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Kean IRL, Clark JA, Zhang Z, Daubney E, White D, Ferrando-Vivas P, Milla G, Cuthbertson B, Pappachan J, Klein N, Mouncey P, Rowan K, Myburgh J, Gouliouris T, Baker S, Parkhill J, Pathan N, Arctic Research Team. Short-duration selective decontamination of the digestive tract infection control does not contribute to increased antimicrobial resistance burden in a pilot cluster randomised trial (the ARCTIC Study). Gut 2024; 73:910-921. [PMID: 38253478 PMCID: PMC11103307 DOI: 10.1136/gutjnl-2023-330851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/11/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Selective decontamination of the digestive tract (SDD) is a well-studied but hotly contested medical intervention of enhanced infection control. Here, we aim to characterise the changes to the microbiome and antimicrobial resistance (AMR) gene profiles in critically ill children treated with SDD-enhanced infection control compared with conventional infection control. DESIGN We conducted shotgun metagenomic microbiome and resistome analysis on serial oropharyngeal and faecal samples collected from critically ill, mechanically ventilated patients in a pilot multicentre cluster randomised trial of SDD. The microbiome and AMR profiles were compared for longitudinal and intergroup changes. Of consented patients, faecal microbiome baseline samples were obtained in 89 critically ill children. Additionally, samples collected during and after critical illness were collected in 17 children treated with SDD-enhanced infection control and 19 children who received standard care. RESULTS SDD affected the alpha and beta diversity of critically ill children to a greater degree than standard care. At cessation of treatment, the microbiome of SDD patients was dominated by Actinomycetota, specifically Bifidobacterium, at the end of mechanical ventilation. Altered gut microbiota was evident in a subset of SDD-treated children who returned late longitudinal samples compared with children receiving standard care. Clinically relevant AMR gene burden was unaffected by the administration of SDD-enhanced infection control compared with standard care. SDD did not affect the composition of the oral microbiome compared with standard treatment. CONCLUSION Short interventions of SDD caused a shift in the microbiome but not of the AMR gene pool in critically ill children at the end mechanical ventilation, compared with standard antimicrobial therapy.
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Affiliation(s)
| | - John A Clark
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Zhenguang Zhang
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | | | | | | | | | - John Myburgh
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Julian Parkhill
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Rodríguez-Gascón A, Lloréns-Villar Y, Solinís MÁ, Barrasa H, Canut-Blasco A. Does selective digestive decontamination (SDD) increase antibiotic resistance? Long-term comparison of two intensive care units (with and without SDD) of the same tertiary hospital. Eur J Clin Microbiol Infect Dis 2024; 43:885-893. [PMID: 38460030 PMCID: PMC11108900 DOI: 10.1007/s10096-024-04792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE The aim of this study was to to compare the antimicrobial resistance rate and its relationship with the antibiotic consumption in two separate Intensive Care Units (ICUs) of the same hospital, one with and other without selective decontamination of the digestive tract (SDD). METHODS We performed a retrospective study in the two ICUs of the Araba University Hospital. Trauma and neurosurgical patients are admitted to the SDD-ICU, and general digestive surgery patients go to the no SDD-ICU. From 2014 to 2018 we analyzed the number of isolates, and the bacterial resistance trends of 47 antimicrobial-microorganism combinations. Additionally, antimicrobial consumption was estimated in both ICUs. Resistance rates were also compared with those reported in ENVIN-HELICS Spanish national registry. RESULTS In the ICU with SDD protocol, there was a significant decrease in the resistance of E. coli to amoxicillin/clavulanic acid and in the resistance of E. faecalis to high concentration of gentamycin and high concentration of streptomycin. A significant increase of resistance of Staphylococcus coagulasa negative (CoNS) to linezolid in the no SDD-ICU was also detected. Overall, the level of resistance in the SDD-ICU was lower or of the same order than in the ICU without SDD and that reported in the Spanish national registry. CONCLUSIONS SDD had neither a clinically relevant impact on emergence and spread of resistance, nor in the overall systemic antimicrobial use. The patient type rather than the SDD protocol showed to condition the ecology and therefore, the resistance rate in the ICUs.
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Affiliation(s)
- Alicia Rodríguez-Gascón
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (Pharma Nano Gene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, Vitoria-Gasteiz, 01006, Spain.
- Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, 01009, Spain.
| | - Yanire Lloréns-Villar
- Hospital Pharmacy Service, Araba University Hospital, Osakidetza Basque Health Service, Vitoria-Gasteiz, 01009, Spain
| | - María Ángeles Solinís
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (Pharma Nano Gene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, Vitoria-Gasteiz, 01006, Spain
- Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, 01009, Spain
| | - Helena Barrasa
- Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, 01009, Spain
- Intensive Care Unit, Osakidetza Basque Health Service, Araba University Hospital, Vitoria-Gasteiz, 01009, Spain
| | - Andrés Canut-Blasco
- Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, 01009, Spain
- Microbiology Service, Osakidetza Basque Health Service, Araba University Hospital, Vitoria-Gasteiz, 01009, Spain
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Hurley J. Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay. Antibiotics (Basel) 2024; 13:316. [PMID: 38666992 PMCID: PMC11047347 DOI: 10.3390/antibiotics13040316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, VIC 3052, Australia;
- Ballarat Health Services, Grampians Health, Ballarat, VIC 3350, Australia
- Ballarat Clinical School, Deakin University, Ballarat, VIC 3350, Australia
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Guillamet CV, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention. Infect Dis Clin North Am 2024; 38:65-86. [PMID: 38040518 DOI: 10.1016/j.idc.2023.11.001] [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] [Indexed: 12/03/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Brown A, Ferrando-Vivas P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson BH, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan K, Pathan N. Use of selective gut decontamination in critically ill children: PICnIC a pilot RCT and mixed-methods study. Health Technol Assess 2024; 28:1-84. [PMID: 38421007 PMCID: PMC11017160 DOI: 10.3310/hdkv1008] [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] [Indexed: 03/02/2024] Open
Abstract
Background Healthcare-associated infections are a major cause of morbidity and mortality in critically ill children. In adults, data suggest the use of selective decontamination of the digestive tract may reduce the incidence of healthcare-associated infections. Selective decontamination of the digestive tract has not been evaluated in the paediatric intensive care unit population. Objectives To determine the feasibility of conducting a multicentre, cluster-randomised controlled trial in critically ill children comparing selective decontamination of the digestive tract with standard infection control. Design Parallel-group pilot cluster-randomised controlled trial with an integrated mixed-methods study. Setting Six paediatric intensive care units in England. Participants Children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 hours were eligible for the PICnIC pilot cluster-randomised controlled trial. During the ecology periods, all children admitted to the paediatric intensive care units were eligible. Parents/legal guardians of recruited patients and healthcare professionals working in paediatric intensive care units were eligible for inclusion in the mixed-methods study. Interventions The interventions in the PICnIC pilot cluster-randomised controlled trial included administration of selective decontamination of the digestive tract as oro-pharyngeal paste and as a suspension given by enteric tube during the period of mechanical ventilation. Main outcome measures The decision as to whether a definitive cluster-randomised controlled trial is feasible is based on multiple outcomes, including (but not limited to): (1) willingness and ability to recruit eligible patients; (2) adherence to the selective decontamination of the digestive tract intervention; (3) acceptability of the definitive cluster-randomised controlled trial; (4) estimation of recruitment rate; and (5) understanding of potential clinical and ecological outcome measures. Results A total of 368 children (85% of all those who were eligible) were enrolled in the PICnIC pilot cluster-randomised controlled trial across six paediatric intensive care units: 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering selective decontamination of the digestive tract, the majority (98%) of children received at least one dose of selective decontamination of the digestive tract, and of these, 68% commenced within the first 6 hours. Consent for the collection of additional swabs was low (44%), though data completeness for potential outcomes, including microbiology data from routine clinical swab testing, was excellent. Recruited children were representative of the wider paediatric intensive care unit population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cluster-randomised controlled trial of 3 children/site/week, based on data from all UK paediatric intensive care units. The proposed trial, including consent and selective decontamination of the digestive tract, was acceptable to parents and staff with adaptations, including training to improve consent and communication, and adaptations to the administration protocol for the paste and ecology monitoring. Clinical outcomes that were considered important included duration of organ failure and hospital stay, healthcare-acquired infections and survival. Limitations The delivery of the pilot cluster-randomised controlled trial was disrupted by the COVID-19 pandemic, which led to slow set-up of sites, and a lack of face-to face training. Conclusions PICnIC's findings indicate that a definitive cluster-randomised controlled trial in selective decontamination of the digestive tract in paediatric intensive care units is feasible with the inclusion modifications, which would need to be included in a definitive cluster-randomised controlled trial to ensure that the efficiency of trial processes is maximised. Future work A definitive trial that incorporates the protocol adaptations and outcomes arising from this study is feasible and should be conducted. Trial registration This trial is registered as ISRCTN40310490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/152/01) and is published in full in Health Technology Assessment; Vol. 28, No. 8. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Alanna Brown
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Mariana Popa
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - John Pappachan
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University of Southampton, Southampton, UK
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Theodore Gouliouris
- Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- Intensive Care Unit, Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - John Myburgh
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Pathan N, Woolfall K, Popa M, de la Fuente GM, Ferrando-Vivas P, Brown A, Gouliouris T, Tume LN, Shulman R, Cuthbertson BH, Sale I, Feltbower RG, Myburgh J, Pappachan J, Harrison D, Mouncey P, Rowan K. Selective digestive tract decontamination to prevent healthcare associated infections in critically ill children: the PICNIC multicentre randomised pilot clinical trial. Sci Rep 2023; 13:21668. [PMID: 38066012 PMCID: PMC10709430 DOI: 10.1038/s41598-023-46232-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. Data from adult studies suggest Selective Decontamination of the Digestive tract (SDD) may reduce the incidence of HCAIs and improve survival. There are no data from randomised clinical trials in the paediatric setting. An open label, parallel group pilot cRCT and mixed-methods perspectives study was conducted in six paediatric intensive care units (PICUs) in England. Participants were children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 h. Sites undertook standard care for a period of 9 weeks and were randomised into 3 sites which continued standard care and 3 where SDD was incorporated into infection control practice for eligible children. Interviews and focus groups were conducted for parents and staff working in PICU. 434 children fulfilled eligibility criteria, of whom 368 (85%) were enrolled. This included 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering SDD, the majority (98%) of children received at least one dose of SDD and of these, 68% commenced within the first 6 h. Whilst admission swabs were collected in 91% of enrolled children, consent for the collection of additional swabs was low (44%). Recruited children were representative of the wider PICU population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cRCT of 3 children/site/week, based on data from all UK PICUs. Parents (n = 65) and staff (n = 44) were supportive of the aims of the study, suggesting adaptations for a larger definitive trial including formulation and administration of SDD paste, approaches to consent and ecology monitoring. Stakeholders identified preferred clinical outcomes, focusing on complications of critical illness and quality-of-life. A definitive cRCT in SDD to prevent HCAIs in critically ill children is feasible but should include adaptations to ecology monitoring along with the dosing schedule and packaging into a paediatric specific format. A definitive study is supported by the findings with adaptations to ecology monitoring and SDD administration.Trial Registration: ISRCTN40310490 Registered 30/10/2020.
