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These trials demonstrate that the full SDD regimen using parenteral and enteral antimicrobials reduces lower airway infection by 72 %, blood stream infection by 37 %, and mortality by 29 %. Resistance is also controlled. Parenteral cefotaxime which reaches high salivary and biliary concentrations eradicates overgrowth of 'normal' bacteria such as Staphylococcus aureus in the throat. Enteral polyenes control 'normal' Candida species. Enteral polymyxin and tobramycin, eradicate, or prevent gut overgrowth of 'abnormal' AGNB. Enteral vancomycin controls overgrowth of 'abnormal' methicillin-resistant S. aureus. SDD controls overgrowth by achieving high antimicrobial concentrations effective against 'normal' and 'abnormal' potential pathogens rather than by selectivity.

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Antifungals, as part of selective decontamination of the digestive tract, reduce fungal carriage and infection but not fungaemia in critically ill patients and may justify the inclusion of an antifungal component in the decontamination protocol.

This study was undertaken to assess whether oropharyngeal vancomycin may control oropharyngeal carriage and lower airway infection due to methicillinresistant Staphylococcus aureus (MRSA) acquired in the intensive care unit (ICU). Secondary endpoints were the emergence of vancomycin-resistant enterococci, vancomycin-intermediate S. aureus and vancomycin consumption.A total of 84 patients, admitted to a medical/surgical ICU and mechanically ventilated for w72 h, were randomly assigned to control (n=42) or test (n=42) group. Both groups received the protocol of selective decontamination of the digestive tract, including polymyxin E, tobramycin and amphotericin B. Patients in the test group received 0.5 g of a 4% vancomycin gel at 6-h intervals in the oropharynx.Lower Aspiration of contaminated oropharyngeal secretions is the main pathway for the development of lower airway infections in patients requiring mechanical ventilation on the intensive care unit (ICU) [1]. Individuals with an underlying disease are often oropharyngeal carriers of abnormal aerobic Gramnegative bacilli (AGNB) [2] and methicillin-resistant Staphylococcus aureus (MRSA) [3]. Prevention and eradication of the abnormal carrier state can be achieved by the administration of nonabsorbable antimicrobials into the oropharynx, as part of selective decontamination of the digestive tract (SDD) [4].The European Task Force on ventilator-associated pneumonia [5] and the Consensus Conference in Critical Care on ICU-acquired pneumonia [6] acknowledged SDD as an evidence-based manoeuvre that reduces both pneumonia and mortality. These recommendations were based on two metaanalyses of randomised controlled trials [7,8]. Recently, two individual trials of huge sample size confirmed the metaanalytic evidence [9,10]. The SDD strategy, using both parenteral and enteral antibiotics, significantly reduced pneumonia and other lower airway infections, combined with 8% absolute mortality reduction. The impact of SDD was similar in medical and surgical patients. Surveillance cultures are recommended to detect emergence of resistance.Three SDD trials included oropharyngeal vancomycin in order to clear MRSA, which is intrinsically resistant to polymyxin and aminoglycosides, from the oropharyngeal cavity [11][12][13]. However, a separate analysis of the impact of topical vancomycin on MRSA lower airway infections was not performed in any of these studies.A randomised trial was conducted to assess the impact of a 4% vancomycin gel, applied into the oropharynx, on MRSA lower airway infections in patients treated on a medical/ surgical ICU. Secondary endpoints were carriage rates and indices of MRSA in the oropharynx, the emergence of vancomycin-resistant enterococci (VRE), as well as vancomycinintermediate S. aureus (VISA) and vancomycin consumption. Material and methods Study subjectsThis study was conducted over a 1-yr period, in an eightbedded ICU, at a multidisciplinary regional-referral hospital. The ICU is a facility with an annual admission rate of y350 pat...

Selective decontamination of the digestive tract reduces the number of patients with multiple organ dysfunction syndrome. Mortality was not significantly reduced, probably because of the small sample size.