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

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.

What we can do? The risk factors for multi-drug resistant infection in pediatric intensive care unit (PICU): a case-control study

“…The use of antibacterial drugs is a key factor related to bacterial resistance [33,34]. The selective pressure of bacteria comes from the use of antibiotic dose [35].…”

“…There is a close correlation between the amount of antibiotics used and bacterial resistance. ICU has higher pathogen composition ratio and bacterial resistance [34], thus it's necessary to fully grasp the basic information of bacterial epidemiology in ICU, and control the resistance of various drug-resistant bacteria with different antibiotics, to provide basis for MDRI treatment and strategies.…”

Prevention of Intensive Care Unit-Acquired Pneumonia

“…75 And indeed, a few hospitals have reported persistently low rates of antibiotic-resistant organisms sustained for many years after implementing selective digestive decontamination. [76][77][78] Nonetheless, active surveillance for resistant pathogens amongst all ICU patients (not just those receiving digestive or oral decontamination) does suggest that selective decontamination is associated with small but significant and sustained increases in the unit-wide prevalence of antibiotic-resistant organisms. 79,80 Most of the large cluster randomized trials of oral and digestive decontamination were conducted in the Netherlands, a country with low prevalence of resistant organisms and low rates of antibiotic utilization compared with many other countries; commentators therefore worry that the effect of digestive decontamination on resistance rates may be magnified in settings with higher baseline rates of resistant pathogens and antibiotic utilization.…”

Proof-of-concept trial of the combination of lactitol with Bifidobacterium bifidum and Lactobacillus acidophilus for the eradication of intestinal OXA-48-producing Enterobacteriaceae

“…This measure is used as a prophylaxis to prevent intestinal translocations in neutropenic patients, and also for prevention of pneumonia associated with mechanical ventilation in intensive care units. Using these antibiotics might be accompanied by a certain risk of promoting antibiotic resistance, but several studies have found it to be non-significant [4,5].…”