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Affiliation(s)
- Nazima Pathan
- University of Cambridge, Cambridge, UK.
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | | | | | | | | | - Alanna Brown
- Intensive Care National Audit and Research Centre, London, UK
- University College London, London, UK
| | | | | | | | | | | | | | - John Myburgh
- The George Institute for Global Health, Sydney, Australia
| | | | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Paul Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre, London, UK
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Hurley J. Indirect (herd) effects of topical antibiotic prophylaxis and oral care versus non-antimicrobial methods increase mortality among ICU patients: realigning Cochrane review data to emulate a three-tier cluster randomised trial. BMJ Open 2023; 13:e064256. [PMID: 38035749 PMCID: PMC10689355 DOI: 10.1136/bmjopen-2022-064256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE This study aimed to estimate the direct effects to recipients and indirect (herd) effects to non-recipients of each of topical antibiotic prophylaxis (TAP) and oral care methods on patient mortality within randomised concurrent controlled trials (RCCT) using Cochrane review data. DESIGN Control and intervention groups from 209 RCCTs of TAP (tier 3), oral care (tier 2) each versus non-antimicrobial (tier 1) ventilator-associated pneumonia (VAP) prevention interventions arranged to emulate a three-tiered cluster randomised trial (CRT). Eligible RCCTs were those including ICU patients with >50% of patients receiving >24 hours of mechanical ventilation (MV) with mortality data available as abstracted in 13 Cochrane reviews. EXPOSURES Direct and indirect exposures to either TAP or oral care within RCCTs versus non-antimicrobial VAP prevention interventions. MAIN OUTCOMES AND MEASURES The ICU mortality within control and intervention groups, respectively, within RCCTs of either TAP or oral care versus that within non-antimicrobial VAP prevention RCCTs serving as benchmark. RESULTS The ICU mortality was 23.9%, 23.0% and 20.3% for intervention groups and 28.7%, 25.5% and 19.5% for control groups of RCCTs of TAP (tier 1), oral care (tier 2) and non-antimicrobial (tier 3) methods of VAP prevention, respectively. In a random effects meta-regression including late mortality data and adjusting for group mean age, year of study publication and MV proportion, the direct effect of TAP and oral care versus non-antimicrobial methods were 1.04 (95% CI 0.78 to 1.30) and 1.1 (95% CI 0.77 to 1.43) whereas the indirect effects were 1.39 (95% CI 1.03 to 1.74) and 1.26 (95% CI 0.89 to 1.62), respectively. CONCLUSIONS Indirect (herd) effects from TAP and oral care methods on mortality are stronger than the direct effects as made apparent by the three-tiered CRT. These indirect effects, being harmful to concurrent control groups by increasing mortality, perversely inflate the appearance of benefit within RCCTs.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Internal Medicine Service, Ballarat Health Services, Grampians Health, Ballarat, Victoria, Australia
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Hurley JC. Length of intensive care unit stay and the apparent efficacy of antimicrobial-based versus non-antimicrobial-based ventilator pneumonia prevention interventions within the Cochrane review database. J Hosp Infect 2023; 140:46-53. [PMID: 37544366 DOI: 10.1016/j.jhin.2023.07.018] [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: 05/16/2023] [Revised: 07/17/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND The risk of acquiring ventilator-associated pneumonia (VAP) increases with intensive care unit (ICU) length of stay (LOS). The objectives here are to estimate, using data derived from randomized concurrent control trials (RCCTs) of non-antimicrobial versus antimicrobial interventions, the relation of LOS with firstly, apparent VAP prevention effect, and secondly, with VAP incidence in control and intervention groups. METHODS Control and intervention group data derived from 13 Cochrane reviews of 78 RCCTs of antimicrobial-based interventions versus 111 RCCTs of various non-antimicrobial-based VAP prevention interventions. RESULTS In meta-regression models of VAP prevention effect versus group mean LOS, the effect size of non-antimicrobial-based interventions regress towards the null (+0.028; +0.002 to +0.054) whereas antimicrobial-based interventions regress away from the null (-0.043; -0.08 to -0.004). The day 9-10 VAP incidence increase is 1.28 (0.97-1.6) percentage points among the control groups of antimicrobial interventions per day. By contrast, these increases among antimicrobial- (0.45; 0.19-0.71) and non-antimicrobial- (0.58; 0.29-0.87) intervention groups and in control groups of non-antimicrobial- (0.76; 0.46-1.05) interventions are all similar. CONCLUSIONS Antimicrobial-based versus non-antimicrobial-based interventions show overall greater apparent VAP prevention which is most apparent with longer group mean LOS. The basis for this surprising relationship with LOS resides, paradoxically, within the control rather than the intervention groups. This discrepancy implicates indirect (spill-over) effects, inapparent within individual antimicrobial-based RCCTs, which could spuriously conflate the appearance of VAP prevention.
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Affiliation(s)
- J C Hurley
- Melbourne Medical School, Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Internal Medicine Service, Ballarat Health Services, Ballarat, Vic, Australia.
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Hurley JC. Trends in ICU mortality and underlying risk over three decades among mechanically ventilated patients. A group level analysis of cohorts from infection prevention studies. Ann Intensive Care 2023; 13:62. [PMID: 37432605 DOI: 10.1186/s13613-023-01159-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Has either the underlying risk or the mortality incidence among ICU patients receiving mechanical ventilation (MV) in the literature changed in recent decades? Interpreting ICU mortality trends requires an adjusted analysis accounting for changes in underlying patient risk. METHODS Control and intervention groups from 147 randomized concurrent control trials (RCCT) of various VAP prevention interventions, as listed primarily within 13 Cochrane reviews and 63 observational studies listed primarily within four systematic reviews. Eligible studies were those including ICU patients with > 50% of patients receiving > 24 h of MV with mortality data available. ICU mortality (censored day 21 or before) or late (after day 21) mortality together with group-mean age, and group-mean APACHE II scores were extracted from all groups. These incidences were summarized in five meta-regression models versus publication year being variously adjusted for age, APACHE II scores, type of study intervention and other group level parameters. RESULTS Among 210 studies published between 1985 and 2021, 169 being found in systematic reviews, the increase per decade in mean mortality incidence, group-mean APACHE II scores, and group-mean age, were < 1 percentage point (p = 0.43), 1.83 (95% CI; 0.51-3.15) points, and 3.9 (95% CI; 1.1-6.7) years, respectively. Only in the model with risk adjustment for both group-mean age and group-mean APACHE II score was a significant decline in mortality apparent. In all models, the mortality incidence among concurrent control groups of decontamination studies was paradoxically five percentage points higher than benchmark and showed greater dispersion. CONCLUSION Mortality incidence has changed little over 35 years among ICU infection prevention studies whilst the patient age and underlying disease severity, measured as APACHE II, have both increased. The paradoxically high mortality among concurrent control groups within studies of decontamination methods of infection prevention remains unaccounted for.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Division of Internal Medicine, Grampians Health, Ballarat, VIC, Australia.
- Internal Medicine Service, Ballarat Health Services, PO Box 577, Ballarat, 3353, Australia.
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10
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Hurley JC. Establishing the safety of selective digestive decontamination within the ICU population: a bridge too far? Trials 2023; 24:337. [PMID: 37198636 DOI: 10.1186/s13063-023-07356-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Infection prevention interventions within the intensive care unit (ICU) setting, whether studied within quality improvement projects or cluster randomized trials (CRT), are seen as low risk and grounded in an ethical imperative. Selective digestive decontamination (SDD) appears highly effective at preventing ICU infections within randomized concurrent control trials (RCCTs) prompting mega-CRTs with mortality as the primary endpoint. FINDINGS Surprisingly, the summary results of RCCTs versus CRTs differ strikingly, being respectively, a 15-percentage-point versus a zero-percentage-point ICU mortality difference between control versus SDD intervention groups. Multiple other discrepancies are equally puzzling and contrary to both prior expectations and the experience within population-based studies of infection prevention interventions using vaccines. Could spillover effects from SDD conflate the RCCT control group event rate differences and represent population harm? Evidence that SDD is fundamentally safe to concurrent non-recipients in ICU populations is absent. A postulated CRT to realize this, the SDD Herd Effects Estimation Trial (SHEET), would require > 100 ICUs to achieve sufficient statistical power to find a two-percentage-point mortality spillover effect. Moreover, as a potentially harmful population-based intervention, SHEET would pose novel and insurmountable ethical issues including who is the research subject; whether informed consent is required and from whom; whether there is equipoise; the benefit versus the risk; considerations of vulnerable groups; and who should be the gatekeeper? CONCLUSION The basis for the mortality difference between control and intervention groups of SDD studies remains unclear. Several paradoxical results are consistent with a spillover effect that would conflate the inference of benefit originating from RCCTs. Moreover, this spillover effect would constitute to herd peril.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Division of Internal Medicine, Grampians Health Services, Ballarat, VIC, Australia.
