Abstract
BackgroundSelective 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.MethodsWe 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.ResultsOf 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.ConclusionsIntestinal 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 registrationNetherlands Trial Registry, NTR3311. Registered on 28 february 2012.
Highlights
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 Intensive care unit (ICU) patients
Patient characteristics During the study period, 1370 patients were discharged from the ICU to a medical or surgical hospital ward, and rectal swabs had been obtained from 996 patients (507 during SDD and 489 during SOD) at the day of ICU discharge
Resistance prevalence at ICU discharge Rectal colonization with a Gram-negative bacterium resistant to any of the phenotypes investigated at the time of ICU discharge in the three hospitals ranged from 3.4% to 5.2% after SDD and from 10.7% to 30.6% after SOD, yielding pooled estimates of 4.1% and 17.8% after SDD and SOD, respectively (p < 0.0001) (Table 2)
Summary
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. Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic interventions for patients in intensive care units (ICUs). They consist of enteral application of non-absorbable antimicrobial agents, most often amphotericin B, tobramycin and colistin, aiming to eradicate yeasts, Staphylococcus aureus and (facultative) aerobic Gram-negative bacteria. If topical antibiotics in the intestinal tract suppress bacterial growth without eradication or if these antibiotics result in false-negative culture results, rapid emergence of resistant bacteria after discontinuation of SDD, usually after patient discharge from ICU, could be expected
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