Selective Decontamination Of Digestive Tract Research Articles

Resistance after selective decontamination

1 de Smet AMGA, Kluytmans JAJW, Blok HEM, et al. Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study. Lancet Infect Dis 2011; 11: 372–80. 2 de Smet AMGA, Kluytmans JAJW, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360: 20–31. 3 Dekkers OM. Fall in ICU mortality due to selective decontamination not yet proven. Ned Tijdschr Geneeskd 2009; 153: A491. 4 Oostdijk EAN, de Smet AMGA, Blok HEM, et al. Ecological eff ects of selective decontamination on resistant Gram-negative bacterial colonization. Am J Respir Crit Care Med 2010; 181: 452–57. led to baseline diff erences between groups and might have also biased their recent analysis: diagnostic investigations, such as microbiological cultures, might have been diff erent in patients known to receive SDD. Protocols in the SDD and the control groups diff ered between the various ICUs: endotracheal cultures were obtained on a regular basis between admission and discharge from all patients in the SDD group, but not from all patients on standard therapy. Thus, colonisation with highly resistant microorganisms (HRMO) on admission could not always be excluded in the control group, because of the protocol rule that patients with the same species of HRMO isolated during the fi rst 3 days and after the third day were not classifi ed as having ICU-acquired HRMO. This rule was applied for patients with cefotaximeresistant and tobramycin-resistant Gram-negative bacteria. The lower frequency of culturing during the fi rst 3 days of admission on standard therapy compared with SDD precludes the recognition of colonisation on admission (and hence exclusion as ICU acquired) in the control group, which implies bias in favour of the SDD group. The authors mention that the fi ndings did not diff er in the fi rst 3 days during the control period between the ICUs that took cultures with diff erent frequencies. This was a post-hoc fi nding, based on the diff erences in the protocol in the various ICUs that participated in the same trial; the conclusion of the paper depends on this casuistic fi nding, but there are no data provided for readers. The frequency of colonisation of patients treated with cefotaxime, tobramycin, and colistin, with microorganisms resistant to these same antibiotics, was lower than in untreated patients. This fi nding defi es microbiological experience. The authors do not discuss this singularity even though this fi nding partly contradicts earlier fi ndings in the same trial, which multidrug-resistant cases that might represent a risk of contamination to society remains open.

The age of red blood cells is associated with bacterial infections in critically ill trauma patients.

Blood transfusion increases the risk of nosocomial infection in trauma patients. Specific patient- and transfusion-related risk factors are largely unknown. In this study, risk factors for developing a bacterial infection after transfusion of red blood cells (RBC) or platelets were determined in a cohort of transfused critically ill trauma patients. A retrospective study was conducted in a mixed medical-surgical Intensive Care Unit (ICU) of a level-1 university trauma centre, in trauma patients who received a RBC or platelet transfusion. Patients who developed a bacterial infection after transfusion were compared to transfused controls who did not develop such an infection. Multivariable logistic regression was used to determine risk factors for infection. Of the 7,118 patients admitted to the ICU during the study period, 196 trauma patients met the inclusion criteria. An infection developed in 56 patients (29%). Infection occurred irrespective of the administration of antibiotics as part of selective digestive tract decontamination, surgery status or Injury Severity Score. Transfusion of RBC stored for more than 14 days was associated with infection in trauma patients (odds ratio 1.038, [95% CI: 1.01-1.07], p=0.036). Neither the amount of RBC nor that of platelets was associated with onset of infection. Transfusion of RBC stored for more then 14 days is a risk factor for onset of bacterial infection after trauma, irrespective of the use of prophylactic antibiotics. Transfusion of platelets was not a risk factor. These results may contribute to designing prospective studies on transfusion of fresh RBC only in trauma patients.

