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.
Highlights
There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection
For patients staying more than 48 h, the risks of ventilator-associated pneumonia (VAP) [2], bacteremia [3] and candidemia [4] are as high as 25%, 10% and 1%, respectively
Overall, the most effective method appears to be that based on oropharyngeal applications of topical antibiotic prophylaxis (TAP), with or without the additional use of protocolized parenteral antibiotic prophylaxis [31]
Summary
Patients in the ICU are at high risk of acquiring a range of infections during their ICU stay [1]. For patients staying more than 48 h, the risks of ventilator-associated pneumonia (VAP) [2], bacteremia [3] and candidemia [4] are as high as 25%, 10% and 1%, respectively. ICU-acquired infections generally originate from bacteria and candida colonizing the patient’s microbiome This colonizing flora originates from external sources, including the ICU environment itself, and by transmission from the microbiomes of other patients concurrent within the ICU. Antibiotic use, while it might prevent infections in individual patients, will contribute to the disruption of the microbiome within ICU patients and the ICU environment itself. The goal here is to test the presumption of symmetry between the effect of antibiotic prophylaxis at the level of individual patients versus the effect of the same antibiotic prophylaxis at the level of the population among studies as reported in the literature
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