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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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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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Pilmis B, Weiss E, Scemla A, Le Monnier A, Grossi PA, Slavin MA, Van Delden C, Lortholary O, Paugam-Burtz C, Zahar JR. Multidrug-resistant Enterobacterales infections in abdominal solid organ transplantation. Clin Microbiol Infect 2023; 29:38-43. [PMID: 35716912 DOI: 10.1016/j.cmi.2022.06.005] [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: 01/13/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Transplant recipients are highly susceptible to multidrug-resistant (MDR) related infections. The lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases. OBJECTIVES In this review, we present the current state of knowledge concerning multidrug-resistant Gram negative bacilli's risk management in the care of solid-organ transplant recipients and suggest control strategies. SOURCES We searched for studies treating MDR g-negative bacilli related infections in the renal and hepatic transplant patient population. We included randomized and observational studies. CONTENT Solid-organ transplant is the best therapeutic option for patients diagnosed with end-stage organ disease. While the incidence of opportunistic infections is decreasing due to better prevention, the burden of "classical" infections related to MDR bacteria especially related to Gram-negative bacteria is constantly increasing. Over the last two decades, various MDR pathogens have emerged as a relevant cause of infection in this specific population associated with significant mortality. Several factors related to the management of transplant donor candidates and recipients increase the risk of MDR infections in transplant recipients. The awareness of this high susceptibility of transplant recipients to MDR-related infections challenges the choice of empirical therapy, while its appropriateness can only be validated a posteriori. Indeed, the lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases. IMPLICATIONS Multidrug-resistant Gram-negative bacteria are associated with high morbidity and mortality in solid organ transplant recipients. It seems important to identify patients at risk of colonization/MDR bacteria to evaluate strategies to limit the risk of secondary infections and to minimize the inappropriate use of broad-spectrum antibiotics.
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Affiliation(s)
- Benoît Pilmis
- Centre d'infectiologie Necker-Pasteur, Hôpital Necker Enfants-Malades, Centre médical de l'institut Pasteur, Université de Paris, Paris, France; Équipe mobile de microbiologie Clinique, Groupe Hospitalier Paris Saint Joseph, Paris, France; Institut Micalis, UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Chatenay-Malabry, France.
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Université de Paris, Paris, France; Inserm UMR S1149, Centre de recherche sur l'inflammation
| | - Anne Scemla
- Departement of Nephrology-Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
| | - Alban Le Monnier
- Institut Micalis, UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Chatenay-Malabry, France; Service de Microbiologie Clinique et Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Paolo Antonio Grossi
- Department of Medicine and Surgery, University of Insubria and ASST Sette Laghi, Ospedale di Circolo of Varese, Varese, Italy
| | - Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Olivier Lortholary
- Centre d'infectiologie Necker-Pasteur, Hôpital Necker Enfants-Malades, Centre médical de l'institut Pasteur, Université de Paris, Paris, France
| | - Catherine Paugam-Burtz
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Université de Paris, Paris, France; Inserm UMR S1149, Centre de recherche sur l'inflammation
| | - Jean-Ralph Zahar
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, France; Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, Bobigny, France
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Candida and the Gram-positive trio: testing the vibe in the ICU patient microbiome using structural equation modelling of literature derived data. Emerg Themes Epidemiol 2022; 19:7. [PMID: 35982466 PMCID: PMC9387012 DOI: 10.1186/s12982-022-00116-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Whether Candida interacts with Gram-positive bacteria, such as Staphylococcus aureus, coagulase negative Staphylococci (CNS) and Enterococci, to enhance their invasive potential from the microbiome of ICU patients remains unclear. Several effective anti-septic, antibiotic, anti-fungal, and non-decontamination based interventions studied for prevention of ventilator associated pneumonia (VAP) and other ICU acquired infections among patients receiving prolonged mechanical ventilation (MV) are known to variably impact Candida colonization. The collective observations within control and intervention groups from numerous ICU infection prevention studies enables tests of these postulated microbial interactions in the clinical context. Methods Four candidate generalized structural equation models (GSEM), each with Staphylococcus aureus, CNS and Enterococci colonization, defined as latent variables, were confronted with blood culture and respiratory tract isolate data derived from 460 groups of ICU patients receiving prolonged MV from 283 infection prevention studies. Results Introducing interaction terms between Candida colonization and each of S aureus (coefficient + 0.40; 95% confidence interval + 0.24 to + 0.55), CNS (+ 0.68; + 0.34 to + 1.0) and Enterococcal (+ 0.56; + 0.33 to + 0.79) colonization (all as latent variables) improved the fit for each model. The magnitude and significance level of the interaction terms were similar to the positive associations between exposure to topical antibiotic prophylaxis (TAP) on Enterococcal (+ 0.51; + 0.12 to + 0.89) and Candida colonization (+ 0.98; + 0.35 to + 1.61) versus the negative association of TAP with S aureus (− 0.45; − 0.70 to − 0.20) colonization and the negative association of anti-fungal exposure and Candida colonization (− 1.41; − 1.6 to − 0.72). Conclusions GSEM modelling of published ICU infection prevention data enables the postulated interactions between Candida and Gram-positive bacteria to be tested using clinically derived data. The optimal model implies interactions occurring in the human microbiome facilitating bacterial invasion and infection. This interaction might also account for the paradoxically high bacteremia incidences among studies of TAP in ICU patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12982-022-00116-9. GSEM modelling of published ICU infection prevention data from > 250 studies enables a test of and provides support to the interaction between Candida and Gram-positive bacteria. The various ICU infection prevention interventions may each broadly impact the patient microbiome.
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Arias-Rivera S, Jam-Gatell R, Nuvials-Casals X, Vázquez-Calatayud M. [Update of the recommendations of the Pneumonia Zero project]. ENFERMERIA INTENSIVA 2022; 33:S17-S30. [PMID: 35911624 PMCID: PMC9326456 DOI: 10.1016/j.enfi.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial. Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales). Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos. Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.
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Affiliation(s)
- S Arias-Rivera
- Investigación de enfermería. Hospital Universitario de Getafe, Getafe. CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - R Jam-Gatell
- Área de críticos. Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - X Nuvials-Casals
- Área de Desarrollo Profesional e investigación de Enfermería, Clínica Universidad de Navarra. Universidad de Navarra. IdisNA, Instituto de Investigación Sanitaria de Navarra, Navarra, España
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Hurley JC. Structural equation modelling the relationship between anti-fungal prophylaxis and Pseudomonas bacteremia in ICU patients. Intensive Care Med Exp 2022; 10:2. [PMID: 35059904 PMCID: PMC8776977 DOI: 10.1186/s40635-022-00429-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/30/2021] [Indexed: 01/20/2023] Open
Abstract
Purpose Animal models implicate candida colonization facilitating invasive bacterial infections. The clinical relevance of this microbial interaction remains undefined and difficult to study directly. Observations from studies of anti-septic, antibiotic, anti-fungal, and non-decontamination-based interventions to prevent ICU acquired infection collectively serve as a natural experiment. Methods Three candidate generalized structural equation models (GSEM), with Candida and Pseudomonas colonization as latent variables, were confronted with blood culture and respiratory tract isolate data derived from 464 groups from 279 studies including studies of combined antibiotic and antifungal exposures within selective digestive decontamination (SDD) interventions. Results Introducing an interaction term between Candida colonization and Pseudomonas colonization substantially improved GSEM model fit. Model derived coefficients for singular exposure to anti-septic agents (− 1.23; − 2.1 to − 0.32), amphotericin (− 1.78; − 2.79 to − 0.78) and topical antibiotic prophylaxis (TAP; + 1.02; + 0.11 to + 1.93) versus Candida colonization were similar in magnitude but contrary in direction. By contrast, the model-derived coefficients for singular exposure to TAP, as with anti-septic agents, versus Pseudomonas colonization were weaker or non-significant. Singular exposure to amphotericin would be predicted to more than halve candidemia and Pseudomonas bacteremia incidences versus literature benchmarks for absolute differences of approximately one percentage point or less. Conclusion GSEM modelling of published data supports the postulated interaction between Candida and Pseudomonas colonization towards promoting bacteremia among ICU patients. This would be difficult to detect without GSEM modelling. The model indicates that anti-fungal agents have greater impact in preventing Pseudomonas bacteremia than TAP, which has no impact. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00429-8.
