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Vicente Arranz JL, Sánchez-Ramírez C, Saavedra P, Rivero Perdomo Y, Lorenzo-Martín MV, Blanco-López J, Domínguez Cabrera C, Hernández-Socorro CR, Ruiz-Santana S. The Relationship between Selective Digestive Decontamination and Nosocomial Infections in Patients Receiving Continuous Renal Replacement Therapy in ICUs: A Multicenter Study. J Clin Med 2024; 13:4211. [PMID: 39064251 PMCID: PMC11278040 DOI: 10.3390/jcm13144211] [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: 06/22/2024] [Revised: 07/17/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Nosocomial infections are a worldwide healthcare issue, especially in intensive care units (ICUs), and they had a prevalence of 21.1% in 2023 in Spain. Numerous predisposing risk factors have been identified, with the most relevant being invasive techniques, including renal replacement therapies (RRTs). Several outstanding strategies have been published that prevent or reduce their incidence, including the nationwide ZERO in Spain, which consists of structured guidelines to be implemented to tackle this problem. One of these strategies, which is defined as 'highly recommended' in these projects, is selective digestive decontamination (SDD). The main aim of this study is to compare the incidences of ICU-acquired infections, including those due to multidrug-resistant bacteria (MDRB), in two cohorts of RRT with or without SDD. Methods: We conducted a multicenter, prospective, observational study at two tertiary hospitals in Spain. In total, 140 patients treated with RRT were recruited based on their exposure to SDD. Surveillance microbiological samples and nosocomial infection risk factors were obtained. Infection rates per 1000 days of exposure and the MDRB incidence density ratio were determined. Results: SDD statistically significantly reduced RRT-associated nosocomial infections (OR: 0.10, 95% CI: (0.04-0.26)) and the MDRB incidence density ratio (IDR: 0.156, 95% CI = 0.048-0.506). However, mechanical ventilation (OR: 7.91, 95% CI: (2.54-24.66)) and peripheral vascular disease (OR: 3.17, 95% CI: (1.33-7.56)) were significantly associated with increases in infections. Conclusions: Our results favor the use of SDD in ICU patients with renal failure undergoing CRRT as a tool for infection control.
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Affiliation(s)
- Juan Luis Vicente Arranz
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n, E-35010 Las Palmas de Gran Canaria, Spain; (J.L.V.A.); (C.S.-R.); (Y.R.P.)
| | - Catalina Sánchez-Ramírez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n, E-35010 Las Palmas de Gran Canaria, Spain; (J.L.V.A.); (C.S.-R.); (Y.R.P.)
| | - Pedro Saavedra
- Department of Mathematics, University of Las Palmas de Gran Canaria, E-35010 Las Palmas de Gran Canaria, Spain;
| | - Yasmina Rivero Perdomo
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n, E-35010 Las Palmas de Gran Canaria, Spain; (J.L.V.A.); (C.S.-R.); (Y.R.P.)
| | - María Victoria Lorenzo-Martín
- Intensive Care Unit, Complejo Hospitalario Universitario Insular-Materno Infantil, Avenida Marítima del Sur s/n, E-35016 Las Palmas de Gran Canaria, Spain; (M.V.L.-M.); (J.B.-L.)
| | - José Blanco-López
- Intensive Care Unit, Complejo Hospitalario Universitario Insular-Materno Infantil, Avenida Marítima del Sur s/n, E-35016 Las Palmas de Gran Canaria, Spain; (M.V.L.-M.); (J.B.-L.)
| | - Casimira Domínguez Cabrera
- Central Laboratory, Department of Clinical Analysis, Hospital Universitario de Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n, E-35010 Las Palmas de Gran Canaria, Spain;
| | - Carmen-Rosa Hernández-Socorro
- Department of Radiology, Hospital Universitario de Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n, E-35010 Las Palmas de Gran Canaria, Spain;
| | - Sergio Ruiz-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n, E-35010 Las Palmas de Gran Canaria, Spain; (J.L.V.A.); (C.S.-R.); (Y.R.P.)