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11
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Hurley JC. Staphylococcus aureus hitchhiking from colonization to bacteremia via Candida within ICU infection prevention studies: a proof of concept modelling. Eur J Clin Microbiol Infect Dis 2023; 42:543-554. [PMID: 36877261 PMCID: PMC10105687 DOI: 10.1007/s10096-023-04573-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/13/2023] [Indexed: 03/07/2023]
Abstract
Whether Candida within the patient microbiome drives the pathogenesis of Staphylococcus aureus bacteremia, described as microbial hitchhiking, cannot be directly studied. Group-level observations from studies of various decontamination and non-decontamination-based ICU infection prevention interventions and studies without study interventions (observational groups) collectively enable tests of this interaction within causal models. Candidate models of the propensity for Staphylococcus aureus bacteremia to arise with versus without various antibiotic, anti-septic, and antifungal exposures, each identified as singleton exposures, were tested using generalized structural equation modelling (GSEM) techniques with Candida and Staphylococcus aureus colonization appearing as latent variables within the models. Each model was tested by confrontation against blood and respiratory isolate data, obtained from 467 groups within 284 infection prevention studies. Introducing an interaction term between Candida colonization and Staphylococcus aureus colonization substantially improved GSEM model fit. Model-derived coefficients for singular exposure to anti-septic agents (- 1.28; 95% confidence interval; - 2.05 to - 0.5), amphotericin (- 1.49; - 2.3 to - 0.67), and topical antibiotic prophylaxis (TAP; + 0.93; + 0.15 to + 1.71) as direct effects versus Candida colonization were similar in magnitude but contrary in direction. By contrast, the coefficients for singleton exposure to TAP, as with anti-septic agents, versus Staphylococcus colonization were weaker or non-significant. Topical amphotericin would be predicted to halve both candidemia and Staphylococcus aureus bacteremia incidences versus literature derived benchmarks for absolute differences of < 1 percentage point. Using ICU infection prevention data, GSEM modelling validates the postulated interaction between Candida and Staphylococcus colonization facilitating bacteremia.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia. .,Division of Internal Medicine, Grampians Health Ballarat, PO Box 577, Ballarat, VIC, 3353, Australia.
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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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13
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Myburgh JA, Seppelt IM, Goodman F, Billot L, Correa M, Davis JS, Gordon AC, Hammond NE, Iredell J, Li Q, Micallef S, Miller J, Mysore J, Taylor C, Young PJ, Cuthbertson BH, Finfer SR. Effect of Selective Decontamination of the Digestive Tract on Hospital Mortality in Critically Ill Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA 2022; 328:1911-1921. [PMID: 36286097 PMCID: PMC9607966 DOI: 10.1001/jama.2022.17927] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Whether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain. OBJECTIVE To determine whether SDD reduces in-hospital mortality in critically ill adults. DESIGN, SETTING, AND PARTICIPANTS A cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021. INTERVENTIONS ICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs. RESULTS Of 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, -1.7% [95% CI, -4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, -11.0%; 95% CI, -14.7% to -7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, -1.95%; 95% CI, -3.5% to -0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, -0.24%; 95% CI, -0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (-3.3% vs -1.59%; mean difference, -1.71% [1-sided 97.5% CI, -∞ to 4.31%] and 0.88% vs 0.55%; mean difference, -0.32% [1-sided 97.5% CI, -∞ to 5.47%]) in the first and second periods, respectively. CONCLUSIONS AND RELEVANCE Among critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02389036.
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Affiliation(s)
| | - John A Myburgh
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- St George Hospital, Sydney, Australia
| | - Ian M Seppelt
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of Sydney, Australia
- Nepean Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Fiona Goodman
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Laurent Billot
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Maryam Correa
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Joshua S Davis
- John Hunter Hospital, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Menzies School of Heath Research, Newcastle, Australia
| | - Anthony C Gordon
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, Imperial College London, London, England
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Jon Iredell
- Faculty of Medicine, University of Sydney, Australia
- Centre for Infectious Disease and Microbiology Westmeath Institute of Medical Research, Sydney, Australia
| | - Qiang Li
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Jennene Miller
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- St George Hospital, Sydney, Australia
- Liverpool Hospital, Sydney, Australia
| | - Jayanthi Mysore
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Colman Taylor
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Paul J Young
- Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Brian H Cuthbertson
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simon R Finfer
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Faculty of Medicine, Imperial College London, London, England
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14
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Hammond NE, Myburgh J, Seppelt I, Garside T, Vlok R, Mahendran S, Adigbli D, Finfer S, Gao Y, Goodman F, Guyatt G, Santos JA, Venkatesh B, Yao L, Di Tanna GL, Delaney A. Association Between Selective Decontamination of the Digestive Tract and In-Hospital Mortality in Intensive Care Unit Patients Receiving Mechanical Ventilation: A Systematic Review and Meta-analysis. JAMA 2022; 328:1922-1934. [PMID: 36286098 PMCID: PMC9607997 DOI: 10.1001/jama.2022.19709] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/07/2022] [Indexed: 11/14/2022]
Abstract
Importance The effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain. Objective To determine whether SDD is associated with reduced risk of death in adults receiving mechanical ventilation in intensive care units (ICUs) compared with standard care. Data Sources The primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022. Study Selection Randomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo. Data Extraction and Synthesis Data extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework. Main Outcomes and Measures The primary outcome was hospital mortality. Subgroups included SDD with an intravenous agent compared with SDD without an intravenous agent. There were 8 secondary outcomes including the incidence of ventilator-associated pneumonia, ICU-acquired bacteremia, and the incidence of positive cultures of antimicrobial-resistant organisms. Results There were 32 randomized clinical trials including 24 389 participants in the analysis. The median age of participants in the included studies was 54 years (IQR, 44-60), and the median proportion of female trial participants was 33% (IQR, 25%-38%). Data from 30 trials including 24 034 participants contributed to the primary outcome. The pooled estimated risk ratio (RR) for mortality for SDD compared with standard care was 0.91 (95% credible interval [CrI], 0.82-0.99; I2 = 33.9%; moderate certainty) with a 99.3% posterior probability that SDD reduced hospital mortality. The beneficial association of SDD was evident in trials with an intravenous agent (RR, 0.84 [95% CrI, 0.74-0.94]), but not in trials without an intravenous agent (RR, 1.01 [95% CrI, 0.91-1.11]) (P value for the interaction between subgroups = .02). SDD was associated with reduced risk of ventilator-associated pneumonia (RR, 0.44 [95% CrI, 0.36-0.54]) and ICU-acquired bacteremia (RR, 0.68 [95% CrI, 0.57-0.81]). Available data regarding the incidence of positive cultures of antimicrobial-resistant organisms were not amenable to pooling and were of very low certainty. Conclusions and Relevance Among adults in the ICU treated with mechanical ventilation, the use of SDD compared with standard care or placebo was associated with lower hospital mortality. Evidence regarding the effect of SDD on antimicrobial resistance was of very low certainty.
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Affiliation(s)
- Naomi E. Hammond
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Department of Intensive Care, St George Hospital, Kogarah, New South Wales, Australia
| | - Ian Seppelt
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia
| | - Tessa Garside
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ruan Vlok
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sajeev Mahendran
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Derick Adigbli
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, School of Public Health, Imperial College, London, United Kingdom
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Goodman
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Alvin Santos
- Biostatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Queensland, Australia
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gian Luca Di Tanna
- Biostatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Innovative Technologies, University of Applied Sciences and Arts of Southern Switzerland, Viganello-Lugano, Switzerland
| | - Anthony Delaney
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
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15
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Brown A, Ferrando P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson B, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan KM, Pathan N. Use of selective gut decontamination in critically ill children: protocol for the Paediatric Intensive Care and Infection Control (PICnIC) pilot study. BMJ Open 2022; 12:e061838. [PMID: 35277414 PMCID: PMC8919465 DOI: 10.1136/bmjopen-2022-061838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. In critically ill adults, there are data that suggest the use of Selective Decontamination of the Digestive tract (SDD), alongside standard infection control measures reduce mortality and the incidence of HCAIs. SDD-enhanced infection control has not been compared directly with standard infection prevention strategies in the Paediatric Intensive Care Unit (PICU) population. The aim of this pilot study is to determine the feasibility of conducting a multicentre cluster randomised controlled trial (cRCT) in critically ill children comparing SDD with standard infection control. METHODS AND ANALYSIS Paediatric Intensive Care and Infection Control is a parallel group pilot cRCT, with integrated mixed-methods study, comparing incorporation of SDD into infection control procedures to standard care. After a 1-week pretrial ecology surveillance period, recruitment to the cRCT will run for a period of 18 weeks, comprising: (1) baseline control period (2) pre, mid and post-trial ecology surveillance periods and (3) intervention period. Six PICUs (in England, UK) will begin with usual care in period 1, then will be randomised 1:1 by the trial statistician using computer-based randomisation, to either continue to deliver usual care or commence delivery of the intervention (SDD) in period 2. Outcomes measures include parent and healthcare professionals' views on trial feasibility, adherence to the SDD intervention, estimation of recruitment rate and understanding of potential patient-centred primary and secondary outcome measures for the definitive trial. The planned recruitment for the cRCT is 324 participants. ETHICS AND DISSEMINATION The trial received favourable ethical opinion from West Midlands-Black Country Research Ethics Committee (reference: 20/WM/0061) and approval from the Health Research Authority (IRAS number: 239324). Informed consent is not required for SDD intervention or anonymised data collection but is sought for investigations as part of the study, any identifiable data collected and monitoring of medical records. Results will be disseminated via publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ISRCTN40310490.