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Asymmetric Effects of Decontamination Using Topical Antibiotics for the ICU Patient. Symmetry (Basel) 2021. [DOI: 10.3390/sym13061027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection. These have been evaluated in >200 studies. Infection prevention using topical antibiotic prophylaxis (TAP) appears to be the most effective. Whether antibiotic use in the ICU may influence the risk of infection among concurrent control patients within the same ICU and result in asymmetrical herd effects cannot be resolved with individual studies examined in isolation. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-center natural experiment enabling the herd effects of antibiotics to be evaluated. Among the TAP control groups, the incidences for both ventilator associated pneumonia (VAP) and mortality are unusually high in comparison to literature-derived benchmarks. Paradoxically, amongst the TAP intervention groups, the incidences of mortality are also unusually high and the VAP incidences are similar (i.e., not lower) compared to the incidences among studies of other interventions. By contrast, the mortality incidences among the intervention groups of other studies are similar to those among the intervention groups of TAP studies. Using topical antibiotics to prevent infections acquired within the ICU environment may result in profoundly asymmetrical effects.
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Candida- Acinetobacter-Pseudomonas Interaction Modelled within 286 ICU Infection Prevention Studies. J Fungi (Basel) 2020; 6:jof6040252. [PMID: 33121074 PMCID: PMC7712580 DOI: 10.3390/jof6040252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Whether Candida interacts to enhance the invasive potential of Acinetobacter and Pseudomonas bacteria cannot be resolved within individual studies. There are several anti-septic, antibiotic, anti-fungal, and non-decontamination-based interventions to prevent ICU acquired infection. These effective prevention interventions would be expected to variably impact Candida colonization. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-centre natural experiment with which to evaluate Candida, Acinetobacter and Pseudomonas interaction (CAPI). METHODS Eight Candidate-generalized structural equation models (GSEM), with Candida, Pseudomonas and Acinetobacter colonization as latent variables, were confronted with blood culture and respiratory tract isolate data derived from >400 groups derived from 286 infection prevention studies. RESULTS Introducing an interaction term between Candida colonization and each of Pseudomonas and Acinetobacter colonization improved model fit in each case. The size of the coefficients (and 95% confidence intervals) for these interaction terms in the optimal Pseudomonas (+0.33; 0.22 to 0.45) and Acinetobacter models (+0.32; 0.01 to 0.5) were similar to each other and similar in magnitude, but contrary in direction, to the coefficient for exposure to topical antibiotic prophylaxis (TAP) on Pseudomonas colonization (-0.45; -0.71 to -0.2). The coefficient for exposure to topical antibiotic prophylaxis on Acinetobacter colonization was not significant. CONCLUSIONS GSEM modelling of published ICU infection prevention data supports the CAPI concept. The CAPI model could account for some paradoxically high Acinetobacter and Pseudomonas infection incidences, most apparent among the concurrent control groups of TAP studies.
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Kubota Y, Nagano H, Ishii K, Kono T, Kono S, Akita S, Mitsukawa N, Tanaka T. Small intestinal bacterial overgrowth as a cause of protracted wound healing and vitamin D deficiency in a spinal cord injured patient with a sacral pressure sore: a case report. BMC Gastroenterol 2020; 20:283. [PMID: 32831031 PMCID: PMC7444194 DOI: 10.1186/s12876-020-01423-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pressure sores are sometimes refractory to treatment, often due to malnutrition. Small intestinal bacterial overgrowth (SIBO) obstructs absorption in the digestive tract and causes malnutrition. However, little is known about the association between pressure sore wound healing and SIBO. Here, we report a case of a patient with a refractory sacral pressure sore and SIBO. CASE PRESENTATION A 66-year-old woman who was spinal cord injured 14 years before visiting our hospital presented with the chief complaint of a sacral pressure sore, 10.0 × 6.5 cm in size, which was refractory to treatment. Physical examination showed abdominal distension and emaciation, with a body mass index of 15. Further examination revealed elevated serum alkaline phosphatase (1260 U/L), bilateral tibial fracture, multiple rib fracture, and osteoporosis. We diagnosed the patient with osteomalacia with vitamin D deficiency. Despite oral supplementation, serum levels of calcium, phosphorous, and vitamin D remained low. Also, despite concentrative wound therapy for the sacral pressure sore by plastic surgeons, no wound healing was achieved. Due to a suspicion of disturbances in nutrient absorption, we performed bacterial examination of collected gastric and duodenal fluid, which showed high numbers of bacteria in gastric content (104 E. coli, 105 Streptococcus species, and 105 Neisseria species) and duodenal content (106 E. coli, 104 Candida glabrata). Therefore, we diagnosed the patient with SIBO and started selective decontamination of the digestive tract using polymyxin B sulfate and amphotericin B. After starting treatment for SIBO, the sacral pressure sore began to heal and was nearly healed after 285 days. The patient's serum levels of calcium, phosphorous, vitamin D, and other fat-soluble vitamins also gradually increased after starting treatment for SIBO. CONCLUSION We report a case of a patient with a refractory sacral pressure sore that healed after starting treatment for SIBO. We conclude that SIBO may be an overlooked cause of malnutrition and poor wound healing in patients with chronic pressure sores.
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Affiliation(s)
- Yoshitaka Kubota
- Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan.
| | - Hidekazu Nagano
- Department of Molecular Diagnosis, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan
| | - Kentaro Ishii
- Department of Plastic Surgery, Chiba Emergency Medical Center, 3-32-1, Isobe, Mihama-ku, Chiba, #261-0012, Japan
| | - Takashi Kono
- Department of Molecular Diagnosis, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan
| | - Satomi Kono
- Department of Molecular Diagnosis, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan
| | - Shinsuke Akita
- Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic Surgery, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, #260-8670, Japan
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Hurley JC. Structural equation modeling the "control of gut overgrowth" in the prevention of ICU-acquired Gram-negative infection. Crit Care 2020; 24:189. [PMID: 32366267 PMCID: PMC7199305 DOI: 10.1186/s13054-020-02906-6] [Citation(s) in RCA: 10] [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: 01/13/2020] [Accepted: 04/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conceptually, the "control of gut overgrowth" (COGO) is key in mediating prevention against infection with Gram-negative bacilli by topical antibiotic prophylaxis, a common constituent of selective digestive decontamination (SDD) regimens. However, the relative importance of the other SDD components, enteral and protocolized parenteral antibiotic prophylaxis, versus other methods of infection prevention and versus other contextual exposures cannot be resolved within individual studies. METHODS Seven candidate generalized structural equation models founded on COGO concepts were confronted with Pseudomonas and Acinetobacter bacteremia as well as ventilator-associated pneumonia data derived from > 200 infection prevention studies. The following group-level exposures were included in the models: use and mode of antibiotic prophylaxis, anti-septic and non-decontamination methods of infection prevention; proportion receiving mechanical ventilation; trauma ICU; mean length of ICU stay; and concurrency versus non-concurrency of topical antibiotic prophylaxis study control groups. RESULTS In modeling Pseudomonas and Acinetobacter gut overgrowth as latent variables, anti-septic interventions had the strongest negative effect against Pseudomonas gut overgrowth but no intervention was significantly negative against Acinetobacter gut overgrowth. Strikingly, protocolized parenteral antibiotic prophylaxis and concurrency each have positive effects in the model, enteral antibiotic prophylaxis is neutral, and Acinetobacter bacteremia incidences are high within topical antibiotic prophylaxis studies, moreso with protocolized parenteral antibiotic prophylaxis exposure. Paradoxically, topical antibiotic prophylaxis (moreso with protocolized parenteral antibiotic prophylaxis) appears to provide the strongest summary prevention effects against overall bacteremia and overall VAP. CONCLUSIONS Structural equation modeling of published Gram-negative bacillus infection data enables a test of the COGO concept. Paradoxically, Acinetobacter and Pseudomonas bacteremia incidences are unusually high among studies of topical antibiotic prophylaxis.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Internal Medicine Service, Ballarat Health Services, PO Box 577, Ballarat, Victoria, 3353, Australia.
