Abstract
BackgroundConceptually, 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.MethodsSeven 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.ResultsIn 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.ConclusionsStructural 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.
Highlights
Of three broad categories of infection prevention in the Intensive care unit (ICU) patient group, selective oral decontamination/selective digestive decontamination (SOD/SDD) shows superior apparent benefit towards overall infection prevention within the ICU context versus anti-septic-based and nondecontamination-based prevention methods [1,2,3,4,5,6,7,8,9].The control of gut overgrowth (COGO) is one mechanism proposed to explain how Selective oral decontamination/selective digestive decontamination (SOD/SDD) regimens might prevent ICU-acquired infection
Topical antibiotic prophylaxis (TAP)-based decontamination regimens appear superior versus other methods at reducing incidences of overall ventilator-associated pneumonia (VAP) and bacteremia infections among ICU patients
Structural equation modeling of published Pseudomonas and Acinetobacter infection data enables a test of the control of gut overgrowth concept in the mediation of TAP-based decontamination
Summary
Of three broad categories of infection prevention in the ICU patient group, selective oral decontamination/selective digestive decontamination (SOD/SDD) shows superior apparent benefit towards overall infection prevention within the ICU context versus anti-septic-based and nondecontamination-based prevention methods [1,2,3,4,5,6,7,8,9].The control of gut overgrowth (COGO) is one mechanism proposed to explain how SOD/SDD regimens might prevent ICU-acquired infection. The exact mechanism for how each of these methods prevents ICU-acquired infection, the basis for the apparent superiority of SOD/SDD among these methods, and even the optimal locus for decontamination, whether the gut or elsewhere, remains unclear despite > 200 studies among patients requiring prolonged mechanical ventilation (MV) or ICU stay [11]. The relative importance of the individual SDD components, topical (TAP), enteral (EAP), and protocolized parenteral antibiotic prophylaxis (PPAP; not contained within SOD regimens), versus other methods of infection prevention and versus other contextual exposures such as length of stay and being in a trauma ICU context remains unclear. 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
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