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Affiliation(s)
- Alanna Brown
- Intensive Care National Audit and Research Centre, London, UK
| | - Paloma Ferrando
- Intensive Care National Audit and Research Centre, London, UK
| | - Mariana Popa
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Brian Cuthbertson
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | | | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - John Myburgh
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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16
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Abu Y, Vitari N, Yan Y, Roy S. Opioids and Sepsis: Elucidating the Role of the Microbiome and microRNA-146. Int J Mol Sci 2022; 23:1097. [PMID: 35163021 PMCID: PMC8835205 DOI: 10.3390/ijms23031097] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
Sepsis has recently been defined as life-threatening organ dysfunction caused by the dysregulated host response to an ongoing or suspected infection. To date, sepsis continues to be a leading cause of morbidity and mortality amongst hospitalized patients. Many risk factors contribute to development of sepsis, including pain-relieving drugs like opioids, which are frequently prescribed post-operatively. In light of the opioid crisis, understanding the interactions between opioid use and the development of sepsis has become extremely relevant, as opioid use is associated with increased risk of infection. Given that the intestinal tract is a major site of origin of sepsis-causing microbes, there has been an increasing focus on how alterations in the gut microbiome may predispose towards sepsis and mediate immune dysregulation. MicroRNAs, in particular, have emerged as key modulators of the inflammatory response during sepsis by tempering the immune response, thereby mediating the interaction between host and microbiome. In this review, we elucidate contributing roles of microRNA 146 in modulating sepsis pathogenesis and end with a discussion of therapeutic targeting of the gut microbiome in controlling immune dysregulation in sepsis.
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Affiliation(s)
- Yaa Abu
- Medical Scientist Training Program, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Nicolas Vitari
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Yan Yan
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Sabita Roy
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
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17
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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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18
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Schulz-Stübner S. [Infection Prevention in the Intensive Care Unit (ICU)]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:485-501. [PMID: 34298569 DOI: 10.1055/a-1249-5156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Secondary to the underlying disease, the need for invasive devices and frequent drug-induced changes in immunocompetence and microbiota, critically ill patients have a high risk of suffering nosocomial infections. According to data from the European Centre for Disease Prevention and Control (ECDC) this affects 8,4% of patients treated in an ICU for more than 48 hours. Key points of infection prevention are maintenance of the patients' microbiota and sometimes individually chosen interventions to its restoration or focused manipulation; development and implementation of care bundles for frequently used medical devices and invasive treatments (esp. intravenous catheters and invasive ventilation); adequate staffing not only for physicians, nurses and other medical staff but also for housekeeping staff, infection surveillance and motivational feedback, patient empowerment and visitor involvement. Functional building design and well organized logistics assist in achieving infection prevention goals by fostering adherence to basic hygiene procedure, esp. hand hygiene and risk-adjusted use of personal protective equipment. Daily interdisciplinary rounds following the principles of crew resource management strategies allow the structured check for unnecessary devices and inadequate use of antiinfective agents in particular and the discussion of all aspects of the patients' situation in general.
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19
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Temkin E, Margalit I, Nutman A, Carmeli Y. Surgical antibiotic prophylaxis in patients colonized with multidrug-resistant Gram-negative bacteria: practical and conceptual aspects. J Antimicrob Chemother 2021; 76:i40-i46. [PMID: 33534884 DOI: 10.1093/jac/dkaa496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Antibiotic resistance threatens the effectiveness of surgical antibiotic prophylaxis (SAP) regimens aimed at preventing surgical site infection (SSI). With a focus on procedures in which Gram-negative bacteria (GNB) are the main pathogens causing SSI, this review summarizes the evidence and describes how SAP must evolve in response to carriage of MDR GNB among surgical patients. Randomized controlled trials of SAP for carriers of resistant GNB require prohibitively large sample sizes. No professional guidelines address the topic of adapting SAP for known carriers of resistant GNB. For patients whose carrier status is unknown, the effects of different SAP strategies have been studied for transrectal ultrasound-guided prostate biopsy and colorectal surgery. The four possible strategies for SAP in the era of antibiotic resistance are: no SAP; universal standard SAP; pre-surgical screening for carriage of antibiotic-resistant pathogens before surgery and targeted SAP (i.e. broad-spectrum antibiotics only for those who screen positive); and universal broad-spectrum SAP. The prevalence of carriage determines the efficiency of each strategy. Decolonization is a potential adjunct to SAP.
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Affiliation(s)
- Elizabeth Temkin
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel
| | - Ili Margalit
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Amir Nutman
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yehuda Carmeli
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
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20
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Bernts LHP, Dekker SEI, Soonawala D, Brüggemann RJM, Wertheim HFL, de Fijter JW, Drenth JPH, Lantinga MA. Efficacy and safety of selective decontamination of the digestive tract (SDD) to prevent recurrent hepatic cyst infections in polycystic liver disease: a retrospective case series. J Antimicrob Chemother 2021; 75:2666-2669. [PMID: 32437580 PMCID: PMC7443730 DOI: 10.1093/jac/dkaa186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/03/2020] [Accepted: 04/15/2020] [Indexed: 12/27/2022] Open
Abstract
Background Hepatic cyst infection is a complication of polycystic liver disease (PLD) that causes substantial morbidity. Repetitive infection is frequent and is increasingly difficult to treat. As translocated gut bacteria are considered the cause, we hypothesize that selective decontamination of the digestive tract (SDD) reduces recurrence of hepatic cyst infection. Methods We performed a retrospective, observational study in two referral centres. All patients with PLD treated with SDD for hepatic cyst infection were included. Efficacy was determined by calculating the infection incidence (hepatic cyst infections per month) before and during SDD therapy. Adverse events were scored according to the Common Terminology Criteria for Adverse Events (CTCAE). Results We identified eight patients who received SDD (88% female, 88% polycystic kidney disease). The median age was 65 years (IQR: 51–74 years). SDD lowered the median incidence from 0.09 episodes per month (IQR: 0.06–0.25 episodes per month) to 0.01 episodes per month (IQR: 0.00–0.05 episodes per month) (P = 0.12). Discontinuation of SDD led to rapid recurrence of cyst infection (71% within 6 weeks). SDD consisted of polymyxins with/without aminoglycosides. The median SDD treatment duration was 20 months (range: 3–89 months). Six patients (75%) developed adverse events [CTCAE Grade 1 (gastrointestinal: n = 3) or Grade 3 (ototoxicity: n = 1; fungal infection: n = 1)], mostly attributable to aminoglycosides; one patient developed polymyxin E resistance. Conclusions SDD prophylaxis provides a novel strategy for limiting recurrent hepatic cyst infection in PLD patients. However, adverse events are frequent and curtail its use. As most were attributable to aminoglycosides, polymyxin E is considered the preferred therapy.
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Affiliation(s)
- Lucas H P Bernts
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Shosha E I Dekker
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Darius Soonawala
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Heiman F L Wertheim
- Department of Medical Microbiology and Radboudumc Center for Infectious Diseases, Radboudumc, Nijmegen, The Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Marten A Lantinga
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
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21
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Billot L, Cuthbertson B, Gordon A, Al-Beidh F, Correa M, Davis J, Finfer S, Glass P, Goodman F, Hammond N, Iredell J, Miller J, Murthy S, Rose L, Seppelt I, Taylor C, Young P, Myburgh J. Protocol summary and statistical analysis plan for the Selective Decontamination of the Digestive Tract in Intensive Care Unit Patients (SuDDICU) crossover, cluster randomised controlled trial. CRIT CARE RESUSC 2021; 23:183-193. [PMID: 38045525 PMCID: PMC10692556 DOI: 10.51893/2021.2.oa5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: It is unclear whether the use of selective decontamination of the digestive tract (SDD) improves outcomes in ventilated patients in intensive care units (ICUs) and whether SDD is associated with the development of antibiotic resistance. Objective: To describe the study protocol and statistical analysis plan for the Selective Decontamination of the Digestive Tract in Intensive Care Unit Patients (SuDDICU) trial. Design, setting, participants and intervention: SuDDICU is an international, crossover, cluster randomised controlled trial of mechanically ventilated patients in ICUs using two 12-month trial periods. For each period, participating ICUs will implement SDD plus standard care or standard care alone. The SuDDICU drug intervention is an oral paste and gastric suspension of three antibiotics combined with a 4-day course of intravenous antibiotics. Observational ecological assessments will be conducted during five surveillance periods. The trial will be conducted in 19 ICUs in Australia and ten ICUs in Canada and the United Kingdom, and will recruit 15 000-17 000 patients. Recruitment commenced in Australia in 2017. Main outcome measures: The primary outcome is all-cause hospital mortality. Secondary outcomes include: duration of ventilation, ICU stay and hospital stay; incidence of new antibiotic-resistant organisms during the index ICU admission; changes in antibiotic-resistant organism rates; incidence of new Clostridioides difficile infections; and total use of antibiotics. Results and conclusions: SuDDICU will determine whether the use of SDD plus standard care is associated with a reduction in hospital mortality in ventilated ICU patients compared with standard care alone. It will also quantify the impact of the use of SDD on the development of antibiotic resistance. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12615000411549) and ClinicalTrials.gov (NCT02389036).