Acute renal failure due to tobramycin intoxication during selective digestive tract decontamination

Dear Editor, A 52-year-old man was admitted to the intensive care unit (ICU) with septic shock due to pneumonia. Two months before he had an oesophago-gastrectomy because of carcinoma of the distal part of the oesophagus. The post-operative course was complicated because of ischaemic lesions in the transverse colon and suture dehiscence of the ileotransversostomy. An ileostomy and colostomy were constructed (Fig. 1). Fig. 1 Schematic drawing of patient’s changed anatomy after surgery. Resection of esophagus and stomach, replaced by a colon segment with a Roux-Y reconstruction. After suture dehiscence of the ileotransversostomy the suture was opened, transversectomy ... Apart from antibiotic treatment, he received selective decontamination of the digestive tract (SDD) as described previously by De Smet et al [1]. SDD was administered four times daily as a 2% oral paste, containing amphotericin B, tobramycin and colistin. Four times daily a 10 ml (containing 500 mg amphotericin B, 100 mg colistin, 80 mg tobramycin) suspension was given nasogastrically. Additionally, twice daily a suppository (containing 500 mg amphotericin B, 40 mg tobramycin, 100 mg colistin) was administered in the colostomy of the descending colon. He recovered but because of ICU-acquired weakness he needed prolonged mechanical ventilation. Thirty days after admission he became oliguric and developed renal failure with renal acidosis without further clinical signs of haemodynamic instability. His creatinine level gradually increased from 50 to 263 μmol/l. Physical, laboratory and radiological examination ruled out sepsis, hypovolaemia and post-renal obstruction. Medication-induced nephrotoxicity was suspected. Serum tobramycin level was elevated (18.9 mg/l). SDD was discontinued. After haemodialysis and veno-venous haemofiltration tobramycin levels became undetectable again. However, renal insufficiency persisted and he remained dependent on dialysis. Elevated serum tobramycin levels during SDD have been shown in patients with normal renal function and pre-existent renal insufficiency [2, 3]. Several mechanisms might explain increased serum levels of non-absorbable antimicrobial agents in this patient. First, the integrity of the mucosal barrier might have been compromised by the initial sepsis causing increased permeability for tobramycin [4]. Secondly, our patient was malnourished as a result of chronic illness and frequent periods of retention of enteral feeding. Malnutrition is associated with increased movements of large molecules through the paracellular tight junction in jejunal epithelia [5]. Thirdly, our patient had a blinded jejunal loop which could act as reservoir for tobramycin. The amphotericin B levels were not measured but could also be increased. The nephrotoxic effect of parenteral administration of amphotericin B is well known. No other medication could explain the acute renal failure. This case indicates that patients with altered abdominal anatomy and/or perforations and/or malnutrition might be at risk to develop nephrotoxicity from SDD, especially when SDD is administered via several routes. Besides the current debate about the effects of SDD on antibiotic resistance, no complications of tobramycin-related toxicity are reported in more than 50 randomized controlled trials. Future studies on SDD should also incorporate such safety analyses.

The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia*

Selective digestive tract decontamination aims to eradicate gram-negative bacteria in both the intestinal tract and respiratory tract and is combined with a 4-day course of intravenous cefotaxime. Selective oropharyngeal decontamination only aims to eradicate respiratory tract colonization. In a recent study, selective digestive tract decontamination and selective oropharyngeal decontamination were associated with lower day-28 mortality, when compared to standard care. Furthermore, selective digestive tract decontamination was associated with a lower incidence of intensive care unit-acquired bacteremia caused by gram-negative bacteria. We quantified the role of intestinal tract carriage with gram-negative bacteria and intensive care unit-acquired gram-negative bacteremia. Data from a cluster-randomized and a single-center observational study. Intensive care unit in The Netherlands. Patients with intensive care unit stay of >48 hrs that received selective digestive tract decontamination (n = 2,667), selective oropharyngeal decontamination (n = 2,166) or standard care (n = 1,945). Selective digestive tract decontamination or selective oropharyngeal decontamination. Incidence densities (episodes/1000 days) of intensive care unit-acquired gram-negative bacteremia were 4.5, 3.0, and 1.4 during standard care, selective oropharyngeal decontamination, and selective digestive tract decontamination, respectively, and the daily risk for developing intensive care unit-acquired gram-negative bacteria bacteremia increased until days 36, 33, and 31 for selective digestive tract decontamination, standard care, and selective oropharyngeal decontamination and was always lowest during selective digestive tract decontamination. Rectal colonization with gram-negative bacteria was present in 26% and 71% of patient days during selective digestive tract decontamination and selective oropharyngeal decontamination, respectively (p < .01). Irrespective of interventions, incidence densities of intensive care unit-acquired gram-negative bacteremia was 4.5 during patient days with both intestinal and respiratory tract gram-negative bacteria carriage. These incidence densities reduced with 33% (to 3.1) during days with intestinal gram-negative bacteria carriage only and with another 45% (to 1.0) during days without gram-negative bacteria carriage at both sites. Respiratory tract decolonization was associated with a 33% and intestinal tract decolonization was associated with a 45% reduction in the occurrence of intensive care unit-acquired gram-negative bacteremia.

