Selective digestive decontamination in patients in intensive care

Abstract

Selective digestive decontamination (SDD) is the most extensively studied method for the prevention of infection in patients in intensive care units (ICUs). Despite 27 prospective randomized studies and six meta-analyses, routine use of SDD is still controversial. In this review, we summarize the available scientific information on effectiveness of SDD in ICU patients. The effects of SDD have been studied in different combinations of the concept, using different antibiotics. Comparison of the individual studies, therefore, is difficult. In most studies, SDD resulted in significant reductions in the number of diagnoses of ventilator-associated pneumonia. However, incidences of ventilator-associated pneumonia in control groups ranged from 5% to 85%. Moreover, these reductions in incidences of ventilator-associated pneumonia in individual studies were not associated with improved patient survival, reductions of duration of ventilation or ICU stay, or reductions in antibiotic use. The numbers of patients studied are too small to determine effects on patient survival. Although two meta-analyses suggested a 20% mortality reduction when using the full concept of SDD (topical and systemic prophylaxis) these results should be interpreted with caution. Formal cost-benefit analyses of SDD have not been performed. SDD is associated with the selection of microorganisms that are intrinsically resistant to the antibiotics used. However, the studies are too small and too short to investigate whether SDD will lead to development of antibiotic resistance. As long as the benefits of SDD (better patient survival, reduction in antibiotic use or improved cost-effectiveness) have not been firmly established, the routine use of SDD for mechanically ventilated patients is not advised.

Risk Factors for Ventilator‐Associated Pneumonia: From Epidemiology to Patient Management

“…Unfortunately, antibiotic resistance has become so prevalent in many ICUs that the benefits of prophylactic use of antibiotics for patients could be overcome by the increased selective pressure for antibiotic-resistant pathogens. The latter has been an important argument against the widespread use of such strategies [95,96]. Moreover, the long-term effects of prophylactic antibiotic use on resistance development are unclear.…”

All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth

“…Concerns expressed about resistance have also hindered the implementation of SDD. All analyses of antimicrobial resistance associated with SDD performed by experts [47,86,89,90] are mostly based on case reports and review articles rather than evidence. Practitioners in the United States have apparently resisted routine SDD [86] because of concerns over antimicrobial resistance among both Gram-positive micro-organisms including enterococci [91] and aerobic Gram-negative bacilli such as Acinetobacter baumannii [92] following the publication of just two reports.…”

“…As opinion leaders control the media, SDD has, since its launch, received unfair and unfavourable criticism [47,85,86,89,90,92,95]. For example, SDD has been a regular feature on the programme of the annual Intensive Care meeting in Brussels, Belgium, though since 1984, apart from 2 years in 1988 and 1990, speakers invited to discuss SDD were selected from a group of experts who openly opposed SDD.…”

“…Indeed in 1992, the first European Consensus conference in Paris, France created an environment hostile towards SDD [95]. The SDD concept of combining parenteral with enteral antibiotics was even dismissed as 'non-scientific' by experts [90]. There is a feeling among the 'heretics' that it has always been easier to get a negative SDD trial published in an American peer-reviewed journal than one with a positive outcome.…”

Selective decontamination of the digestive tract: to stimulate or stifle?

“…Potential methodological pitfalls of meta-analyses in general, and of SDD trials in particular, have been reviewed [24].…”