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Steyer GE, Puchinger M, Pfeifer J. Successful Clinical Avoidance of Colorectal Anastomotic Leakage through Local Decontamination. Antibiotics (Basel) 2024; 13:79. [PMID: 38247638 PMCID: PMC10812415 DOI: 10.3390/antibiotics13010079] [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: 12/16/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
AIM An anastomotic leak is an unpredictable postoperative complication during recovery from colorectal surgery that may require a re-operation. Potentially pathogenic bacteria like Pseudomonas (and Enterococcus) contribute to the pathogenesis of an anastomotic leak through their capacity to degrade collagen and to activate tissue matrix metalloprotease-9 in host intestinal tissues. The microbiome, therefore, is the key to preventing an anastomotic leak after colorectal surgery. The aim of this trial was to investigate whether perioperative selective decontamination with a new mixture of locally acting antibiotics specially designed against Pseudomonas aeruginosa and Enterococcus faecalis can reduce or even stop early symptomatic leakage. METHOD All hospitalized patients in our University Clinic undergoing colorectal surgery with a left-sided anastomosis were included as two groups; patients in the intervention group received polymyxin B, gentamicin and vancomycin every six hours for five postoperative days and those in the control group did not receive such an intervention. An anastomotic leak was defined as a clinically obvious defect of the intestinal wall integrity at the colorectal anastomosis site (including suture) that leads to a communication between the intra- and extraluminal compartments, requiring a re-do surgery within seven postoperative days. RESULTS Between February 2017 and May 2023, a total of 301 patients (median age of 63 years) were analyzed. An anastomotic leak was observed in 11 patients in the control group (n = 152), but in no patients in the intervention group (n = 149); this difference was highly significant. CONCLUSION The antibiotic mixture (with polymyxin B, gentamicin and vancomycin) used for local decontamination in our study stopped the occurrence of anastomotic leaks completely. According to the definition of anastomotic leak, no further surgery was required after local perioperative decontamination.
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Affiliation(s)
- Gerhard Ernst Steyer
- Division of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria;
- Doctoral School of Lifestyle-Related Diseases, Medical University of Graz, Neue Stiftingtalstraße 6, 8010 Graz, Austria
| | - Markus Puchinger
- Medical Engineering and Computing, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria;
| | - Johann Pfeifer
- Division of General, Visceral and Transplant Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria;
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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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Roson-Calero N, Ballesté-Delpierre C, Fernández J, Vila J. Insights on Current Strategies to Decolonize the Gut from Multidrug-Resistant Bacteria: Pros and Cons. Antibiotics (Basel) 2023; 12:1074. [PMID: 37370393 DOI: 10.3390/antibiotics12061074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
In the last decades, we have witnessed a steady increase in infections caused by multidrug-resistant (MDR) bacteria. These infections are associated with higher morbidity and mortality. Several interventions should be taken to reduce the emergence and spread of MDR bacteria. The eradication of resistant pathogens colonizing specific human body sites that would likely cause further infection in other sites is one of the most conventional strategies. The objective of this narrative mini-review is to compile and discuss different strategies for the eradication of MDR bacteria from gut microbiota. Here, we analyse the prevalence of MDR bacteria in the community and the hospital and the clinical impact of gut microbiota colonisation with MDR bacteria. Then, several strategies to eliminate MDR bacteria from gut microbiota are described and include: (i) selective decontamination of the digestive tract (SDD) using a cocktail of antibiotics; (ii) the use of pre and probiotics; (iii) fecal microbiota transplantation; (iv) the use of specific phages; (v) engineered CRISPR-Cas Systems. This review intends to provide a state-of-the-art of the most relevant strategies to eradicate MDR bacteria from gut microbiota currently being investigated.