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Affiliation(s)
- Laurent Billot
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Brian Cuthbertson
- The George Institute for Global Health, Sydney, NSW, Australia
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anthony Gordon
- The George Institute for Global Health, Sydney, NSW, Australia
- Imperial College London, London, UK
| | | | - Maryam Correa
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Joshua Davis
- University of Newcastle, Newcastle, NSW, Australia
| | - Simon Finfer
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - Parisa Glass
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Fiona Goodman
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Naomi Hammond
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jonathon Iredell
- University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Sydney, NSW, Australia
| | | | | | | | - Ian Seppelt
- The George Institute for Global Health, Sydney, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
- Nepean Hospital, Sydney, NSW, Australia
| | - Colman Taylor
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Wellington Hospital, Wellington, New Zealand
| | - John Myburgh
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- St George Hospital, Sydney, NSW, Australia
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22
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Nutritional Status and the Critically Ill Patient: Gut Microbiota and Immuno-Nutrition in I.C.U. at the Time of SARS-COV 2 Pandemic. GASTROENTEROLOGY INSIGHTS 2021. [DOI: 10.3390/gastroent12020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Gut microbiota is a complex ecosystem of bacteria, viruses, archaea, protozoa and yeasts in our intestine. It has several functions, including maintaining human body equilibrium. Microbial “dysbiosis” can be responsible for outbreak of local and systemic infections, especially in critically ill patients. Methods: to build a narrative review, we performed a Pubmed, Medline and EMBASE search for English language papers, reviews, meta-analyses, case series and randomized controlled trials (RCTs) by keywords and their associations: critically ill patient; nutrition; gut microbiota; probiotics; gut virome; SARS-COV 2. Results: Over the antibiotic-based “selective decontamination”, potentially responsible for drug-resistant microorganisms development, there is growing interest of scientists and the pharmaceutical industry for pre-, probiotics and their associations as safe and reliable remedies restoring gut microbial “eubiosis”. Very first encouraging evidences link different gut microbiota profiles with SARS-COV 2 disease stage and gravity. Thus, there is frame for a probiotic therapeutic approach of COVID-19. Conclusions: gut microbiota remodulation seems to be a promising and safe therapeutic approach to prevent local and systemic multi-resistant bug infections in the intensive care unit (ICU) patients. This approach deserves more and more attention at the time of SARS-COV 2 pandemic.
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23
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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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24
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Su F, Luo Y, Yu J, Shi J, Zhao Y, Yan M, Huang H, Tan Y. Tandem fecal microbiota transplantation cycles in an allogeneic hematopoietic stem cell transplant recipient targeting carbapenem-resistant Enterobacteriaceae colonization: a case report and literature review. Eur J Med Res 2021; 26:37. [PMID: 33910622 PMCID: PMC8080403 DOI: 10.1186/s40001-021-00508-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/13/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Due to limited antibiotic options, carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with high non-relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Also, intestinal CRE colonization is a risk factor for subsequent CRE infection. Several clinical studies have reported successful fecal microbiota transplantation (FMT) for the gut decontamination of a variety of multidrug-resistant bacteria (MDRB), even in immunosuppressed patients. Similarly, other studies have also indicated that multiple FMTs may increase or lead to successful therapeutic outcomes. CASE PRESENTATION We report CRE colonization in an allo-HSCT patient with recurrent CRE infections, and its successful eradication using tandem FMT cycles at 488 days after allo-HSCT. We also performed a comprehensive microbiota analysis. No acute or delayed adverse events (AEs) were observed. The patient remained clinically stable with CRE-negative stool culture at 26-month follow-up. Our analyses also showed some gut microbiota reconstruction. We also reviewed the current literature on decolonization strategies for CRE. CONCLUSIONS CRE colonization led to a high no-relapse mortality after allo-HSCT; however, well-established decolonization strategies are currently lacking. The successful decolonization of this patient suggests that multiple FMT cycles may be potential options for CRE decolonization.
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Affiliation(s)
- Fengqin Su
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jian Yu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Jimin Shi
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yanmin Zhao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Mengni Yan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yamin Tan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, China. .,Hematology Department, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, 1 Banshan East Road, Hangzhou, 310022, Zhejiang, China.
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25
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Hurley JC. Is selective decontamination (SDD/SOD) safe in the ICU context? J Antimicrob Chemother 2021; 74:1167-1172. [PMID: 30753529 DOI: 10.1093/jac/dky573] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Multiple individual studies of selective digestive decontamination/selective oropharyngeal decontamination (SDD/SOD) among ICU patients appear to show potent infection prevention effects. Surprisingly, the event rates for multiple endpoints including ventilator-associated pneumonia, bacteraemia and candidaemia among concurrent control groups within SDD/SOD studies appear unusually high versus other rates in the literature. These paradoxical observations raise concern that the contextual effects of SDD/SOD, as postulated in the original SDD/SOD study, not only exist but also are strong. Until these effects are addressed within an optimally designed study, the safety of SDD/SOD within the 'whole of ICU' remains questionable.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
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26
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Abstract
Background: Pneumonia, as a fairly prevalent illness, is the main cause of hospital mortality. The major cause of mortality and morbidity of pneumonia is due to bacteria. The presence of multi-drug resistant pathogens and no response to treatment have aroused considerable interest in the use of probiotic components to prevent infections. Objectives: Given that few studies have evaluated the efficacy of probiotics in reducing bacterial pneumonia, the current aimed to evaluate the role of probiotics in decreasing pneumonia. Methods: This double-blind, randomized clinical trial study was conducted on 100 patients diagnosed with bacterial pneumonia in Shahid Beheshti Hospital, Kashan, Iran, during 2018. Patients were randomly classified into two groups (n = 50). One group (case) received two sachets of probiotic/daily for five days, and another group (control) received placebo. Moreover, patients in both groups received the same treatment protocol. All data were extracted from medical records. Chi-square test and independent t-test were used for analysis of data. P < 0.05 was considered statistically significant. Results: No significant difference was seen between case and control groups regarding age, gender, and duration of symptoms before hospitalization (P > 0.05), which implies a completely random classification of two groups. The mean duration of hospitalization, dyspnea, tachypnea, cough, fever, and crackles was significantly decreased in the case group compared to the control group (P < 0.05). Conclusion: The use of probiotics can be effective in reducing the duration of dyspnea, tachypnea, cough, fever, and length of hospitalization. Therefore, probiotics may be considered a promising treatment for the development of new anti-infectious therapy. In addition, the usage of probiotics along with antibiotics is suggested for decreasing pneumonia complications and improving the efficacy of therapy.
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27
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Choi E, Lee SJ, Lee S, Yi J, Lee YS, Chang SY, Jeong HY, Joo Y. Comprehensive, multisystem, mechanical decolonization of Vancomycin-Resistant Enterococcus and Carbapenem-Resistant Enterobacteriacease without the use of antibiotics. Medicine (Baltimore) 2021; 100:e23686. [PMID: 33545935 PMCID: PMC7837958 DOI: 10.1097/md.0000000000023686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/16/2020] [Indexed: 12/24/2022] Open
Abstract
Among multidrug-resistant organisms (MDROs), Vancomycin-resistant Enterococcus (VRE), and Carbapenem-resistant Enterobacteriaceae (CRE) have become major nosocomial pathogens that are endemic worldwide. If VRE/CRE are present as colonizing organisms but do not act as pathogens, these organisms do not cause symptoms and do not require antibiotic use. However, once gastrointestinal colonization with VRE/CRE occurs, it can persist for long periods and serve as a reservoir for transmission to other patients. Therefore, a breakthrough strategy to control the spread of MDRO colonization is needed. We herein introduce decolonization method, which is a comprehensive, multisystem, consecutive mechanical MDRO decolonization protocol that does not utilize antibiotics. Our protocol included: (1).. Mechanical evacuation using a glycerin enema, (2).. Replacement of the normal gut flora using daily lactobacillus ingestion, (3).. Skin hygiene cleansing using chlorhexidine, and (4).. Environmental cleansing by changing the bed sheets and clothing every day. These steps were repeated consecutively until the patient was released from quarantine. We conducted VRE/CRE tests every week. Because our protocol was a comprehensive and multisystem decolonization protocol, the cooperation of patients and/or caregivers was essential, and family support was important for patient care. Patients were divided into VRE and CRE groups and were subdivided into success and failure groups according to decolonization status. Thirty-two patients with VRE or CRE colonization were enrolled, and our protocol was performed. A total of 20 patients (62.5%) were successfully decolonized after repeated protocols. Univariate analysis revealed that patients with younger age, higher body mass index (BMI), shorter period of MDRO isolation without trial, and higher functional status showed significantly enhanced success rates with our decolonization protocol. This study presents the decolonization effects of a comprehensive, multisystem, mechanical decolonization protocol for VRE and CRE. Most importantly, our decolonization protocol does not use antibiotics and is thus not harmful. These results suggest an active decolonization trial to be performed as early as possible in patients with VRE or CRE colonization. This simple, easy-to-apply protocol can be used as 1 of the basic treatment options for MDROs infection or colonization, regardless of whether it requires antibiotic treatment.
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Affiliation(s)
- Eunseok Choi
- Department of Physical Medicine and Rehabilitation
| | | | - Sangjee Lee
- Department of Physical Medicine and Rehabilitation
| | | | - Yeon Soo Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea, Seoul, Republic of Korea
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28
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Hurley JC. How the Cluster-randomized Trial "Works". Clin Infect Dis 2021; 70:341-346. [PMID: 31260511 DOI: 10.1093/cid/ciz554] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/29/2019] [Indexed: 11/13/2022] Open
Abstract
Cluster-randomized trials (CRTs) are able to address research questions that randomized controlled trials (RCTs) of individual patients cannot answer. Of great interest for infectious disease physicians and infection control practitioners are research questions relating to the impact of interventions on infectious disease dynamics at the whole-of-population level. However, there are important conceptual differences between CRTs and RCTs relating to design, analysis, and inference. These differences can be illustrated by the adage "peas in a pod." Does the question of interest relate to the "peas" (the individual patients) or the "pods" (the clusters)? Several examples of recent CRTs of community and intensive care unit infection prevention interventions are used to illustrate these key concepts. Examples of differences between the results of RCTs and CRTs on the same topic are given.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Australia.,Division of Internal Medicine, Ballarat Health Services, Australia
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29
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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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30
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Choy A, Freedberg DE. Impact of microbiome-based interventions on gastrointestinal pathogen colonization in the intensive care unit. Therap Adv Gastroenterol 2020; 13:1756284820939447. [PMID: 32733601 PMCID: PMC7370550 DOI: 10.1177/1756284820939447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/15/2020] [Indexed: 02/04/2023] Open
Abstract
In the intensive care unit (ICU), colonization of the gastrointestinal tract by potentially pathogenic bacteria is common and often precedes clinical infection. Though effective in the short term, traditional antibiotic-based decolonization methods may contribute to rising resistance in the long term. Novel therapies instead focus on restoring gut microbiome equilibrium to achieve pathogen colonization resistance. This review summarizes the existing data regarding microbiome-based approaches to gastrointestinal pathogen colonization in ICU patients with a focus on prebiotics, probiotics, and synbiotics.
