Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance

Catalina Sánchez-Ramírez,María Adela Hernández-Viera,Pedro Saavedra,Nayra Sangil-Monroy,Liliana Caipe-Balcázar,Miriam Cabrera-Santana,Carlos Federico Lübbe-Vázquez,Fernando Artiles-Campelo,Sergio Ruiz-Santana,Silvia Hípola-Escalada

doi:10.1186/s13054-018-2057-2

Abstract

BackgroundWe examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin-, tobramycin-, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB).MethodsIn this cohort study, which was conducted in a 30-bed medical-surgical ICU, clinical outcomes before (1 year, non-SDD group) and after (4 years) implementation of SDD were compared. ICU patients who were expected to require tracheal intubation for > 48 hours were given a standard prophylactic SDD regimen. Oropharyngeal and rectal swabs were obtained on admission and once weekly thereafter.ResultsICU-acquired infections occurred in 110 patients in the non-SDD group and in 258 in the SDD group. A significant (P < 0.001) reduction of infections caused by MDRB (risk ratio [RR], 0.31; 95% CI, 0.23–0.41) was found after SDD and was associated with low rates of colistin- and tobramycin-resistant colonization. Colistin- and tobramycin-acquired increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at admission, was nonsignificant (0.82; 95% CI, 0.56 to 1.95; 1.13; 95% CI, 0.75 to 1.70, respectively). SDD was also a protective factor for ICU-acquired infections caused by MDR gram-negative pathogens and Acinetobacter baumannii in the multivariate analysis. In addition, a significant (P < 0.001) reduction of ventilator-associated pneumonia (VAP) (RR, 0.43; 95% CI, 0.32–0.59) and secondary bloodstream infection (BSI) (RR, 0.35; 95% CI, 0.24–0.52) was found. A decrease in antibiotic consumption was also observed.ConclusionsTreatment with SDD during 4 years was effective in an ICU setting with a high level of resistance, with clinically relevant reductions of infections caused by MDRB, and with low rates of colistin- and tobramycin-resistant colonization with nonsignificant increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at ICU admission. In addition, VAP and secondary BSI rates were significantly lower after SDD. Notably, a decrease in antimicrobial consumption was also observed.

Highlights

We examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin, tobramycin, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB)
We investigated whether long-term use of SDD was efficacious in reducing ICU-acquired MDR-Gram-negative bacilli (GNB) infection and sought to determine its effect, including colistin- and tobramycin-resistant colonization as well as other nosocomial infections and subsequent antibiotic consumption, in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB)
During the 5-year study period, 3948 critically ill patients were admitted to the ICU, and ICU-acquired infection (VAP, central line-associated primary bloodstream infection (CLABSI), secondary bloodstream infection (BSI), urinary tract infection) was diagnosed in 368 of them (7.8%)

Summary

Introduction

We examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin-, tobramycin-, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB). Selective digestive decontamination (SDD) is a prophylactic treatment for critically ill patients that is based on an oropharyngeal paste and enteral suspension containing antimicrobials, usually tobramycin, colistin, and an antifungal as well as an intravenous antibiotic, administered during the first 4 days of intensive care unit (ICU) admission (usually a second-generation cephalosporin). We investigated whether long-term use of SDD was efficacious in reducing ICU-acquired MDR-GNB infection and sought to determine its effect, including colistin- and tobramycin-resistant colonization as well as other nosocomial infections and subsequent antibiotic consumption, in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB)

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