Selective Digestive Tract Decontamination Decreases Time on Ventilator in Guillain–Barré Syndrome

Ventilator-associated pneumonia (VAP) occurs in more than half of mechanically ventilated patients with Guillain-Barré syndrome (GBS) and is associated with prolonged mechanical ventilation (MV). We investigated the impact of selective decontamination of the digestive tract (SDD), an intervention that reduces hospital acquired infections in ICU patients, on duration of MV in GBS and neurological outcome at 6 months. We performed a retrospective study in mechanically ventilated GBS patients in the Netherlands. We compared patients treated with and without SDD. Main outcomes were duration of MV and the ability to walk independently at 6 months. Statistical comparison was done with logistic and ordinal regression analyses. We included 124 GBS patients on MV at 2 weeks after first symptoms (SDD, n = 54 and non-SDD, n = 70). The median duration of MV without SDD was 42 days (interquartile range, IQR 25-77 days) versus 29 days with SDD (IQR 17-45 days). Median duration of MV for all included patients was 35 days. The adjusted odds ratio (OR) for duration of MV > 35 days in the SDD versus the non-SDD cohort was 0.37 (95% CI 0.17-0.77). SDD did not affect neurological recovery after 6 months from first symptoms. VAP occurred in 12% (95% CI 2-22%) in the SDD cohort and in 47% (95% CI 35-59%) in the non-SDD cohort. SDD in mechanically ventilated GBS patients reduced the time on the ventilator, probably by preventing VAP, but did not affect neurological recovery after 6 months.

Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study

Previously, we assessed selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) on survival and prevention of bacteraemia in patients in intensive-care units. In this analysis, we aimed to assess effectiveness of these interventions for prevention of respiratory tract colonisation and bacteraemia with highly resistant microorganisms acquired in intensive-care units. We did an open-label, clustered group-randomised, crossover study in 13 intensive-care units in the Netherlands between May, 2004, and July, 2006. Participants admitted to intensive-care units with an expected duration of mechanical ventilation of more than 48 h or an expected stay of more than 72 h received SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx), SDD (SOD antibiotics in the oropharynx and stomach plus 4 days' intravenous cefotaxime), or standard care. The computer-randomised order of study regimens was applied by an independent clinical pharmacist who was masked to intensive-care-unit identity. We calculated crude odds ratios (95% CI) for rates of bacteraemia or respiratory tract colonisation with highly resistant microorganisms in patients who stayed in intensive-care units for more than 3 days (ie, acquired infection). This trial is registered at http://isrctn.org, number ISRCTN35176830. Data were available for 5927 (>99%) of 5939 patients, of whom 5463 (92%) were in intensive-care units for more than 3 days. 239 (13%) of 1837 patients in standard care acquired bacteraemia after 3 days, compared with 158 (9%) of 1758 in SOD (odds ratio 0·66, 95% CI 0·53-0·82), and 124 (7%) of 1868 in SDD (0·48, 0·38-0·60). Eight patients acquired bacteraemia with highly resistant microorganisms during SDD, compared with 18 patients (with 19 episodes) during standard care (0·41, 0·18-0·94; rate reduction [RR] 59%, absolute risk reduction [ARR] 0·6%) and 20 during SOD (0·37, 0·16-0·85; RR 63%, ARR 0·7%). Of the patients staying in intensive-care units for more than 3 days, we obtained endotracheal aspirate cultures for 881 (49%) patients receiving standard care, 886 (50%) receiving SOD, and 828 (44%) receiving SDD. 128 (15%) patients acquired respiratory tract colonisation with highly resistant microorganisms during standard care, compared with 74 (8%) during SDD (0·58, 0·43-0·78; RR 38%, ARR 5·5%) and 88 (10%) during SOD (0·65, 0·49-0·87; RR 32%, ARR 4·6%). Acquired respiratory tract colonisation with Gram-negative bacteria or cefotaxime-resistant and colistin-resistant pathogens was lowest during SDD. Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified. None.