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Affiliation(s)
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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31
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Adelman MW, Woodworth MH, Langelier C, Busch LM, Kempker JA, Kraft CS, Martin GS. The gut microbiome's role in the development, maintenance, and outcomes of sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:278. [PMID: 32487252 PMCID: PMC7266132 DOI: 10.1186/s13054-020-02989-1] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
The gut microbiome regulates a number of homeostatic mechanisms in the healthy host including immune function and gut barrier protection. Loss of normal gut microbial structure and function has been associated with diseases as diverse as Clostridioides difficile infection, asthma, and epilepsy. Recent evidence has also demonstrated a link between the gut microbiome and sepsis. In this review, we focus on three key areas of the interaction between the gut microbiome and sepsis. First, prior to sepsis onset, gut microbiome alteration increases sepsis susceptibility through several mechanisms, including (a) allowing for expansion of pathogenic intestinal bacteria, (b) priming the immune system for a robust pro-inflammatory response, and (c) decreasing production of beneficial microbial products such as short-chain fatty acids. Second, once sepsis is established, gut microbiome disruption worsens and increases susceptibility to end-organ dysfunction. Third, there is limited evidence that microbiome-based therapeutics, including probiotics and selective digestive decontamination, may decrease sepsis risk and improve sepsis outcomes in select patient populations, but concerns about safety have limited uptake. Case reports of a different microbiome-based therapy, fecal microbiota transplantation, have shown correlation with gut microbial structure restoration and decreased inflammatory response, but these results require further validation. While much of the evidence linking the gut microbiome and sepsis has been established in pre-clinical studies, clinical evidence is lacking in many areas. To address this, we outline a potential research agenda for further investigating the interaction between the gut microbiome and sepsis.
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Affiliation(s)
- Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA.
| | - Michael H Woodworth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA
| | - Charles Langelier
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, CA, USA
| | - Lindsay M Busch
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Jordan A Kempker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Colleen S Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA, 30303, USA.,Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
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32
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Reddi B, Finnis M, Peake S. Difficulties in knowing which critical care trial data warrant change in practice. Med J Aust 2019; 211:306-307.e1. [PMID: 31495917 DOI: 10.5694/mja2.50331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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33
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Oropharyngeal Bacterial Colonization after Chlorhexidine Mouthwash in Mechanically Ventilated Critically Ill Patients. Anesthesiology 2019; 129:1140-1148. [PMID: 30247201 DOI: 10.1097/aln.0000000000002451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Oropharyngeal care with chlorhexidine to prevent ventilator-associated pneumonia is currently questioned, and exhaustive microbiologic data assessing its efficacy are lacking. The authors therefore aimed to study the effect of chlorhexidine mouthwash on oropharyngeal bacterial growth, to determine chlorhexidine susceptibility of these bacteria, and to measure chlorhexidine salivary concentration after an oropharyngeal care. METHODS This observational, prospective, single-center study enrolled 30 critically ill patients under mechanical ventilation for over 48 h. Oropharyngeal contamination was assessed by swabbing the gingivobuccal sulcus immediately before applying 0.12% chlorhexidine with soaked swabs, and subsequently at 15, 60, 120, 240, and 360 min after. Bacterial growth and identification were performed, and chlorhexidine minimal inhibitory concentration of recovered pathogens was determined. Saliva was collected in 10 patients, at every timepoint, with an additional timepoint after 30 min, to measure chlorhexidine concentration. RESULTS Two hundred fifty bacterial samples were analyzed and identified 48 pathogens including Streptococci (27.1%) and Enterobacteriaceae (20.8%). Oropharyngeal contamination before chlorhexidine mouthwash ranged from 10 to 10 colony-forming units (CFU)/ml in the 30 patients (median contamination level: 2.5·10 CFU/ml), and remained between 8·10 (lowest) and 3·10 CFU/ml (highest count) after chlorhexidine exposure. These bacterial counts did not decrease overtime after chlorhexidine mouthwash (each minute increase in time resulted in a multiplication of bacterial count by a coefficient of 1.001, P = 0.83). Viridans group streptococci isolates had the lowest chlorhexidine minimal inhibitory concentration (4 [4 to 8] mg/l); Enterobacteriaceae isolates had the highest ones (32 [16 to 32] mg/l). Chlorhexidine salivary concentration rapidly decreased, reaching 7.6 [1.8 to 31] mg/l as early as 60 min after mouthwash. CONCLUSIONS Chlorhexidine oropharyngeal care does not seem to reduce bacterial oropharyngeal colonization in critically ill ventilated patients. Variable chlorhexidine minimal inhibitory concentrations along with low chlorhexidine salivary concentrations after mouthwash could explain this ineffectiveness, and thus question the use of chlorhexidine for ventilator-associated pneumonia prevention.
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Gargiullo L, Del Chierico F, D’Argenio P, Putignani L. Gut Microbiota Modulation for Multidrug-Resistant Organism Decolonization: Present and Future Perspectives. Front Microbiol 2019; 10:1704. [PMID: 31402904 PMCID: PMC6671974 DOI: 10.3389/fmicb.2019.01704] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/10/2019] [Indexed: 01/10/2023] Open
Abstract
The emergence of antimicrobial resistance (AMR) is of great concern to global public health. Treatment of multi-drug resistant (MDR) infections is a major clinical challenge: the increase in antibiotic resistance leads to a greater risk of therapeutic failure, relapses, longer hospitalizations, and worse clinical outcomes. Currently, there are no validated treatments for many MDR or pandrug-resistant (PDR) infections, and preventing the spread of these pathogens through hospital infection control procedures and antimicrobial stewardship programs is often the only tool available to healthcare providers. Therefore, new solutions to control the colonization of MDR pathogens are urgently needed. In this narrative review, we discuss current knowledge of microbiota-mediated mechanisms of AMR and strategies for MDR colonization control. We focus particularly on fecal microbiota transplantation for MDR intestinal decolonization and report updated literature on its current clinical use.
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Affiliation(s)
- Livia Gargiullo
- Division of Immunology and Infectious Diseases, University-Hospital Pediatric Department, Bambino Gesù Children’s Hospital, IRCSS, Rome, Italy
| | | | - Patrizia D’Argenio
- Division of Immunology and Infectious Diseases, University-Hospital Pediatric Department, Bambino Gesù Children’s Hospital, IRCSS, Rome, Italy
| | - Lorenza Putignani
- Human Microbiome Unit and Parasitology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Vazquez Guillamet C, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable?: Practical Approaches to Ventilator-Associated Pneumonia Prevention. Clin Chest Med 2019; 39:809-822. [PMID: 30390751 DOI: 10.1016/j.ccm.2018.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions implemented effective VAP prevention bundles that combined head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. More recently, spontaneous breathing and awakening trials have consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP. More recent data question the overall positive impact of prevention bundles, including some of their core component interventions.
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Affiliation(s)
- Cristina Vazquez Guillamet
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, 2425 Camino de Salud, Albuquerque, NM 87106, USA; Division of Infectious Diseases, University of New Mexico School of Medicine, 2425 Camino de Salud, Albuquerque, NM 87106, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110, USA.
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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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Abis GSA, Stockmann HBAC, Bonjer HJ, van Veenendaal N, van Doorn-Schepens MLM, Budding AE, Wilschut JA, van Egmond M, Oosterling SJ, Abis GSA, Bonjer HJ, van Veenendaal N, van Doorn-Schepens MLM, Budding AE, de Lange ESM, Tuynman JB, E. Vandenbroucke-Grauls CMJ, Wilschut JA, van Egmond M, C. Stockmann HBA, van der Bij GJ, de Korte N, Oosterling SJ, Acherman YIZ, den Boer FC, Sonneveld DJA, Poort L. Randomized clinical trial of selective decontamination of the digestive tract in elective colorectal cancer surgery (SELECT trial). Br J Surg 2019; 106:355-363. [DOI: 10.1002/bjs.11117] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/29/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Infectious complications and anastomotic leakage affect approximately 30 per cent of patients after colorectal cancer surgery. The aim of this multicentre randomized trial was to investigate whether selective decontamination of the digestive tract (SDD) reduces these complications of elective colorectal cancer surgery.
Methods
The effectiveness of SDD was evaluated in a multicentre, open-label RCT in six centres in the Netherlands. Patients with colorectal cancer scheduled for elective curative surgery with a primary anastomosis were eligible. Oral colistin, tobramycin and amphotericin B were administered to patients in the SDD group to decontaminate the digestive tract. Both treatment and control group received intravenous cefazolin and metronidazole for perioperative prophylaxis. Mechanical bowel preparation was given for left-sided colectomies, sigmoid and anterior resections. Anastomotic leakage was the primary outcome; infectious complications and mortality were secondary outcomes.
Results
The outcomes for 228 patients randomized to the SDD group and 227 randomized to the control group were analysed. The trial was stopped after interim analysis demonstrated that superiority was no longer attainable. Effective SDD was confirmed by interspace DNA profiling analysis of rectal swabs. Anastomotic leakage was observed in 14 patients (6·1 per cent) in the SDD group and in 22 patients (9·7 per cent) in the control group (odds ratio (OR) 0·61, 95 per cent c.i. 0·30 to 1·22). Fewer patients in the SDD group had one or more infectious complications than patients in the control group (14·9 versus 26·9 per cent respectively; OR 0·48, 0·30 to 0·76). Multivariable analysis indicated that SDD reduced the rate of infectious complications (OR 0·47, 0·29 to 0·76).
Conclusion
SDD reduces infectious complications after colorectal cancer resection but did not significantly reduce anastomotic leakage in this trial. Registration number: NCT01740947 (https://www.clinicaltrials.gov).