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Buitinck S, Jansen R, Rijkenberg S, Wester JPJ, Bosman RJ, van der Meer NJM, van der Voort PHJ. The ecological effects of selective decontamination of the digestive tract (SDD) on antimicrobial resistance: a 21-year longitudinal single-centre study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:208. [PMID: 31174575 PMCID: PMC6555978 DOI: 10.1186/s13054-019-2480-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/19/2019] [Indexed: 02/03/2023]
Abstract
Background The long-term ecological effects on the emergence of antimicrobial resistance at the ICU level during selective decontamination of the digestive tract (SDD) are unknown. We determined the incidence of newly acquired antimicrobial resistance of aerobic gram-negative potentially pathogenic bacteria (AGNB) during SDD. Methods In a single-centre observational cohort study over a 21-year period, all consecutive patients, treated with or without SDD, admitted to the ICU were included. The antibiotic regime was unchanged over the study period. Incidence rates for ICU-acquired AGNB’s resistance for third-generation cephalosporins, colistin/polymyxin B, tobramycin/gentamicin or ciprofloxacin were calculated per year. Changes over time were tested by negative binomial regression in a generalized linear model. Results Eighty-six percent of 14,015 patients were treated with SDD. Most cultures were taken from the digestive tract (41.9%) and sputum (21.1%). A total of 20,593 isolates of AGNB were identified. The two most often found bacteria were Escherichia coli (N = 6409) and Pseudomonas (N = 5269). The incidence rate per 1000 patient-day for ICU-acquired resistance to cephalosporins was 2.03, for polymyxin B/colistin 0.51, for tobramycin 2.59 and for ciprofloxacin 2.2. The incidence rates for ICU-acquired resistant microbes per year ranged from 0 to 4.94 per 1000 patient-days, and no significant time-trend in incidence rates were found for any of the antimicrobials. The background prevalence rates of resistant strains measured on admission for cephalosporins, polymyxin B/colistin and ciprofloxacin rose over time with 7.9%, 3.5% and 8.0% respectively. Conclusions During more than 21-year SDD, the incidence rates of resistant microbes at the ICU level did not significantly increase over time but the background resistance rates increased. An overall ecological effect of prolonged application of SDD by counting resistant microorganisms in the ICU was not shown in a country with relatively low rates of resistant microorganisms. Electronic supplementary material The online version of this article (10.1186/s13054-019-2480-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie Buitinck
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.,TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Rogier Jansen
- Department of Medical Microbiology, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Saskia Rijkenberg
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Jos P J Wester
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Rob J Bosman
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Nardo J M van der Meer
- TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.,Department of Intensive Care, Amphia Hospital, Molengracht 21, 4814 CK, Breda, The Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands. .,TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
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Liu WC, Zhan YP, Wang XH, Hou BC, Huang J, Chen SB. Comprehensive preoperative regime of selective gut decontamination in combination with probiotics, and smectite for reducing endotoxemia and cytokine activation during cardiopulmonary bypass: A pilot randomized, controlled trial. Medicine (Baltimore) 2018; 97:e12685. [PMID: 30431563 PMCID: PMC6257461 DOI: 10.1097/md.0000000000012685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Both selective digestive decontamination (SDD) and probiotics have been reported to reduce endotoxemia. However, the available results are conflicting and few studies have investigated the combined effect of SDD and probiotics. This study aimed to examine the effectiveness of a comprehensive preoperative regimen of SDD in combination with probiotics and smectite on perioperative endotoxemia and cytokine activation in patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB) in a pilot, prospective, randomized, controlled trial. METHODS Patients who underwent elective Aortic Valve Replacement or Mitral Valve Replacement surgery from July 2010 to March 2015 were included. In total, 30 eligible patients were randomly assigned to receive either the comprehensive preoperative regimen (n = 15) (a combination of preoperative SDD, probiotics, and smectite) or the control group (n = 15) who did not receive this treatment. The levels of endotoxin, IL-6, and procalcitonin were measured at the time before anesthesia induction, immediately after cardiopulmonary bypass (CPB), 24 hours after CPB, and 48 hours after CPB. The primary outcomes were changes in endotoxin, IL-6, and procalcitonin concentrations after CPB. RESULTS The mean levels of change in endotoxin levels after CPB in patients receiving the comprehensive preoperative regimen was marginally significantly lower than those in control group (F = 4.0, P = .0552) but was not significantly different for procalcitonin (F = .14, P = .7134). An interaction between group and time for IL-6 was identified (F = 4.35, P = .0231). The increase in IL-6 concentration immediately after CPB in the comprehensive preoperative group was significantly lower than that in the control group (P = .0112). The changes in IL-6 concentration at 24 hours and 48 hours after CPB were not significant between the comprehensive preoperative group and control group. CONCLUSION The present pilot, prospective, randomized, controlled study in patients undergoing cardiac surgery with CPB demonstrated that 3 days of a comprehensive preoperative regime of SDD in combination with probiotics and smectite may reduce the endotoxin and IL-6 levels after CPB compared with the control group.
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Hurley JC. Unusually High Incidences of Pseudomonas Bacteremias Within Topical Polymyxin-Based Decolonization Studies of Mechanically Ventilated Patients: Benchmarking the Literature. Open Forum Infect Dis 2018; 5:ofy256. [PMID: 30465011 PMCID: PMC6238150 DOI: 10.1093/ofid/ofy256] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/04/2018] [Indexed: 12/17/2022] Open
Abstract
Background Topical polymyxin (PM)–based regimens to decolonize patients receiving prolonged mechanical ventilation (MV) have been widely studied. However, paradoxical bacteremia incidences remain unexplained. Methods The literature was searched for studies of topical PM–based regimens used to decontaminate MV patients reporting incidences of overall and Pseudomonas bacteremia data. In addition, observational groups without any intervention and trials of various interventions other than topical PM (non-PM studies) served to provide external benchmarks and additional points of reference, respectively. The bacteremia incidences were extracted from the control and intervention (component) groups of these studies and compared with metaregression using generalized estimating equation methods. Results The summary odds ratio derived from studies of topical PM–based interventions against overall bacteremia was 0.60 (95% confidence interval [CI], 0.53–0.69). Benchmark incidences per 100 MV patients for overall (mean, 8.9%; 95% CI, 6.9% to 10.9%) and Pseudomonas (mean, 0.7%; 95% CI, 0.5% to 1.1%) bacteremia were derived from 16 observational studies. By contrast, among 17 studies of topical PM, the mean incidences among control groups for overall (mean, 15.3%; 95% CI, 11.5% to 20.3%) and Pseudomonas (mean, 1.6%; 95% CI, 0.9% to 3.1%) bacteremia were both higher, whereas these incidences in the intervention groups for both topical PM and non-PM studies were in each case more similar to the respective benchmarks. These paradoxical incidences cannot readily be explained in metaregression models. Conclusions Paradoxically, despite an apparent prevention effect of topical PM–based methods against bacteremia overall, the incidences of Pseudomonas bacteremia within the component groups of these studies are unusually high vs literature-derived benchmarks.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Ballarat, Victoria, Australia.,Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Ballarat, Victoria, Australia.,Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
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15
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de Jonge E, de Wilde RBP, Juffermans NP, Oostdijk EAN, Bernards AT, van Essen EHR, Kuijper EJ, Visser CE, Kesecioglu J, Bonten MJM. Carriage of antibiotic-resistant Gram-negative bacteria after discontinuation of selective decontamination of the digestive tract (SDD) or selective oropharyngeal decontamination (SOD). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:243. [PMID: 30268133 PMCID: PMC6162962 DOI: 10.1186/s13054-018-2170-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/27/2018] [Indexed: 12/04/2022]
Abstract
Background Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) reduce colonization with antibiotic-resistant Gram-negative bacteria (ARGNB), incidence of nosocomial infections and improve survival in ICU patients. The effect on bacterial gut colonization might be caused by growth suppression by antibiotics during SDD/SOD. We investigated intestinal colonization with ARGNB after discharge from ICU and discontinuation of SDD or SOD. Methods We performed a prospective, observational follow-up study in regular hospital wards of three teaching hospitals in the Netherlands in patients discharged from the ICU, who were participating in a cluster randomized trial comparing SDD with SOD. We determined rectal carriage with ARGNB at ICU discharge (time (T) = 0) and 3, 6 and 10 days after discharge. The primary endpoint was time to first colonization with ARGNB that was not present at T = 0. Bacteria that are intrinsically resistant to antibiotics were not included in the primary analysis, but were included in post-hoc analysis. Results Of 1370 patients screened for inclusion, 996 patients had samples at T = 0 (507 after SDD and 489 after SOD). At ICU discharge, the prevalence of intestinal carriage with any ARGNB was 22/507 (4.3%) after SDD and 87/489 (17.8%) after SOD (p < 0.0001): 426 (SDD) and 409 (SOD) patients had at least one follow-up sample for analysis. The hazard rate for acquiring carriage of ARGNB after discontinuation of SDD, compared to SOD, in the ICU was 0.61 (95% CI 0.40–0.91, p = 0.02), and cumulative risks of acquisition of at least one ARGNB until day 10 were 13% (SDD) and 18% (SOD). At day 10 after ICU discharge, the prevalence of intestinal carriage with ARGNB was 11.3% (26/230 patients) after SDD and 12.5% (28/224 patients) after SOD (p = 0.7). In post-hoc analysis of all ARGNB, including intrinsically resistant bacteria, colonization at ICU discharge was lower after SDD (4.9 vs. 22.3%, p < 0.0001), but acquisition rates after ICU discharge were similar in both groups. Conclusions Intestinal carriage at ICU discharge and the acquisition rate of ARGNB after ICU discharge are lower after SDD than after SOD. The prevalence of intestinal carriage with ARGNB at 10 days after ICU discharge was comparable in both groups, suggesting rapid clearance of ARGNB from the gut after ICU discharge. Trial registration Netherlands Trial Registry, NTR3311. Registered on 28 february 2012. Electronic supplementary material The online version of this article (10.1186/s13054-018-2170-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E de Jonge
- Department of Intensive Care, Leiden University Medical Center, B4-32, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - R B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, B4-32, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - N P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - E A N Oostdijk
- Department of Medical Microbiology, University Medical Center, Utrecht, The Netherlands
| | - A T Bernards
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E H R van Essen
- Department of Intensive Care, Leiden University Medical Center, B4-32, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - E J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - C E Visser
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
| | - J Kesecioglu
- Department of Intensive Care, University Medical Center, Utrecht, The Netherlands
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Center, Utrecht, The Netherlands
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16
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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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Silvestri L, van Saene HKF, Bion J. Antipathy against SDD is justified: No. Intensive Care Med 2018; 44:1169-1173. [PMID: 29881988 DOI: 10.1007/s00134-018-5144-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/17/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Luciano Silvestri
- Department of Anaesthesia and Intensive Care, St. John of God Hospital, Gorizia, Italy.,Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Julian Bion
- Intensive Care Medicine, University of Birmingham, Birmingham, UK.