Incidence of lower respiratory tract infections in patients treated with post-cardiac arrest mild therapeutic hypothermia and selective digestive tract decontamination

Mild therapeutic hypothermia (MTH) is known to have a neuroprotective effect after cardiac arrest (CA). Among the well-recognized side effects is an increased incidence of infections. A useful strategy in preventing lower respiratory tract infections (LRIs) during MTH is selective digestive tract decontamination (SDD). To this purpose, we examined the use of antibiotics and microbial flora in sputum in post-CA patients treated with MTH and SDD and compared this with the infection rate during MTH that has been reported in literature.

Progress in neonatal ventilator-associated pneumonia

At present,the standard for the diagnosis of ventilator-associated pneumonia(VAP)is imperfect.The risk factors of VAP include body position, medical staffing, invasive procedure and so on. To strengthen the education and management of medical staff, improve the standard of care and breast feeding can reduce the incidence rate of VAP.There are controversial that H2 blockers/sucralfate, selective digestive tract decontamination and topical treatment with skin barrier can reduce the incidence rate of VAP. Common pathogenic bacteria of VAP are Klebsiella pneumoniae,Escherichia coli,Pseudomonas aeruginosa,Baumanii and so on in our country.Compreh-ensive prevention and treatment measures including selection of antibiotics appropriately and generalized supportive therapy should be applied. Key words: Pneuonia; Mechanical ventilation; Neonates; Nosocomial infection

Selective decontamination of the digestive tract: What outcomes matter?*

Selective decontamination of the digestive tract: What outcomes matter?*

Ecological Effects of Selective Decontamination on Resistant Gram-negative Bacterial Colonization

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. 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). 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. 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). 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.

Dirty mouth? Should you clean it out? Decontamination for the prevention of pneumonia and mortality in the ICU

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, Bernards AT, Kuijper EJ, Joore JC, Leverstein-van Hall MA, Bindels AJ, Jansz AR, Wesselink RM, de Jongh BM, Dennesen PJ, van Asselt GJ, te Velde LF, Frenay IH, Kaasjager K, Bosch FH, van Iterson M, Thijsen SF, Kluge GH, Pauw W, de Vries JW, Kaan JA, Arends JP, Aarts LP, Sturm PD, Harinck HI, Voss A, Uijtendaal EV, Blok HE, Thieme Groen ES, Pouw ME, Kalkman CJ, Bonten MJ: Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009, 360:20-31 [1]. Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. Objective: To evaluate the effectiveness of SDD and SOD in intensive care unit (ICU) patients. A controlled, crossover study using cluster randomization. 13 ICUs in the Netherlands between May 2004 and July 2006. 5939 patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Mortality at day 28 was the primary end point. Monthly point-prevalence studies were performed to analyze antibiotic resistance. A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Advances in Critical Care and Emergency Medicine

In 2008, there were clinical trial advances in 3 areas that will impact on the way stroke care is practiced in the emergency department and intensive care unit (ICU). These include (1) the positive results of the European Cooperative Acute Stroke Study (ECASS) III trial, extending the time window for intravenous thrombolytic therapy for acute ischemic stroke; (2) the negative results of 2 trials investigating the use of intensive insulin therapy in the ICU; and (3) new data from the Phase 2 Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT), investigating the role of intensive blood pressure (BP) control after intracerebral hemorrhage (ICH). Intravenous thrombolysis with alteplase is still the only approved treatment for acute ischemic stroke. However, the time window for applying this therapy, which significantly reduces morbidity but not mortality, up to now has been restricted to 3 hours after symptom onset.1 Various stroke trials trying to expand this strict time window, selecting patients based on CT or MRI perfusion, and using thrombolytic agents other than recombinant tissue plasminogen activator (rtPA), have up until now failed to prove efficacy regarding clinical end points.2–5 After a couple of years without any positive stroke trials, ECASS III adds on to the encouraging results of the pooled analyses of the ECASS and National Institute of Neurological Diseases and Stroke trials,6 now expanding the time window for CT-based treatment of acute ischemic stroke up to 4.5 hours.7 The ECASS III trial randomly assigned 821 patients either to receive 0.9 mg rtPA per kilogram body weight or placebo. After ruling out intracranial hemorrhage using CT, thrombolysis was administered between 3 and 4.5 hours (median, 4 hours). The dichotomized primary end point of recovery with no disability after 90 days (modified …