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Affiliation(s)
- Natalia Roson-Calero
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- Department of Basic Clinical Practice, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Clara Ballesté-Delpierre
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, 08036 Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure (EF-Clif), 08021 Barcelona, Spain
| | - Jordi Vila
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- Department of Basic Clinical Practice, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, 28029 Madrid, Spain
- Department of Clinical Microbiology, Biomedical Diagnostic Center, Hospital Clinic, 08036 Barcelona, Spain
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Hurley JC. Structural equation modelling the impact of antimicrobials on the human microbiome. Colonization resistance versus colonization susceptibility as case studies. J Antimicrob Chemother 2023; 78:328-337. [PMID: 36512373 DOI: 10.1093/jac/dkac408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The impact of antimicrobials on the human microbiome and its relationship to human health are of great interest. How antimicrobial exposure might drive change within specific constituents of the microbiome to effect clinically relevant endpoints is difficult to study. Clinical investigation of each step within a network of causation would be challenging if done 'step-by-step'. An analytic tool of great potential to clinical microbiome research is structural equation modelling (SEM), which has a long history of applications to research questions arising within subject areas as diverse as psychology and econometrics. SEM enables postulated models based on a network of causation to be tested en bloc by confrontation with data derived from the literature. Case studies for the potential application of SEM techniques are colonization resistance (CR) and its counterpart, colonization susceptibility (CS), wherein specific microbes within the microbiome are postulated to either impede (CR) or facilitate (CS) invasive infection with pathogenic bacteria. These postulated networks have three causation steps: exposure to specific antimicrobials are key drivers, clinically relevant infection endpoints are the measurable observables and the activity of key microbiome constituents mediating CR or CS, which may be unobservable, appear as latent variables in the model. SEM methods have potential application towards evaluating the activity of specific antimicrobial agents within postulated networks of causation using clinically derived data.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
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Chan KS, Shelat VG. Diagnosis, severity stratification and management of adult acute pancreatitis-current evidence and controversies. World J Gastrointest Surg 2022; 14:1179-1197. [PMID: 36504520 PMCID: PMC9727576 DOI: 10.4240/wjgs.v14.i11.1179] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Arias-Rivera S, Jam-Gatell R, Nuvials-Casals X, Vázquez-Calatayud M. [Update of the recommendations of the Pneumonia Zero project]. ENFERMERIA INTENSIVA 2022; 33:S17-S30. [PMID: 35911624 PMCID: PMC9326456 DOI: 10.1016/j.enfi.2022.05.005] [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] [Indexed: 12/04/2022]
Abstract
La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial. Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales). Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos. Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.
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Affiliation(s)
- S Arias-Rivera
- Investigación de enfermería. Hospital Universitario de Getafe, Getafe. CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - R Jam-Gatell
- Área de críticos. Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - X Nuvials-Casals
- Área de Desarrollo Profesional e investigación de Enfermería, Clínica Universidad de Navarra. Universidad de Navarra. IdisNA, Instituto de Investigación Sanitaria de Navarra, Navarra, España
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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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Hurley JC. Selective digestive decontamination, a seemingly effective regimen with individual benefit or a flawed concept with population harm? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:323. [PMID: 34470654 PMCID: PMC8408564 DOI: 10.1186/s13054-021-03744-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Abstract
Selective digestive decontamination (SDD) regimens, variously constituted with topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP), appear highly effective for preventing ICU-acquired infections but only within randomized concurrent control trials (RCCT's). Confusingly, SDD is also a concept which, if true, implies population benefit. The SDD concept can finally be reified in humans using the broad accumulated evidence base, including studies of TAP and PPAP that used non-concurrent controls (NCC), as a natural experiment. However, this test implicates overall population harm with higher event rates associated with SDD use within the ICU context.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia. .,Division of Internal Medicine, Ballarat Health Services, PO Box 577, Ballarat, VIC, 3353, Australia.
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Rommes H, Taylor N, Petros A, de la Cal M, Silvestri L. Selective decontamination of the digestive tract is a four-component strategy. Intensive Care Med 2020; 46:1796-1797. [PMID: 32086546 DOI: 10.1007/s00134-020-05958-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Hans Rommes
- , Bosweg 58, 7314 HD, Apeldoorn, The Netherlands.
| | - Nia Taylor
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Andy Petros
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Miguel de la Cal
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Spain
| | - Luciano Silvestri
- Department of Cardiological, Thoracic, Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiolgy and Public Health, University of Padova, 35133, Padova, Italy
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Taylor N, Rommes H, van Saene H. Decontamination Strategies for Critically Ill Patients. JAMA 2019; 321:1408-1409. [PMID: 30964522 DOI: 10.1001/jama.2019.0452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nia Taylor
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | | | - Hendrick van Saene
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
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Management of multidrug resistant Gram-negative bacilli infections in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2017; 32:36-57. [PMID: 28811074 DOI: 10.1016/j.trre.2017.07.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/02/2017] [Indexed: 12/17/2022]
Abstract
Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate's phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection.