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18
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Hurley JC. Paradoxical Acinetobacter-associated ventilator-associated pneumonia incidence rates within prevention studies using respiratory tract applications of topical polymyxin: benchmarking the evidence base. J Hosp Infect 2018; 100:105-113. [PMID: 29649555 DOI: 10.1016/j.jhin.2018.04.005] [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: 02/21/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Regimens containing topical polymyxin appear to be more effective in preventing ventilator-associated pneumonia (VAP) than other methods. AIM To benchmark the incidence rates of Acinetobacter-associated VAP (AAVAP) within component (control and intervention) groups from concurrent controlled studies of polymyxin compared with studies of various VAP prevention methods other than polymyxin (non-polymyxin studies). METHODS An AAVAP benchmark was derived using data from 77 observational groups without any VAP prevention method under study. Data from 41 non-polymyxin studies provided additional points of reference. The benchmarking was undertaken by meta-regression using generalized estimating equation methods. RESULTS Within 20 studies of topical polymyxin, the mean AAVAP was 4.6% [95% confidence interval (CI) 3.0-6.9] and 3.7% (95% CI 2.0-5.3) for control and intervention groups, respectively. In contrast, the AAVAP benchmark was 1.5% (95% CI 1.2-2.0). In the AAVAP meta-regression model, group origin from a trauma intensive care unit (+0.55; +0.16 to +0.94, P = 0.006) or membership of a polymyxin control group (+0.64; +0.21 to +1.31, P = 0.023), but not membership of a polymyxin intervention group (+0.24; -0.37 to +0.84, P = 0.45), were significant positive correlates. CONCLUSIONS The mean incidence of AAVAP within the control groups of studies of topical polymyxin is more than double the benchmark, whereas the incidence rates within the groups of non-polymyxin studies and, paradoxically, polymyxin intervention groups are more similar to the benchmark. These incidence rates, which are paradoxical in the context of an apparent effect against VAP within controlled trials of topical polymyxin-based interventions, force a re-appraisal.
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Affiliation(s)
- J C Hurley
- Rural Health Academic Centre, Melbourne Medical School, University of Melbourne, Victoria, Australia; Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia.
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Selective Digestive Decontamination Attenuates Organ Dysfunction in Critically Ill Burn Patients. Shock 2018; 46:492-497. [PMID: 27755474 DOI: 10.1097/shk.0000000000000664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether selective decontamination of the digestive tract (SDD) attenuates organ dysfunction in critically ill burn patients. BACKGROUND The effect of SDD on the development and progression of organ dysfunction, as an important determinant of mortality in burned patients, is still unknown. We asked whether organ dysfunction is mitigated by treatment with SDD. METHODS Patients with burns >20% of total body surface or suspected inhalation injury from a randomized placebo-controlled trial were analyzed to determine the relationship between treatment received (placebo or SDD) and the severity of organ dysfunction as measured by the area under the curve of the Sequential Organ Failure Assessment (SOFA) score (and its individual components) from day 1 to day 7 of admission. RESULTS One hundred seven patients (53 in the SDD group and 54 in the placebo group) were included. Survival was significantly higher in SDD-treated patients (48 of 53, 90.6%) than in placebo-treated patients (39 of 54, 72.2%, P = 0.013). Total (P < 0.01) and respiratory (P < 0.01), cardiovascular (P = 0.04) and hematological (not reaching statistical significance, P = 0.07) organ dysfunction was associated with mortality after adjusting for predicted mortality. In multivariate logistic regression, SDD treatment was independently associated with total (P < 0.01), respiratory (P = 0.02), and hematological (P < 0.01) dysfunction over the first week postinjury. CONCLUSIONS The beneficial effect of SDD on mortality in critically ill burned patients is accompanied by a reduction in the degree of organ dysfunction. SDD seems to be a valuable therapeutic strategy to prevent organ dysfunction and, more specifically, respiratory and hematological dysfunction in severely ill burn patients.
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Management of multidrug resistant Gram-negative bacilli infections in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2017; 32:36-57. [PMID: 28811074 DOI: 10.1016/j.trre.2017.07.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/02/2017] [Indexed: 12/17/2022]
Abstract
Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate's phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection.
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Hurley JC. Topical antibiotics as a major contextual hazard toward bacteremia within selective digestive decontamination studies: a meta-analysis. BMC Infect Dis 2014; 14:714. [PMID: 25551776 PMCID: PMC4300056 DOI: 10.1186/s12879-014-0714-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/11/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Among methods for preventing pneumonia and possibly also bacteremia in intensive care unit (ICU) patients, Selective Digestive Decontamination (SDD) appears most effective within randomized concurrent controlled trials (RCCT's) although more recent trials have been cluster randomized. However, of the SDD components, whether protocolized parenteral antibiotic prophylaxis (PPAP) is required, and whether the topical antibiotic actually presents a contextual hazard, remain unresolved. The objective here is to compare the bacteremia rates and patterns of isolates in SDD-RCCT's versus the broader evidence base. METHODS Bacteremia incidence proportion data were extracted from component (control and intervention) groups decanted from studies investigating antibiotic (SDD) or non-antibiotic methods of VAP prevention and summarized using random effects meta-analysis of study and group level data. A reference category of groups derived from purely observational studies without any prevention method under study provided a benchmark incidence. RESULTS Within SDD RCCTs, the mean bacteremia incidence among concurrent component groups not exposed to PPAP (27 control; 17.1%; 13.1-22.1% and 12 intervention groups; 16.2%; 9.1-27.3%) is double that of the benchmark bacteremia incidence derived from 39 benchmark groups (8.3; 6.8-10.2%) and also 20 control groups from studies of non-antibiotic methods (7.1%; 4.8 - 10.5). There is a selective increase in coagulase negative staphylococci (CNS) but not in Pseudomonas aeruginosa among bacteremia isolates within control groups of SDD-RCCT's versus benchmark groups with data available. CONCLUSIONS The topical antibiotic component of SDD presents a major contextual hazard toward bacteremia against which the PPAP component partially mitigates.
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22
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Hurley JC. Ventilator-associated pneumonia prevention methods using topical antibiotics: herd protection or herd peril? Chest 2014; 146:890-898. [PMID: 25287997 DOI: 10.1378/chest.13-2926] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) develops in approximately 20% of patients in the ICU receiving prolonged mechanical ventilation (MV). Among the range of methods for preventing VAP, the evidence base for topical antibiotics (TAs), including selective digestive decontamination, appears to be the most compelling. However, several observations are puzzling, and the contextual influence resulting from concurrent use of both topical placebo and TA within an ICU remains untested. As with herd protection conferred by vaccination, contextual influences resulting from a population-based intervention cannot be estimated at the level of a single trial. Estimating contextual effects requires multilevel random-effects methods. In this way the dispersion in VAP incidence across groups from 206 studies, as cited in various-source systematic reviews, was calibrated. The benchmark mean VAP incidence derived from 49 observational groups of patients receiving MV is 23.7% (95% CI, 20.6%-27.2%). In contrast, for 20 and 15 concurrent control groups from the TA evidence base that did vs did not receive topical placebo, respectively, this incidence is 38% (95% CI, 29%-48%) and 33% (95% CI, 20%-50%). This contextual influence remains significant in a meta-regression model adjusted for group-level variables, such as within a trauma ICU context. The mean VAP incidence for five other categories of control groups from the broader evidence base is within four percentage points of the benchmark. The contextual effect of TA is paradoxic, peculiar, potent, perfidious, and potentially perilous. The TA evidence base requires reappraisal to consider this herd peril.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Melbourne; Infection Control Committees, St. John of God Hospital and Ballarat Health Services, and Division of Internal Medicine, Ballarat Health Services, Ballarat, VIC, Australia.