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Affiliation(s)
- G S A Abis
- Department of Surgery, VU University Medical Centre, Amsterdam, the Netherlands
| | - H B A C Stockmann
- Department of Surgery, Spaarne Gasthuis, Haarlem/Hoofddorp, the Netherlands
| | - H J Bonjer
- Department of Surgery, VU University Medical Centre, Amsterdam, the Netherlands
| | - N van Veenendaal
- Department of Surgery, VU University Medical Centre, Amsterdam, the Netherlands
| | - M L M van Doorn-Schepens
- Department of Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, the Netherlands
| | - A E Budding
- Department of Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, the Netherlands
| | - J A Wilschut
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, the Netherlands
| | - M van Egmond
- Department of Surgery, VU University Medical Centre, Amsterdam, the Netherlands
| | - S J Oosterling
- Department of Surgery, Spaarne Gasthuis, Haarlem/Hoofddorp, the Netherlands
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The Use of Microbiome Restoration Therapeutics to Eliminate Intestinal Colonization With Multidrug-Resistant Organisms. Am J Med Sci 2018; 356:433-440. [PMID: 30384952 DOI: 10.1016/j.amjms.2018.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/17/2022]
Abstract
Antibiotic resistance (AR) has been described by the World Health Organization as an increasingly serious threat to global public health. Many mechanisms of AR have become widespread due to global selective pressures such as widespread antibiotic use. The intestinal tract is an important reservoir for many multidrug-resistant organisms (MDROs), and next-generation sequencing has expanded understanding of the resistome, defined as the comprehensive sum of genetic determinants of AR. Intestinal decolonization has been explored as a strategy to eradicate MDROs with selective digestive tract decontamination and probiotics being notable examples with mixed results. This review focuses on fecal microbiota transplantation and the early evidence supporting its efficacy in decolonizing MDROs and potential mechanisms of action to reduce AR genes. Current evidence suggests that fecal microbiota transplantation may have promise in restoring healthy microbial diversity and reducing AR, and clinical trials are underway to better characterize its safety and efficacy.
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Incidences of Pseudomonas aeruginosa-Associated Ventilator-Associated Pneumonia within Studies of Respiratory Tract Applications of Polymyxin: Testing the Stoutenbeek Concurrency Postulates. Antimicrob Agents Chemother 2018; 62:AAC.00291-18. [PMID: 29784844 DOI: 10.1128/aac.00291-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/10/2018] [Indexed: 01/18/2023] Open
Abstract
Regimens containing topical polymyxin appear highly effective at preventing ventilator-associated pneumonia (VAP) overall and, more so, VAP caused by Gram-negative bacteria. However, Stoutenbeek's postulates that VAP incidences within studies of topical antibiotics depend on the context of whether the component (control and intervention) groups of each study were concurrent versus nonconcurrent remain untested. The literature was searched for concurrent control (CC) versus nonconcurrent control (NCC) designed studies of respiratory tract applications of topical polymyxin to mechanically ventilated (MV) patients that reported incidences of Pseudomonas-associated ventilator-associated pneumonia (PsVAP). Studies of various interventions other than topical polymyxin (nonpolymyxin studies) served to provide additional points of reference. The PsVAP incidences within the component groups of all studies were benchmarked against groups from observational studies. This was undertaken by meta-regression using generalized estimating equation methods. Dot plots, caterpillar plots, and funnel plots enable visual benchmarking. The PsVAP benchmark (and 95% confidence interval [CI]) derived from 102 observational groups is 4.6% (4.0 to 5.3%). In contrast, the mean PsVAP within NCC polymyxin intervention groups (1.6%; CI, 1.0 to 4.5%) is lower than that of all other component group categories. The mean PsVAP within CC polymyxin control groups (9.9%; CI, 7.6 to 12.8%) is higher than that of all other component group categories. The PsVAP incidences of control and intervention groups of studies of respiratory tract applications of polymyxin are dependent on whether the groups were within a concurrent versus nonconcurrent study. Stoutenbeek's concurrency postulates are validated.
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Timsit JF, Bassetti M. Antipathy against SDD is justified: Yes. Intensive Care Med 2018; 44:1165-1168. [PMID: 29881989 DOI: 10.1007/s00134-018-5183-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/12/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Jean-François Timsit
- UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France. .,APHP Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, Paris, France.
| | - Matteo Bassetti
- Clinica Malattie Infettive, Azienda Ospedaliera Universitaria Santa Maria della Misericorida, Udine, Italy.,University of Udine School of Medicine, Udine, Italy
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Abstract
PURPOSE OF REVIEW The composition and diversity of the microbiota of the human gut, skin, and several other sites is severely deranged in critically ill patients on the ICU, and it is likely that these disruptions can negatively affect outcome. We here review new and ongoing studies that investigate the use of microbiota-targeted therapeutics in the ICU, and provide recommendations for future research. RECENT FINDINGS Practically every intervention in the ICU as well as the physiological effects of critical illness itself can have a profound impact on the gut microbiota. Therapeutic modulation of the microbiota, aimed at restoring the balance between 'pathogenic' and 'health-promoting' microbes is therefore of significant interest. Probiotics have shown to be effective in the treatment of ventilator-associated pneumonia, and the first fecal microbiota transplantations have recently been safely and successfully performed in the ICU. However, all-encompassing data in this vulnerable patient group remain sparse, and only a handful of novel studies that study microbiota-targeted therapies in the ICU are currently ongoing. SUMMARY Enormous strides have been made in characterizing the gut microbiome of critically ill patients in the ICU, and an increasing amount of preclinical data reveals the huge potential of microbiota-targeted therapies. Further understanding of the causes and consequences of dysbiosis on ICU-related outcomes are warranted to push the field forward.
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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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Karacaer F, Hamed I, Özogul F, Glew RH, Özcengiz D. The function of probiotics on the treatment of ventilator-associated pneumonia (VAP): facts and gaps. J Med Microbiol 2017; 66:1275-1285. [PMID: 28855004 DOI: 10.1099/jmm.0.000579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Probiotics have been used for centuries in making fermented dairy products. The health benefits related to probiotics consumption are well recognized and they are generally regarded as safe (GRAS). Their therapeutic effects are due to the production of a variety of antimicrobial compounds, such as short-chain fatty acids, organic acids (such as lactic, acetic, formic, propionic and butyric acids), ethanol, hydrogen peroxide and bacteriocins. Ventilator-associated pneumonia (VAP) is a nosocomial infection associated with high mortality in intensive care units. VAP can result from endotracheal intubation and mechanical ventilation. These interventions increase the risk of infection as patients lose the natural barrier between the oropharynx and the trachea, which in turn facilitates the entry of pathogens through the aspiration of oropharyngeal secretions containing bacteria into the lung. In order to prevent this, probiotics have been used extensively against VAP. This review is an update containing information extracted from recent studies on the use of probiotics to treat VAP. In addition, probiotic safety, the therapeutic properties of probiotics, the probiotic strains used and the action of the probiotics mechanism are reviewed. Furthermore, the therapeutic effects of probiotic treatment procedures for VAP are compared to those of antibiotics. Finally, the influences of bacteriocin on the growth of human pathogens, and the side-effects and limitations of using probiotics for the treatment of VAP are addressed.
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Affiliation(s)
- Feride Karacaer
- Department of Anaesthesiology and Reanimation, School of Medicine, Cukurova University, Adana, Turkey
| | - Imen Hamed
- Biotechnology Research and Application Centre, Cukurova University, Adana, Turkey
| | - Fatih Özogul
- Department of Seafood Processing Technology, Faculty of Fisheries, Cukurova University, 01330, Adana, Turkey
| | - Robert H Glew
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Dilek Özcengiz
- Department of Anaesthesiology and Reanimation, School of Medicine, Cukurova University, Adana, Turkey
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Mahieu R, Cassisa V, Hilliquin D, Coron N, Pailhoriès H, Kempf M, Joly-Guillou ML, Eveillard M. Impact of faecal microbiota transplantation on mouse digestive colonization with two extensively resistant bacteria. J Infect 2017; 75:75-77. [PMID: 28461230 DOI: 10.1016/j.jinf.2017.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Rafael Mahieu
- Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Université de Nantes, Université d'Angers, Angers, France; Equipe Atip-Avenir, Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire et Université d'Angers, Angers, France
| | - Viviane Cassisa
- Laboratoire de bactériologie, CHU Angers, 4 rue Larrey, F-49933 Angers, France
| | - Delphine Hilliquin
- Laboratoire de bactériologie, CHU Angers, 4 rue Larrey, F-49933 Angers, France
| | - Noémie Coron
- Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Université de Nantes, Université d'Angers, Angers, France; Equipe Atip-Avenir, Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire et Université d'Angers, Angers, France
| | - Hélène Pailhoriès
- Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Université de Nantes, Université d'Angers, Angers, France; Equipe Atip-Avenir, Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire et Université d'Angers, Angers, France; Laboratoire de bactériologie, CHU Angers, 4 rue Larrey, F-49933 Angers, France
| | - Marie Kempf
- Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Université de Nantes, Université d'Angers, Angers, France; Equipe Atip-Avenir, Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire et Université d'Angers, Angers, France; Laboratoire de bactériologie, CHU Angers, 4 rue Larrey, F-49933 Angers, France
| | - Marie-Laure Joly-Guillou
- Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Université de Nantes, Université d'Angers, Angers, France; Equipe Atip-Avenir, Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire et Université d'Angers, Angers, France; Laboratoire de bactériologie, CHU Angers, 4 rue Larrey, F-49933 Angers, France
| | - Matthieu Eveillard
- Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Université de Nantes, Université d'Angers, Angers, France; Equipe Atip-Avenir, Center for Research in Cancerology and Immunology Nantes-Angers, Institut National de la Santé et de la Recherche Médicale, Centre Hospitalier Universitaire et Université d'Angers, Angers, France; Laboratoire de bactériologie, CHU Angers, 4 rue Larrey, F-49933 Angers, France.