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Resino E, San-Juan R, Aguado JM. Selective intestinal decontamination for the prevention of early bacterial infections after liver transplantation. World J Gastroenterol 2016; 22:5950-5957. [PMID: 27468189 PMCID: PMC4948279 DOI: 10.3748/wjg.v22.i26.5950] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 05/06/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection in the first month after liver transplantation is a frequent complication that poses a serious risk for liver transplant recipients as contributes substantially to increased length of hospitalization and hospital costs being a leading cause of death in this period. Most of these infections are caused by gram-negative bacilli, although gram-positive infections, especially Enterococcus sp. constitute an emerging infectious problem. This high rate of early postoperative infections after liver transplant has generated interest in exploring various prophylactic approaches to surmount this problem. One of these approaches is selective intestinal decontamination (SID). SID is a prophylactic strategy that consists of the administration of antimicrobials with limited anaerobicidal activity in order to reduce the burden of aerobic gram-negative bacteria and/or yeast in the intestinal tract and so prevent infections caused by these organisms. The majority of studies carried out to date have found SID to be effective in the reduction of gram-negative infection, but the effect on overall infection is limited due to a higher number of infection episodes by pathogenic enterococci and coagulase-negative staphylococci. However, difficulties in general extrapolation of the favorable results obtained in specific studies together with the potential risk of selection of multirresistant microorganisms has conditioned controversy about the routinely application of these strategies in liver transplant recipients.
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Effect of leaving chronic oral foci untreated on infectious complications during intensive chemotherapy. Br J Cancer 2016; 114:972-8. [PMID: 27002936 PMCID: PMC4984907 DOI: 10.1038/bjc.2016.60] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/04/2016] [Accepted: 02/16/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Leukaemic patients receiving intensive chemotherapy and patients undergoing autologous stem-cell transplantation (ASCT) are routinely screened for oral foci of infection to reduce infectious complications that could occur during therapy. In this prospective study we assessed the effect of leaving chronic oral foci of infection untreated on the development of infectious complications in intensively treated haematological patients. METHODS We included and prospectively evaluated all intensively treated leukaemic patients and patients undergoing ASCT who were referred to our medical centre between September 2012 and May 2014, and who matched the inclusion/exclusion criteria. Acute oral foci of infection were removed before chemotherapy or ASCT, whereas chronic oral foci were left untreated. RESULTS In total 28 leukaemic and 35 ASCT patients were included. Acute oral foci of infection were found in 2 leukaemic (7%) and 2 ASCT patients (6%), and chronic oral foci of infection in 24 leukaemic (86%) and 22 ASCT patients (63%). Positive blood cultures with microorganisms potentially originating from the oral cavity occurred in 7 patients during treatment, but were uneventful on development of infectious complications. CONCLUSIONS Our prospective study supports the hypothesis that chronic oral foci of infection can be left untreated as this does not increase infectious complications during intensive chemotherapy.
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Price R, MacLennan G, Glen J. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 2014; 348:g2197. [PMID: 24687313 PMCID: PMC3970764 DOI: 10.1136/bmj.g2197] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis. DESIGN Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence. INCLUSION CRITERIA Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo. RESULTS Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain. CONCLUSION Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.
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Affiliation(s)
- Richard Price
- Intensive Care Unit, Royal Alexandra Hospital, Paisley PA2 9PN, UK
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Kirkpatrick AW, Roberts DJ, De Waele J, Laupland K. Is intra-abdominal hypertension a missing factor that drives multiple organ dysfunction syndrome? Crit Care 2014; 18:124. [PMID: 25030025 PMCID: PMC4057196 DOI: 10.1186/cc13785] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In a recent issue of Critical Care, Cheng and colleagues conducted a rabbit model study that demonstrated that intra-abdominal hypertension (IAH) may damage both gut anatomy and function. With only 6 hours of IAH at 25 mmHg, these authors observed an 80% reduction in mucosal blood flow, an exponential increase in mucosal permeability, and erosion and necrosis of the jejunal villi. Such dramatic findings should remind all caring for the critically ill that IAH may severely damage the normal gut barrier functions and thus may be reasonably expected to facilitate bacterial and mediator translocation. The potential contribution of IAH as a confounding factor in the efficacy of selective decontamination of the digestive tract should be considered.