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Price R, MacLennan G, Glen J. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 2014; 348:g2197. [PMID: 24687313 PMCID: PMC3970764 DOI: 10.1136/bmj.g2197] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis. DESIGN Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence. INCLUSION CRITERIA Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo. RESULTS Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain. CONCLUSION Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.
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Affiliation(s)
- Richard Price
- Intensive Care Unit, Royal Alexandra Hospital, Paisley PA2 9PN, UK
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Marshall AP, Weisbrodt L, Rose L, Duncan E, Prior M, Todd L, Wells E, Seppelt I, Cuthbertson B, Francis J. Implementing selective digestive tract decontamination in the intensive care unit: A qualitative analysis of nurse-identified considerations. Heart Lung 2013; 43:13-8. [PMID: 24239299 DOI: 10.1016/j.hrtlng.2013.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 09/05/2013] [Accepted: 09/05/2013] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To describe factors senior critical care nurses identify as being important to address when introducing selective digestive tract decontamination (SDD) in the clinical setting. BACKGROUND Critically ill patients are at risk of developing ventilator-associated pneumonia (VAP). SDD is one strategy shown to prevent VAP and possibly improve survival in the critically ill. METHODS We performed a secondary analysis of qualitative data obtained from 20 interviews. An inductive thematic analysis approach was applied to data obtained from senior critical care nurses during phase two of a multi-methods study. RESULTS There were four primary considerations identified that should be addressed or considered prior to implementation of SDD. These considerations included education of health care professionals, patient comfort, compatibility of SDD with existing practices, and cost. CONCLUSIONS Despite a lack of experience with, or knowledge of SDD, nurses were able to articulate factors that may influence its implementation and delivery. Organizations or researchers considering implementation of SDD should include nurses as key members of the implementation team.
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Affiliation(s)
- Andrea P Marshall
- Centre for Health Practice Innovation, Griffith Health Institute, Griffith University, Parklands Drive, Southport, Queensland 4222, Australia; The Gold Coast University Hospital, 1 Hospital Blvd, Southport, Queensland 4215, Australia.
| | - Leonie Weisbrodt
- Intensive Care Unit, Nepean Hospital, Derby Street, Penrith, NSW 2750, Australia
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Suite 276, Toronto, Ontario M5T 1P8, Canada
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Maria Prior
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Laura Todd
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario M5G 1V7, Canada
| | - Elisabeth Wells
- Centre for the Study of Social and Legal Responses to Violence, University of Guelph, Guelph, Ontario, Canada
| | - Ian Seppelt
- Intensive Care Unit, Nepean Hospital, Derby Street, Penrith, NSW 2750, Australia; Sydney Medical School (Nepean), University of Sydney, Australia; Critical Care and Trauma Division, The George Institute for Global Health, Australia
| | - Brian Cuthbertson
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D128, Toronto, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Jill Francis
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK; School of Health Sciences, City University London, Room C332, Tait Building, Northampton Square, London EC1V0HG, UK
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Houben AJM, Oostdijk EAN, van der Voort PHJ, Monen JCM, Bonten MJM, van der Bij AK, Vlaspolder F, Stuart JWTC, van Hees BC, Vijfhuizen J, Wintermans RGF, der Kuil WAV, Alblas J, van der Bij AK, Frentz D, Leenstra T, Monen JC, Muilwijk J, Notermans DW, de Greeff SC, van Keulen PHJ, Kluytmans JAJW, Mattsson EE, Sebens FW, Frenay HME, Maraha B, Heilmann FGC, Halaby T, Versteeg D, Hendrix R, Schellekens JFP, Diederen BMW, de Brauwer EIGB, Stals FS, Bakker LJ, Dorigo-Zetsma JW, van Zeijl JH, Bernards AT, de Jongh BM, Vlaminckx BJM, Horrevorts A, Kuipers S, Wintermans RGF, Moffie B, Brimicombe RW, Jansen CL, Renders NHM, Hendrickx BGA, Buiting AGM, Kaan JA, Thijsen SFT, Deege MPD, Ekkelenkamp MB, Tjhie HT, van Zwet AA, Voorn GP, Ruijs GJHM, Wolfhagen MJHM. Selective decontamination of the oropharynx and the digestive tract, and antimicrobial resistance: a 4 year ecological study in 38 intensive care units in the Netherlands. J Antimicrob Chemother 2013; 69:797-804. [DOI: 10.1093/jac/dkt416] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Prävention der nosokomialen beatmungsassoziierten Pneumonie. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013. [DOI: 10.1007/s00103-013-1846-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hurley JC. The perfidious effect of topical placebo: calibration of Staphylococcus aureus ventilator-associated pneumonia incidence within selective digestive decontamination studies versus the broader evidence base. Antimicrob Agents Chemother 2013; 57:4524-31. [PMID: 23836178 PMCID: PMC3754294 DOI: 10.1128/aac.00424-13] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 07/02/2013] [Indexed: 11/20/2022] Open
Abstract
Among various methods for preventing ventilator-associated pneumonia (VAP), the evidence base for selective digestive decontamination (SDD) appears most compelling. However, the extent of Staphylococcus aureus emergence with SDD use remains uncertain. Groups from 37 observational studies and component (control and intervention) groups from 58 studies of SDD and other methods of VAP prevention were sourced exclusively from 10 systematic reviews. S. aureus as a proportion of VAP isolates (S. aureus isolate proportion [S. aureus IP]) among component groups was calibrated versus that among observational groups (the benchmark). The influence of topical placebo used for blinding purposes and other group-level factors was estimated using generalized estimating equation methods (GEE). The mean S. aureus IP is 22% (95% confidence interval [CI], 19 to 25) for 37 observational groups versus 32% (24 to 41) and 20% (15 to 25) for 22 control groups from the SDD evidence base which did versus did not receive topical placebo, respectively. In GEE models including all 148 observational and component groups, membership of a control (P = 0.03) or intervention (P < 0.001) group of an SDD study that used topical placebo was associated with higher S. aureus IP, whereas, in contrast, membership of these groups was without effect on Pseudomonas aeruginosa. Topical placebo is implicated as a vehicle for selective cross-infection with S. aureus within the specific context of the SDD evidence base. This effect of topical placebo is perfidious; it could contribute to the higher VAP incidence and inflate the apparent "effectiveness" of SDD. The SDD evidence base requires reappraisal.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Ballarat Health Services, and Infection Control Committees, St John of God Hospital and Ballarat Health Services, Ballarat, Victoria, Australia.
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Oral topical decontamination for preventing ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. J Hosp Infect 2013; 84:283-93. [DOI: 10.1016/j.jhin.2013.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 04/22/2013] [Indexed: 10/26/2022]
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Daneman N, Sarwar S, Fowler RA, Cuthbertson BH. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2013; 13:328-41. [PMID: 23352693 DOI: 10.1016/s1473-3099(12)70322-5] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many meta-analyses have shown reductions in infection rates and mortality associated with the use of selective digestive decontamination (SDD) or selective oropharyngeal decontamination (SOD) in intensive care units (ICUs). These interventions have not been widely implemented because of concerns that their use could lead to the development of antimicrobial resistance in pathogens. We aimed to assess the effect of SDD and SOD on antimicrobial resistance rates in patients in ICUs. METHODS We did a systematic review of the effect of SDD and SOD on the rates of colonisation or infection with antimicrobial-resistant pathogens in patients who were critically ill. We searched for studies using Medline, Embase, and Cochrane databases, with no limits by language, date of publication, study design, or study quality. We included all studies of selective decontamination that involved prophylactic application of topical non-absorbable antimicrobials to the stomach or oropharynx of patients in ICUs, with or without additional systemic antimicrobials. We excluded studies of interventions that used only antiseptic or biocide agents such as chlorhexidine, unless antimicrobials were also included in the regimen. We used the Mantel-Haenszel model with random effects to calculate pooled odds ratios. FINDINGS We analysed 64 unique studies of SDD and SOD in ICUs, of which 47 were randomised controlled trials and 35 included data for the detection of antimicrobial resistance. When comparing data for patients in intervention groups (those who received SDD or SOD) versus data for those in control groups (who received no intervention), we identified no difference in the prevalence of colonisation or infection with Gram-positive antimicrobial-resistant pathogens of interest, including meticillin-resistant Staphylococcus aureus (odds ratio 1·46, 95% CI 0·90-2·37) and vancomycin-resistant enterococci (0·63, 0·39-1·02). Among Gram-negative bacilli, we detected no difference in aminoglycoside-resistance (0·73, 0·51-1·05) or fluoroquinolone-resistance (0·52, 0·16-1·68), but we did detect a reduction in polymyxin-resistant Gram-negative bacilli (0·58, 0·46-0·72) and third-generation cephalosporin-resistant Gram-negative bacilli (0·33, 0·20-0·52) in recipients of selective decontamination compared with those who received no intervention. INTERPRETATION We detected no relation between the use of SDD or SOD and the development of antimicrobial-resistance in pathogens in patients in the ICU, suggesting that the perceived risk of long-term harm related to selective decontamination cannot be justified by available data. However, our study indicates that the effect of decontamination on ICU-level antimicrobial resistance rates is understudied. We recommend that future research includes a non-crossover, cluster randomised controlled trial to assess long-term ICU-level changes in resistance rates. FUNDING None.