Highlights from the 2008 Surviving Sepsis Campaign: Part 2

Previously, 1 key issues surrounding the 2008 Surviving Sepsis Campaign (SSC) were examined, 2 including evidence-based ratings, initial resuscitation, antimicrobial therapy, vasopressor support, and the role of the pharmaceutical industry in the SSC. In part 2 of this series, the recommendations for corticotherapy, intensive insulin therapy, activated protein C, blood transfusions, and selective digestive tract decontamination are discussed.

Selective Digestive Tract Decontamination: A Tough Pill to Swallow

Nosocomial infections are an important cause of death and excess length of stay in individuals hospitalized in the intensive care unit (ICU) (1). Ventilator-acquired pneumonia is common in this setting, occurring at an estimated incidence of 15 cases per 1000 ventilator-days (2). Notwithstanding the adoption of care guidelines that advocate best practices, such as the use of sterile water for enteral feeds, elevation of the head of the bed and optimal removal of ventilator circuit condensates, ventilator-acquired pneumonia is a frustratingly common occurrence (3). The reasons for this high burden of infectious disease in the intensive care unit extend beyond the obvious mechanical disruption of host defenses by invasive tubes and lines, and likely include the decline in immune function associated with critical illness.

Decontamination of the Digestive Tract and Oropharynx in ICU Patients

Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

Reducing susceptibility to bacteremia after experimental burn injury: a role for selective decontamination of the digestive tract

Reducing susceptibility to bacteremia after experimental burn injury: a role for selective decontamination of the digestive tract

Comment on “Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” by Dellinger et al.

Comment on “Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008” by Dellinger et al.

Selective Digestive-Tract Decontamination in Trauma Patients, Revisited

In 1983, Stoutenbeek and colleagues introduced selective decontamination of the digestive tract (SDD) as a way to prevent infection in intensive care

Selective Digestive Tract Decontamination—Will It Prevent Infection with Multidrug-Resistant Gram-Negative Pathogens but Still Be Applicable in Institutions where Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci Are Endemic?

The purposes of selective decontamination of the digestive tract are to treat infections that may be incubating at the time a patient is admitted to an intensive care unit (ICU), by intravenous administration of antibiotics during the first days of a stay in the ICU, and to prevent ICU-acquired infections, by topical application of antibiotics in the oropharynx and the gastrointestinal tract. Despite multiple trials in which a considerable reduction in the incidence of ventilator-associated pneumonia was demonstrated, major objections against the routine use of selective decontamination of the digestive tract have included a lack of demonstrated reductions in mortality rates and in length of stay (in individual trials), a lack of cost-efficacy data, and the threat of selection of multidrug-resistant bacteria. Recently, 2 controlled, randomized studies reported significant reductions in mortality rates among patients in ICUs who underwent selective decontamination of the digestive tract in combination with reduced selection of antibiotic-resistant pathogens. However, those studies were performed in settings where levels of antibiotic resistance are low, and some methodological issues remain unresolved. If these beneficial results are confirmed, the question of how to balance these benefits against the expected enhanced selection of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and, possibly, multidrug-resistant gram-negative bacteria will emerge.

Which is the most effective method on the selective decontamination of digestive tract in the intoxicated patients?

1Department of Anesthesiology, Clinical Toxicology Unit; 2Department of Microbiology, Uludag University School of Medicine, Bursa, Turkey