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Andrews T, Steen C. A review of oral preventative strategies to reduce ventilator-associated pneumonia. Nurs Crit Care 2013; 18:116-22. [DOI: 10.1111/nicc.12002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Silvestri L, de la Cal MA, van Saene HKF. Selective decontamination of the digestive tract: the mechanism of action is control of gut overgrowth. Intensive Care Med 2012; 38:1738-50. [PMID: 23001446 DOI: 10.1007/s00134-012-2690-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/03/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Gut overgrowth is the pathophysiological event in the critically ill requiring intensive care. In relation to the risk of developing a clinically important outcome, gut overgrowth is defined as ≥10(5) potential pathogens including 'abnormal' aerobic Gram-negative bacilli (AGNB), 'normal' bacteria and yeasts, per mL of digestive tract secretion. Surveillance samples of throat and gut are the only samples to detect overgrowth. Gut overgrowth is the crucial event which precedes both primary and secondary endogenous infection, and a risk factor for the development of de novo resistance. Selective decontamination of the digestive tract (SDD) is an antimicrobial prophylaxis designed to control overgrowth. METHODS There have been 65 randomised controlled trials of SDD in 15,000 patients over 25 years and 11 meta-analyses, which are reviewed. RESULTS AND CONCLUSIONS These trials demonstrate that the full SDD regimen using parenteral and enteral antimicrobials reduces lower airway infection by 72 %, blood stream infection by 37 %, and mortality by 29 %. Resistance is also controlled. Parenteral cefotaxime which reaches high salivary and biliary concentrations eradicates overgrowth of 'normal' bacteria such as Staphylococcus aureus in the throat. Enteral polyenes control 'normal' Candida species. Enteral polymyxin and tobramycin, eradicate, or prevent gut overgrowth of 'abnormal' AGNB. Enteral vancomycin controls overgrowth of 'abnormal' methicillin-resistant S. aureus. SDD controls overgrowth by achieving high antimicrobial concentrations effective against 'normal' and 'abnormal' potential pathogens rather than by selectivity.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170, Gorizia, Italy
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Silvestri L, Petros AJ, Roos D, Zandstra DF, Taylor N, van Saene HK. Selective Digestive Decontamination, Selective Oropharyngeal Decontamination, and Oropharyngeal Chlorhexidine: Three Different Maneuvers. Surg Infect (Larchmt) 2012; 13:175-6. [DOI: 10.1089/sur.2011.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Luciano Silvestri
- Department of Emergency Medicine, Unit of Anesthesia and Intensive Care, Presidio Ospedaliero, Gorizia, Italy
| | - Andy J. Petros
- Pediatric Intensive Care Unit, Great Ormond Street Children's Hospital, London, United Kingdom
| | - Daphne Roos
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Durk F. Zandstra
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Nia Taylor
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
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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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Prowle JR, Heenen S, Singer M. Infection in the critically ill--questions we should be asking. J Antimicrob Chemother 2011; 66 Suppl 2:ii3-10. [PMID: 21398305 PMCID: PMC7109642 DOI: 10.1093/jac/dkq517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Best practice in infection control and management in the critically ill continues to generate considerable debate. The wide variation in current practice is witness to this continuing uncertainty. In large part this is due to the lack of a decent evidence base and to an over-reliance on deep-set dogma. Data that go against the grain are often conveniently overlooked and political imperatives frequently supervene. This article highlights some of these discrepancies and argues for a more balanced, scientific approach. In this time of financial restraint, we need to identify true priorities from both health and economic perspectives, and to see what practices can safely and effectively be modified or abandoned.