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Affiliation(s)
- Nick Daneman
- Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada.
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Abstract
Critically ill patients in intensive care units are subject to many complications associated with therapy. Many of these complications are health care-associated infections and are related to indwelling devices, including ventilator-associated pneumonia, central line-associated bloodstream infection, catheter-associated urinary tract infection; surgical site infection, venous thromboembolism, deep venous thrombosis, and pulmonary embolus are other common complications. All efforts should be undertaken to prevent these complications in surgical critical care, and national efforts are under way for each of these complications. In this article, epidemiology, risk factors, diagnosis, treatment, and prevention of these complications in critically ill patients are discussed.
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Affiliation(s)
- Kathleen B To
- Division of Acute Care Surgery [Trauma, Burns, Surgical Critical Care, Emergency Surgery], Department of Surgery, University of Michigan Health System, Ann Arbor, MI 48109-5033, USA
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Emergence of OXA-48 and OXA-181 carbapenemases among Enterobacteriaceae in South Africa and evidence of in vivo selection of colistin resistance as a consequence of selective decontamination of the gastrointestinal tract. J Clin Microbiol 2012; 51:369-72. [PMID: 23152549 DOI: 10.1128/jcm.02234-12] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This study reports on the emergence of OXA-48-like carbapenemases among isolates of Enterobacteriaceae in South Africa. In addition, the emergence during therapy of a colistin-resistant OXA-181-producing Klebsiella pneumoniae isolate was documented following selective digestive tract decontamination with oral colistin, which is therefore strongly discouraged.
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Silvestri L, de la Cal MA, van Saene HKF. Selective decontamination of the digestive tract: the mechanism of action is control of gut overgrowth. Intensive Care Med 2012; 38:1738-50. [PMID: 23001446 DOI: 10.1007/s00134-012-2690-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/03/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Gut overgrowth is the pathophysiological event in the critically ill requiring intensive care. In relation to the risk of developing a clinically important outcome, gut overgrowth is defined as ≥10(5) potential pathogens including 'abnormal' aerobic Gram-negative bacilli (AGNB), 'normal' bacteria and yeasts, per mL of digestive tract secretion. Surveillance samples of throat and gut are the only samples to detect overgrowth. Gut overgrowth is the crucial event which precedes both primary and secondary endogenous infection, and a risk factor for the development of de novo resistance. Selective decontamination of the digestive tract (SDD) is an antimicrobial prophylaxis designed to control overgrowth. METHODS There have been 65 randomised controlled trials of SDD in 15,000 patients over 25 years and 11 meta-analyses, which are reviewed. RESULTS AND CONCLUSIONS These trials demonstrate that the full SDD regimen using parenteral and enteral antimicrobials reduces lower airway infection by 72 %, blood stream infection by 37 %, and mortality by 29 %. Resistance is also controlled. Parenteral cefotaxime which reaches high salivary and biliary concentrations eradicates overgrowth of 'normal' bacteria such as Staphylococcus aureus in the throat. Enteral polyenes control 'normal' Candida species. Enteral polymyxin and tobramycin, eradicate, or prevent gut overgrowth of 'abnormal' AGNB. Enteral vancomycin controls overgrowth of 'abnormal' methicillin-resistant S. aureus. SDD controls overgrowth by achieving high antimicrobial concentrations effective against 'normal' and 'abnormal' potential pathogens rather than by selectivity.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170, Gorizia, Italy
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Silvestri L, van Saene HKF, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother 2012; 13:1113-29. [PMID: 22533385 DOI: 10.1517/14656566.2012.681778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) has been proposed to prevent endogenous and exogenous infections and to reduce mortality in critically ill patients. Although the efficacy of SDD has been confirmed by randomized controlled trials (RCTs) and systematic reviews, SDD has been the subject of intense controversy, based mainly on an insufficient evidence of efficacy and on concerns about resistance. AREAS COVERED This article reviews the philosophy, the current evidence on the efficacy of SDD and the issue of emergence of resistance. All SDD RCTs were searched using Embase and Medline, with no restriction of language, gender or age. Personal archives were also explored, including abstracts from major scientific meetings; references in papers and published meta-analyses on SDD were crosschecked. Up-to-date evidence of the impact of SDD on carriage, infections and mortality is presented, and the efficacy of SDD in selected patient groups was investigated, along with the problem of the emergence of resistance. EXPERT OPINION SDD significantly reduces the number of infections of the lower respiratory tract and bloodstream, multiple organ failure and mortality. It also controls resistance, particularly when the full protocol of parenteral and enteral antimicrobials is used.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170 Gorizia, Italy.
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Sachdev G, Napolitano LM. Postoperative pulmonary complications: pneumonia and acute respiratory failure. Surg Clin North Am 2012; 92:321-44, ix. [PMID: 22414416 DOI: 10.1016/j.suc.2012.01.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Postoperative pulmonary complications (atelectasis, pneumonia, pulmonary edema, acute respiratory failure) are common, particularly after abdominal and thoracic surgery, pneumonia and atelectasis being the most common. Postoperative pneumonia is associated with increased morbidity, length of hospital stay, and costs. Few institutions have pneumonia prevention programs for surgical patients, and these should be strongly considered. Acute respiratory failure is a life-threatening pulmonary complication that requires institution of mechanical ventilation and admission to the intensive care unit, and is associated with increased risk for ventilator-associated pneumonia. This article discusses epidemiology, risk factors, diagnosis, treatment, and prevention of these pulmonary complications in surgical patients.
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Affiliation(s)
- Gaurav Sachdev
- Division of Acute Care Surgery (Trauma, Burns, Critical Care, Emergency Surgery), Department of Surgery, University of Michigan, Ann Arbor, MI 48109-0033, USA
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Selective digestive decontamination reduces bacteremia following eradication of gut overgrowth. Crit Care Med 2012; 39:2785-6; author reply 2786. [PMID: 22094521 DOI: 10.1097/ccm.0b013e31822d21b8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reed RL. Prevention of Hospital-Acquired Infections by Selective Digestive Decontamination. Surg Infect (Larchmt) 2011; 12:221-9. [DOI: 10.1089/sur.2011.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- R. Lawrence Reed
- Department of Trauma Services, IU Health Methodist Hospital, Indiana University, Indianapolis, Indiana
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Prowle JR, Heenen S, Singer M. Infection in the critically ill--questions we should be asking. J Antimicrob Chemother 2011; 66 Suppl 2:ii3-10. [PMID: 21398305 PMCID: PMC7109642 DOI: 10.1093/jac/dkq517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Best practice in infection control and management in the critically ill continues to generate considerable debate. The wide variation in current practice is witness to this continuing uncertainty. In large part this is due to the lack of a decent evidence base and to an over-reliance on deep-set dogma. Data that go against the grain are often conveniently overlooked and political imperatives frequently supervene. This article highlights some of these discrepancies and argues for a more balanced, scientific approach. In this time of financial restraint, we need to identify true priorities from both health and economic perspectives, and to see what practices can safely and effectively be modified or abandoned.