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Murthy S, Pathan N, Cuthbertson BH. Selective digestive decontamination in critically ill children: A survey of Canadian providers. J Crit Care 2017; 39:169-171. [PMID: 28267670 DOI: 10.1016/j.jcrc.2017.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/13/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Selective digestive decontamination of the digestive tract involves the routine administration of oral, gastric, and intravenous antibiotics to mechanically ventilated children to prevent hospital-acquired infections. It has a strong evidence base in adults, with limited pediatric evidence. Current utilization of this intervention among pediatric physicians in North America is unknown. METHODS An electronic survey administered to pediatric critical care and pediatric infectious disease providers in Canada. Participants were surveyed on current institutional practices, their current knowledge of the evidence base, and perceptions of the risks and benefits of the intervention. Descriptive statistics were utilized. RESULTS 50 out of 143 (35%) surveyed responded. No hospital in Canada routinely performs SDD and the majority of respondents (74%) have neutral opinions on the subject of SDD. There was concern for increasing antibiotic resistance (43%) and some disagreement with the intravenous component of SDD (46%). The majority of respondents stated a need for pediatric-specific evidence before integrating SDD into their practice, even if further, large adult RCTs were performed. CONCLUSION Among surveyed providers, there is little knowledge and no use of selective digestive decontamination for the prevention of hospital-acquired infections. Before interventional studies are performed in pediatric practice, there is a need for study of facilitators, barriers and acceptability of SDD in practice.
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Krentz T, Allen S. Bacterial translocation in critical illness. J Small Anim Pract 2017; 58:191-198. [PMID: 28186322 DOI: 10.1111/jsap.12626] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/18/2016] [Accepted: 11/08/2016] [Indexed: 12/19/2022]
Abstract
Bacterial translocation involves the passage of intestinal bacteria to extraintestinal sites and has been shown to increase morbidity and mortality in critical illness. This review outlines the pathophysiology of bacterial translocation, host defence mechanisms, and reviews the evidence for the clinical management of critically ill patients in order to minimise the negative outcomes associated with bacterial translocation.
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Affiliation(s)
- T Krentz
- Department of Emergency and Critical Care, Massachusetts Veterinary Referral Hospital, Woburn, MA, 01801, USA
| | - S Allen
- Department of Emergency and Critical Care, Massachusetts Veterinary Referral Hospital, Woburn, MA, 01801, USA
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Liu H, Fei CN, Zhang Y, Liu GW, Liu J, Dong J. Presence, distribution and molecular epidemiology of multi-drug-resistant Gram-negative bacilli from medical personnel of intensive care units in Tianjin, China, 2007-2015. J Hosp Infect 2017; 96:101-110. [PMID: 28268024 DOI: 10.1016/j.jhin.2017.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/21/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multi-drug-resistant Gram-negative bacteria (MDRGNB) have become an important cause of nosocomial infection in intensive care units (ICUs). AIMS To investigate the molecular epidemiology of MDRGNB isolated from medical personnel (MP) and non-medical personnel (NMP) at 69 ICUs in Tianjin, China. METHODS From April 2007 to October 2015, 2636 nasal and hand swab samples from 1185 MP and 133 NMP were cultured for GNB (including MDRGNB), meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The susceptibilities of GNB to 14 antimicrobial agents were determined, and 80 MDRGNB were characterized using pulsed-field gel electrophoresis (PFGE) and dendrogram analysis. FINDINGS In total, 301 GNB were identified in 269 MP, including 109 MDRGNB isolates in 104 MP. Forty-two GNB were isolated from 39 NMP, which included 20 NMP with MDRGNB. Overall, 8.8% of MP were colonized with MDRGNB, which greatly exceeded colonization rates with MRSA (0.9%) and VRE (0.1%). Three pairs of Klebsiella pneumoniae and one pair of Enterobacter aerogenes were indistinguishable from each other, but the majority of isolate tests had distinct PFGE profiles. CONCLUSIONS The prevalence of MDRGNB was high among ICU MP in Tianjin, and greatly exceeded that of VRE and MRSA. There was no difference in the rates of nasal carriage of MDRGNB between MP and NMP, but NMP were significantly more likely to have hand colonization with MDRGNB. PFGE profiles showed that there was only limited sharing of strains of MDR E. aerogenes and K. pneumoniae between personnel.
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Affiliation(s)
- H Liu
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China.
| | - C N Fei
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - Y Zhang
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - G W Liu
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - J Liu
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
| | - J Dong
- Department of Infectious Disease, Tianjin Centres for Disease Control and Prevention, Tianjin, China
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The role of the gut microbiota in sepsis. Lancet Gastroenterol Hepatol 2017; 2:135-143. [PMID: 28403983 DOI: 10.1016/s2468-1253(16)30119-4] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/18/2016] [Accepted: 08/18/2016] [Indexed: 02/07/2023]
Abstract
For decades, the gut was thought to play an important role in sepsis pathogenesis. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ failure assessment for sepsis focuses on respiratory, cardiovascular, hepatic, renal, neurological, and haematological systems. Unfortunately, symptoms of gut failure are non-specific and are therefore not assessed. The composition of the intestinal microbiome, however, is affected by sepsis, and might contribute to the development of organ failure. Experimental work underscores the role of the microbiota in maintaining gut-barrier function, and modulation of the innate and adaptive immune system. Translation of these preclinical findings into functional characterisations will be essential to understand how disruption of commensals affects susceptibility and outcome of sepsis. In this Review, we identify knowledge gaps which, if addressed, will help researchers understand the role of the microbiota in sepsis, and provide microbiota-targeted tools to improve sepsis management.
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Laffin M, Millan B, Madsen KL. Fecal microbial transplantation as a therapeutic option in patients colonized with antibiotic resistant organisms. Gut Microbes 2017; 8:221-224. [PMID: 28059612 PMCID: PMC5479404 DOI: 10.1080/19490976.2016.1278105] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Despite increasing interest in fecal microbiota transplantation (FMT), its full therapeutic potential has yet to be determined. Since its increase in popularity, FMT has been shown to be highly effective in the treatment of both Clostridium difficile infection (CDI) and its recurrent form. Interest in FMT now expands well beyond the treatment of CDI to other processes with known associations to the microbiota such as antibiotic resistant infections, inflammatory bowel disease (IBD), hepatic encephalopathy, neuropsychiatric disorders, and metabolic disease. The rampant use and misuse of antibiotics in both medicine and agriculture has resulted in an increase in antibiotic resistant organisms which pose a significant risk to human health. The purpose of this commentary is to address the general issue of antibiotic resistance in the human microbiota and the restorative potential of FMT in this area.
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Affiliation(s)
- Michael Laffin
- Department of Medicine, CEGIIR: Center of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta
| | - Braden Millan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Karen L. Madsen
- Department of Medicine, CEGIIR: Center of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta,CONTACT Dr. Karen L. Madsen 7–142 Katz Group Center, University of Alberta, Edmonton, Alberta
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50
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Mourand G, Paboeuf F, Fleury MA, Jouy E, Bougeard S, Denamur E, Kempf I. Escherichia coli Probiotic Strain ED1a in Pigs Has a Limited Impact on the Gut Carriage of Extended-Spectrum-β-Lactamase-Producing E. coli. Antimicrob Agents Chemother 2017; 61:e01293-16. [PMID: 27795372 PMCID: PMC5192156 DOI: 10.1128/aac.01293-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/09/2016] [Indexed: 11/20/2022] Open
Abstract
Four trials were conducted to evaluate the impact of Escherichia coli probiotic strain ED1a administration to pigs on the gut carriage or survival in manure of extended-spectrum-β-lactamase-producing E. coli Groups of pigs were orally inoculated with strain E. coli M63 carrying the blaCTX-M-1 gene (n = 84) or used as a control (n = 26). In the first two trials, 24 of 40 E. coli M63-inoculated pigs were given E. coli ED1a orally for 6 days starting 8 days after oral inoculation. In the third trial, 10 E. coli M63-inoculated pigs were given either E. coli ED1a or probiotic E. coli Nissle 1917 for 5 days. In the fourth trial, E. coli ED1a was given to a sow and its 12 piglets, and these 12 piglets plus 12 piglets that had not received E. coli ED1a were then inoculated with E. coli M63. Fecal shedding of cefotaxime-resistant Enterobacteriaceae (CTX-RE) was studied by culture, and blaCTX-M-1 genes were quantified by PCR. The persistence of CTX-RE in manure samples from inoculated pigs or manure samples inoculated in vitro with E. coli M63 with or without probiotics was studied. The results showed that E. coli M63 and ED1a were good gut colonizers. The reduction in the level of fecal excretion of CTX-RE in E. coli ED1a-treated pigs compared to that in nontreated pigs was usually less than 1 log10 CFU and was mainly observed during the probiotic administration period. The results obtained with E. coli Nissle 1917 did not differ significantly from those obtained with E. coli ED1a. CTX-RE survival did not differ significantly in manure samples with or without probiotic treatment. In conclusion, under our experimental conditions, E. coli ED1a and E. coli Nissle 1917 could not durably prevent CTX-RE colonization of the pig gut.
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Affiliation(s)
- G Mourand
- ANSES, Laboratoire de Ploufragan-Plouzané, Ploufragan, France
- Université Bretagne Loire, Rennes, France
| | - F Paboeuf
- ANSES, Laboratoire de Ploufragan-Plouzané, Ploufragan, France
- Université Bretagne Loire, Rennes, France
| | - M A Fleury
- ANSES, Laboratoire de Ploufragan-Plouzané, Ploufragan, France
- Université Bretagne Loire, Rennes, France
| | - E Jouy
- ANSES, Laboratoire de Ploufragan-Plouzané, Ploufragan, France
- Université Bretagne Loire, Rennes, France
| | - S Bougeard
- ANSES, Laboratoire de Ploufragan-Plouzané, Ploufragan, France
- Université Bretagne Loire, Rennes, France
| | - E Denamur
- INSERM, IAME, UMR 1137, Paris, France
- Université Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, Paris, France
- APHP, Hôpitaux Universitaires Paris Nord Val-de-Seine, Site Bichat Claude-Bernard, Paris, France
| | - I Kempf
- ANSES, Laboratoire de Ploufragan-Plouzané, Ploufragan, France
- Université Bretagne Loire, Rennes, France
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