration for each patient was 0.12 mg/L; 99% of the patients had at least one positive urinary sample (> 0.5 mg/L), 49% had a urinary concentration ≥ 1 mg/L. The highest tobramycin serum concentration was significantly associated with vasopressor support, renal and hepatic dysfunction, and C-reactive protein. At binary logistic regression analysis, high dopamine dose and low urinary output on Day 1 were the significant predictors of tobramycin leakage. Nephrotoxicity could not be shown. CONCLUSIONS The majority of acute critically ill patients treated with enteral tobramycin as a component of SDD had traces of tobramycin in the blood, especially those with severe shock, inflammation and subsequent acute kidney injury, suggesting loss of gut barrier and decreased renal removal. Unexpectedly, urinary tobramycin was above the therapeutic trough level in half of the patients. Nephrotoxicity could not be demonstrated.
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Acute renal failure due to tobramycin intoxication during selective digestive tract decontamination. Intensive Care Med 2011; 37:1386-7. [PMID: 21590348 PMCID: PMC3136690 DOI: 10.1007/s00134-011-2242-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2011] [Indexed: 10/31/2022]
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Posthouwer D, Spronk PE, Ros JJW, Rommes JH. Absorption of tobramycin and amphotericin B during SDD in a patient with a bowel perforation. Acta Anaesthesiol Scand 2009; 53:412. [PMID: 19243341 DOI: 10.1111/j.1399-6576.2008.01856.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine, 2008: I. Brain injury and neurology, renal failure and endocrinology, metabolism and nutrition, sepsis, infections and pneumonia. Intensive Care Med 2008; 35:30-44. [PMID: 19066847 PMCID: PMC7094904 DOI: 10.1007/s00134-008-1371-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 12/01/2008] [Indexed: 12/16/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
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