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Affiliation(s)
- John R. Prowle
- Intensive Care Unit, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK
| | - Sarah Heenen
- Intensive Care Unit, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK
| | - Mervyn Singer
- Intensive Care Unit, University College London Hospitals NHS Foundation Trust, Euston Road, London, UK
- Bloomsbury Institute of Intensive Care Medicine, Department of Medicine, University College London, Gower Street, London WC1E 6BT, UK
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Hurley JC. Lack of impact of selective digestive decontamination on Pseudomonas aeruginosa ventilator-associated pneumonia: benchmarking the evidence base. J Antimicrob Chemother 2011; 66:1365-73. [PMID: 21429939 DOI: 10.1093/jac/dkr112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The selective digestive decontamination (SDD) component antibiotics have activity against Pseudomonas aeruginosa, an important ventilator-associated pneumonia (VAP) isolate. Evaluating the relationship between the anti-pseudomonal activity of SDD towards its VAP prevention effect is complicated by postulated indirect effects of SDD mediated in the concurrent control groups. The objective here is to address these effects through a benchmarking analysis of the evidence base. METHODS Forty-eight observational studies of VAP incidence and 43 interventional studies of SDD and other methods of VAP prevention were sourced from 10 reviews. The P. aeruginosa isolate proportion (P. aeruginosa-IP) data were summarized by meta-analysis using random effects methods. The mode of VAP diagnosis, proportion of trauma admissions and the intervention method under study were examined in meta-regression models as potential group-level predictors of P. aeruginosa-IP. RESULTS The mean P. aeruginosa-IP derived from the observational studies (the benchmark) is 22.3% [95% confidence interval (CI) 19.8%-25.2%] versus 19.6% (95% CI 15.6%-24.4%) and 20.8% (95% CI 14.6%-28.5%) for concurrent control groups and intervention groups of SDD studies, respectively. In the meta-regression models, the proportion of trauma admissions is negatively correlated with P. aeruginosa-IP, whereas membership of neither a concurrent control nor intervention group of an SDD study is negatively correlated. CONCLUSIONS There is no evidence for either direct or indirect effects of SDD on P. aeruginosa-IP that could account for the profound effects of SDD on VAP incidence.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Centre, Melbourne Medical School, University of Melbourne, Ballarat 3350, Victoria, Australia.
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Schultz MJ, Haas LE. Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review. Crit Care 2011; 15:R18. [PMID: 21232110 PMCID: PMC3222052 DOI: 10.1186/cc9963] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 11/08/2010] [Accepted: 01/13/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction Mechanically ventilated critically ill patients frequently develop ventilator-associated pneumonia (VAP), a life-threatening complication. Proposed preventive measures against VAP include, but are not restricted to, selective decontamination of the digestive tract (SDD), selective oropharyngeal decontamination (SOD) and the use of probiotics. Probiotics are live bacteria that could have beneficial effects on the host by altering gastrointestinal flora. Similar to SDD and SOD, a prescription of probiotics aims at the prevention of secondary colonization of the upper and/or lower digestive tract. Methods We performed a literature review to describe the differences and similarities between SDD/SOD and probiotic preventive strategies, focusing on (a) efficacy, (b) risks, and (c) the routing of these strategies. Results Reductions in the incidence of VAP have been achieved with SDD and SOD. Two large randomized controlled trials even showed reduced mortality with these preventive strategies. Randomized controlled trials of probiotic strategies also showed a reduction of the incidence of VAP, but trials were too small to draw firm conclusions. Preventive strategies with antibiotics and probiotics may be limited due to the risk of emerging resistance to the locally applied antibiotics and the risk of probiotic-related infections, respectively. The majority of trials of SDD and SOD did not exhaustively address the issue of emerging resistance. Likewise, trials of probiotic strategies did not adequately address the risk of colonization with probiotics and probiotic-related infection. In studies of SDD and SOD the preventive strategy aimed at decontamination of the oral cavity, throat, stomach and intestines, and the oral cavity and throat, respectively. In the vast majority of studies of probiotic therapy the preventive strategy aimed at decontamination of the stomach and intestines. Conclusions Prophylactic use of antibiotics in critically ill patients is effective in reducing the incidence of VAP. Probiotic strategies deserve consideration in future well-powered trials. Future studies are needed to determine if preventive antibiotic and probiotic strategies are safe with regard to development of antibiotic resistance and probiotic infections. It should be determined whether the efficacy of probiotics improves when these agents are provided to the mouth and the intestines simultaneously.
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Affiliation(s)
- Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Selective decontamination of the digestive tract reduces pneumonia and mortality. Crit Care Res Pract 2010; 2010:501031. [PMID: 20981328 PMCID: PMC2958652 DOI: 10.1155/2010/501031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 09/20/2010] [Indexed: 11/20/2022] Open
Abstract
Selective decontamination of the digestive tract (SDD) has been subject of numerous randomized controlled trials in critically ill patients. Almost all clinical trials showed SDD to prevent pneumonia. Nevertheless, SDD has remained a controversial strategy. One reason for why clinicians remained reluctant to implement SDD into daily practice could be that mortality was reduced in only 2 trials. Another reason could be the heterogeneity of trials of SDD. Indeed, many different prophylactic antimicrobial regimes were tested, and dissimilar diagnostic criteria for pneumonia were applied amongst the trials. This heterogeneity impeded interpretation and comparison of trial results. Two other hampering factors for implementation of SDD have been concerns over the risk of antimicrobial resistance and fear for escalation of costs associated with the use of prophylactic antimicrobials. This paper describes the concept of SDD, summarizes the results of published trials of SDD in mixed medical-surgical intensive care units, and rationalizes the risk of antimicrobial resistance and rise of costs associated with this potentially life-saving preventive strategy.
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Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials. Crit Care Med 2010; 38:1370-6. [PMID: 20308882 DOI: 10.1097/ccm.0b013e3181d9db8c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We examined the impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and meetings proceedings. STUDY SELECTION We included all randomized trials comparing both oropharyngeal and intestinal administration of antibiotics in selective decontamination of the digestive tract with or without a parenteral component, with placebo or standard therapy used in the controls. DATA EXTRACTION Two reviewers independently applied selection criteria, performed quality assessment, and extracted the data. The primary end point was the number of patients with multiple organ dysfunction syndrome developing during intensive care unit stay. Secondary end points were overall mortality and multiple organ dysfunction syndrome-related mortality. Odds ratios were pooled with the random effect model. DATA SYNTHESIS We identified seven randomized trials including 1270 patients. Multiple organ dysfunction syndrome was found in 132 of 637 patients (20.7%) in the selective decontamination of the digestive tract group and in 219 of 633 patients (34.6%) in the control group (odds ratio, 0.50; 95% confidence interval, 0.34-0.74; p < .001). Overall mortality for selective decontamination of the digestive tract vs. control patients was 119 of 637 (18.7%) and 145 of 633 (22.9%), respectively, demonstrating a nonsignificant reduction in the odds of death (odds ratio, 0.82; 95% confidence interval, 0.51-1.32; p = .41). In five studies including 472 patients, multiple organ dysfunction syndrome-related mortality was demonstrated in 31 of 239 (13%) patients in selective decontamination of the digestive tract group and 37 of 233 (15.9%) in the controls (odds ratio, 0.84; 95% confidence interval, 0.48-1.41; p = .54). CONCLUSIONS Selective decontamination of the digestive tract reduces the number of patients with multiple organ dysfunction syndrome. Mortality was not significantly reduced, probably because of the small sample size.
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Silvestri L, van Saene HK, Folla L, Milanese M. Selective digestive decontamination is superior to oropharyngeal chlorhexidine in preventing pneumonia and reducing mortality in critically ill patients. J Bras Pneumol 2010; 36:270-2; author reply 272-3. [DOI: 10.1590/s1806-37132010000200018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Micek ST, Skrupky LP. Current Concepts in the Prevention and Treatment of Ventilator-Associated Pneumonia. J Pharm Pract 2010; 23:25-32. [DOI: 10.1177/0897190009356553] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most common causes of infection in intensive care unit (ICU) patients. Efforts to prevent VAP have focused on both pharmacologic and nonpharmacologic strategies. Two of the more controversial pharmacologic approaches included selective decontamination of the digestive tract (SDD) and decontamination of the oropharynx using topical antimicrobials or antiseptics including chlorhexidine (CHX). Additionally, avoidance of pharmacotherapy-related risk factors is hypothesized to reduce VAP rates. Successful treatment of VAP is becoming increasingly difficult in the era of antibiotic resistance. Utilization of local antibiograms, implementation of standardized treatment pathways, and optimization of pharmacodynamic-based dosing offer methods to improve empiric therapy selections. De-escalation of therapy should be a constant focus in an attempt to reduce overall antibiotic consumption and the selection pressure on ICU flora, thus minimizing the development and spread of antimicrobial resistance in the ICU.