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Affiliation(s)
- John R. Prowle
- Intensive Care Unit, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK
| | - Sarah Heenen
- Intensive Care Unit, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK
| | - Mervyn Singer
- Intensive Care Unit, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK
- Bloomsbury Institute of Intensive Care Medicine, Department of Medicine, University College London, Gower Street, London WC1E 6BT, UK
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Silvestri L, Taylor N, Zandstra DF, van Saene HKF. Selective digestive decontamination is superior to selective oropharyngeal decontamination. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:411. [PMID: 21457516 PMCID: PMC3219328 DOI: 10.1186/cc10068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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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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Silvestri L, van Saene HKF, Tomasino S, Taylor N. Current status on VAP prevention: evidence-based medicine makes the ethics of withholding SDD questionable. J Clin Monit Comput 2010; 24:305-6. [PMID: 20652378 DOI: 10.1007/s10877-010-9249-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 07/09/2010] [Indexed: 11/26/2022]
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Selective decontamination of the digestive tract in burn patients: an evidence-based maneuver that reduces mortality. J Burn Care Res 2010; 31:372-3; author reply 374. [PMID: 20182385 DOI: 10.1097/bcr.0b013e3181d1b61f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials. Crit Care Med 2010; 38:1370-6. [PMID: 20308882 DOI: 10.1097/ccm.0b013e3181d9db8c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We examined the impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and meetings proceedings. STUDY SELECTION We included all randomized trials comparing both oropharyngeal and intestinal administration of antibiotics in selective decontamination of the digestive tract with or without a parenteral component, with placebo or standard therapy used in the controls. DATA EXTRACTION Two reviewers independently applied selection criteria, performed quality assessment, and extracted the data. The primary end point was the number of patients with multiple organ dysfunction syndrome developing during intensive care unit stay. Secondary end points were overall mortality and multiple organ dysfunction syndrome-related mortality. Odds ratios were pooled with the random effect model. DATA SYNTHESIS We identified seven randomized trials including 1270 patients. Multiple organ dysfunction syndrome was found in 132 of 637 patients (20.7%) in the selective decontamination of the digestive tract group and in 219 of 633 patients (34.6%) in the control group (odds ratio, 0.50; 95% confidence interval, 0.34-0.74; p < .001). Overall mortality for selective decontamination of the digestive tract vs. control patients was 119 of 637 (18.7%) and 145 of 633 (22.9%), respectively, demonstrating a nonsignificant reduction in the odds of death (odds ratio, 0.82; 95% confidence interval, 0.51-1.32; p = .41). In five studies including 472 patients, multiple organ dysfunction syndrome-related mortality was demonstrated in 31 of 239 (13%) patients in selective decontamination of the digestive tract group and 37 of 233 (15.9%) in the controls (odds ratio, 0.84; 95% confidence interval, 0.48-1.41; p = .54). CONCLUSIONS Selective decontamination of the digestive tract reduces the number of patients with multiple organ dysfunction syndrome. Mortality was not significantly reduced, probably because of the small sample size.
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Silvestri L, van Saene HK, Folla L, Milanese M. Selective digestive decontamination is superior to oropharyngeal chlorhexidine in preventing pneumonia and reducing mortality in critically ill patients. J Bras Pneumol 2010; 36:270-2; author reply 272-3. [DOI: 10.1590/s1806-37132010000200018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Silvestri L, van Saene HKF, Zandstra DF, Viviani M, Gregori D. SDD, SOD, or oropharyngeal chlorhexidine to prevent pneumonia and to reduce mortality in ventilated patients: which manoeuvre is evidence-based? Intensive Care Med 2010; 36:1436-7. [PMID: 20237766 DOI: 10.1007/s00134-010-1809-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2009] [Indexed: 11/26/2022]
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Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 2010; 340:c241. [PMID: 20156911 PMCID: PMC2822136 DOI: 10.1136/bmj.c241] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the evidence for prophylactic treatment with systemic antibiotics in burns patients. DESIGN Systematic review and meta-analysis of randomised or quasi-randomised controlled trials recruiting burns inpatients that compared antibiotic prophylaxis (systemic, non-absorbable, or topical) with placebo or no treatment. DATA SOURCES PubMed, Cochrane Library, LILACS, Embase, conference proceedings, and bibliographies. No language, date, or publication status restrictions were imposed. Review methods Two reviewers independently extracted data. The primary outcome was all cause mortality. Risk or rate ratios with 95% confidence intervals were pooled with a fixed effect model if no heterogeneity was present. RESULTS 17 trials were included. Trials that assessed systemic antibiotic prophylaxis given for 4-14 days after admission showed a significant reduction in all cause mortality (risk ratio 0.54, 95% confidence interval 0.34 to 0.87, five trials). The corresponding number needed to treat was 8 (5 to 33), with a control event rate of 26%. Perioperative non-absorbable or topical antibiotics alone did not significantly affect mortality. There was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. Staphylococcus aureus infection or colonisation was reduced with anti-staphylococcal antibiotics. In three trials, resistance to the antibiotic used for prophylaxis significantly increased (rate ratio 2.84, 1.38 to 5.83). The overall methodological quality of the trials was poor. CONCLUSIONS Prophylaxis with systemic antibiotics has a beneficial effect in burns patients, but the methodological quality of the data is weak. As such prophylaxis is currently not recommended for patients with severe burns other than perioperatively, there is a need for randomised controlled trials to assess its use.
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Affiliation(s)
- Tomer Avni
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Sackler Faculty of Medicine, Tel-Aviv University, Israel
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