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Affiliation(s)
- Scott T. Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, MO, USA
| | - Lee P. Skrupky
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, MO, USA
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Anderson DJ, Kaye KS. Controlling antimicrobial resistance in the hospital. Infect Dis Clin North Am 2010; 23:847-64, vii-viii. [PMID: 19909887 DOI: 10.1016/j.idc.2009.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most evidence-based methods to control the spread of antimicrobial resistance have been developed and applied to the hospital setting. Strategies to control the emergence and spread of antimicrobial resistance in hospitals can be categorized as either infection control or antibiotic stewardship strategies. Infection control is the discipline focused on preventing the spread of infections within the health care setting; antibiotic stewardship can help minimize the emergence of multidrug-resistant organisms by promoting prudent use of antibiotics. This article describes different infection control and antibiotic management strategies that can be used to control antimicrobial resistance in hospital settings.
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Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M. Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 2010; 340:c241. [PMID: 20156911 PMCID: PMC2822136 DOI: 10.1136/bmj.c241] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the evidence for prophylactic treatment with systemic antibiotics in burns patients. DESIGN Systematic review and meta-analysis of randomised or quasi-randomised controlled trials recruiting burns inpatients that compared antibiotic prophylaxis (systemic, non-absorbable, or topical) with placebo or no treatment. DATA SOURCES PubMed, Cochrane Library, LILACS, Embase, conference proceedings, and bibliographies. No language, date, or publication status restrictions were imposed. Review methods Two reviewers independently extracted data. The primary outcome was all cause mortality. Risk or rate ratios with 95% confidence intervals were pooled with a fixed effect model if no heterogeneity was present. RESULTS 17 trials were included. Trials that assessed systemic antibiotic prophylaxis given for 4-14 days after admission showed a significant reduction in all cause mortality (risk ratio 0.54, 95% confidence interval 0.34 to 0.87, five trials). The corresponding number needed to treat was 8 (5 to 33), with a control event rate of 26%. Perioperative non-absorbable or topical antibiotics alone did not significantly affect mortality. There was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. Staphylococcus aureus infection or colonisation was reduced with anti-staphylococcal antibiotics. In three trials, resistance to the antibiotic used for prophylaxis significantly increased (rate ratio 2.84, 1.38 to 5.83). The overall methodological quality of the trials was poor. CONCLUSIONS Prophylaxis with systemic antibiotics has a beneficial effect in burns patients, but the methodological quality of the data is weak. As such prophylaxis is currently not recommended for patients with severe burns other than perioperatively, there is a need for randomised controlled trials to assess its use.
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Affiliation(s)
- Tomer Avni
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Sackler Faculty of Medicine, Tel-Aviv University, Israel
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Oostdijk EAN, de Smet AMGA, Blok HEM, Thieme Groen ES, van Asselt GJ, Benus RFJ, Bernards SAT, Frénay IHME, Jansz AR, de Jongh BM, Kaan JA, Leverstein-van Hall MA, Mascini EM, Pauw W, Sturm PDJ, Thijsen SFT, Kluytmans JAJW, Bonten MJM. Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am J Respir Crit Care Med 2009; 181:452-7. [PMID: 19965807 DOI: 10.1164/rccm.200908-1210oc] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) eradicate gram-negative bacteria (GNB) from the intestinal and respiratory tract in intensive care unit (ICU) patients, but their effect on antibiotic resistance remains controversial. OBJECTIVES We quantified the effects of SDD and SOD on bacterial ecology in 13 ICUs that participated in a study, in which SDD, SOD, or standard care was used during consecutive periods of 6 months (de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, van der Hoeven JG, Pickkers P, Bogaers-Hofman D, van der Meer NJ, et al. N Engl J Med 2009;360:20-31). METHODS Point prevalence surveys of rectal and respiratory samples were performed once monthly in all ICU patients (receiving or not receiving SOD/SDD). Effects of SDD on rectal, and of SDD/SOD on respiratory tract, carriage of GNB were determined by comparing results from consecutive point prevalence surveys during intervention (6 mo for SDD and 12 mo for SDD/SOD) with consecutive point prevalence data in the pre- and postintervention periods. MEASUREMENTS AND MAIN RESULTS During SDD, average proportions of patients with intestinal colonization with GNB resistant to either ceftazidime, tobramycin, or ciprofloxacin were 5, 7, and 7%, and increased to 15, 13, and 13% postintervention (P < 0.05). During SDD/SOD resistance levels in the respiratory tract were not more than 6% for all three antibiotics but increased gradually (for ceftazidime; P < 0.05 for trend) during intervention and to levels of 10% or more for all three antibiotics postintervention (P < 0.05). CONCLUSIONS SOD and SDD have marked effects on the bacterial ecology in an ICU, with rising ceftazidime resistance prevalence rates in the respiratory tract during intervention and a considerable rebound effect of ceftazidime resistance in the intestinal tract after discontinuation of SDD.
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Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, GA Utrecht, The Netherlands.
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van Saene HKF, Silvestri L, de la Cal MA, Baines P. The emperor's new clothes: the fairy tale continues. J Crit Care 2009; 24:149-52. [PMID: 19272552 DOI: 10.1016/j.jcrc.2008.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
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Evaluation of CHROMagar Acinetobacter for detection of enteric carriage of multidrug-resistant Acinetobacter baumannii in samples from critically ill patients. J Clin Microbiol 2009; 47:2249-51. [PMID: 19439546 DOI: 10.1128/jcm.00634-09] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
CHROMagar Acinetobacter was used to screen stool and perineal swabs for enteric carriage of multidrug-resistant Acinetobacter baumannii in samples from critically ill patients. Results were compared with a molecular assay resulting in sensitivity and specificity of culture compared to PCR of 91.7% and 89.6%, respectively.
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van Saene HKF, Petros AJ, Sarginson RE, Gordon AC, Bion JF. Is Selective Decontamination of the Digestive Tract a Solution to the Antimicrobial Resistance Problem in the UK? J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hendrick KF van Saene
- Consultant/Reader Medical Microbiology, School of Clinical Sciences, University of Liverpool
| | - Andy J Petros
- Consultant Intensivist, Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children
| | - Richard E Sarginson
- Consultant Anaesthetist & Intensive Care Medicine, Intensive Care Unit, Royal Liverpool Children's NHS Trust
| | - Anthony C Gordon
- Consultant and Honorary Senior Lecturer, Critical Care Medicine, Charing Cross Hospital, Imperial College NHS Trust
| | - Julian F Bion
- Professor of Intensive Care Medicine, University Dept Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham
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Silvestri L, van Saene HKF, Weir I, Gullo A. Survival benefit of the full selective digestive decontamination regimen. J Crit Care 2009; 24:474.e7-14. [PMID: 19327325 DOI: 10.1016/j.jcrc.2008.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 10/17/2008] [Accepted: 11/23/2008] [Indexed: 01/15/2023]
Abstract
PURPOSE We assessed the impact of the full protocol of selective decontamination of the digestive tract (SDD) using parenteral and enteral antimicrobials on mortality. MATERIALS AND METHODS A systematic review was performed searching MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and conferences proceedings. We included all randomized controlled trials (RCTs) comparing the full protocol of SDD, including oropharyngeal and intestinal administration of antibiotics combined with the parenteral component, with no treatment or placebo. The primary end points were overall mortality, mortality attributable to infection, early, and late mortality. RESULTS Twenty-one RCTs on 4902 patients were included. Overall mortality was significantly reduced (odds ratio [OR], 0.71; 95% confidence interval [CI]; 0.61-0.82; P < .001). There was a nonsignificant reduction in infection-related mortality (6 RCTs; OR, 0.40; 95% CI, 0.10-1.59; P = .19) and early mortality (4 RCTs; OR, 0.64; 95% CI, 0.34-1.19; P = 0.16), and a significant reduction in late mortality (5 RCTs; OR, 0.56; 95% CI, 0.40-0.77; P < .001). The subgroup analysis showed a significant mortality reduction in successfully decontaminated patients (OR, 0.58; 95% CI, 0.45-0.77; P < .001), and when parenteral and enteral antimicrobials were administered to every patient receiving treatment in the intensive care unit (OR, 0.59; 95% CI, 0.42-0.82; P < .001). CONCLUSIONS The findings strongly indicated that the full protocol of SDD reduces mortality in critically ill patients, in particular when successful decontamination is obtained. Eighteen patients should be treated with SDD to prevent one death.
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Affiliation(s)
- Luciano Silvestri
- Unit of Anesthesia and Intensive Care, Department of Emergency, Presidio Ospedaliero di Gorizia, 34170 Gorizia, Italy.
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