Selective Gut Decontamination Reduces Nosocomial Infections and Length of Stay but Not Mortality or Organ Failure in Surgical Intensive Care Unit Patients

Abstract

Suppression of the gut luminal aerobic flora to reduce nosocomial infections was tested in a prospective, randomized, double-blind, placebo-controlled clinical trial in patients in a surgical intensive care unit who had persistent hypermetabolism. Forty-six patients were randomized to receive either norfloxacin, 500-mg suspension every 8 hours, together with nystatin, 1 million units every 6 hours, or matching placebo solutions administered through a nasogastric tube within 48 hours of surgical intensive care unit admission. Selective gut decontamination with the experimental therapy or placebo solutions continued for at least 5 days or until the time of surgical intensive care unit discharge. Patients were monitored with routine surveillance cultures for the development of nosocomial infections, as defined by criteria from the Centers for Disease Control. All other therapy was given as clinically indicated, including systemic antibiotics. The selective gut decontamination group experienced a significant reduction in the incidence of nosocomial infections and a reduced length of stay. However, these results were not associated with a concomitant decrease in progressive multiple organ failure syndrome, adult respiratory distress syndrome, or mortality.

Prophylaxis with enteral antibiotics in ventilated patients: selective decontamination or selective cross-infection?

“…This was not the case for the SDDtreated groups from the studies with either concurrent or historic controls. Moreover, this was not the case for the control groups of 5 (9,25,32,44,45) of the 12 studies with concurrent controls for which data were available. Interestingly, the patterns of the pathogens in both the treated and the control groups of four of five of these concurrent controlled SDD studies (9,25,32,44) were unusual because of the high degree of identity, with at least 50% of isolates of the two groups being the same for each of these four studies.…”

“…Moreover, this was not the case for the control groups of 5 (9,25,32,44,45) of the 12 studies with concurrent controls for which data were available. Interestingly, the patterns of the pathogens in both the treated and the control groups of four of five of these concurrent controlled SDD studies (9,25,32,44) were unusual because of the high degree of identity, with at least 50% of isolates of the two groups being the same for each of these four studies. For example, at least 50% of respiratory pathogens in both the SDD and the control groups in one study (32) were Staphylococcus aureus or, in another study (9), were either Candida spp.…”

“…Interestingly, the patterns of the pathogens in both the treated and the control groups of four of five of these concurrent controlled SDD studies (9,25,32,44) were unusual because of the high degree of identity, with at least 50% of isolates of the two groups being the same for each of these four studies. For example, at least 50% of respiratory pathogens in both the SDD and the control groups in one study (32) were Staphylococcus aureus or, in another study (9), were either Candida spp. or Staphylococcus epidermidis, three organisms commonly isolated from patients receiving SDD.…”

Selective decontamination of the digestive tract in intensive care

“…Studies to date have not shown a statistically significant effect of SDD on length of ICU stay. However, a reduction of 2-3 days was apparent in several studies [3,31,47,53].…”

Fluoroquinolones are not a blanket cover for gram-negative bacilli

“…[2][3][4] Belgian and Austrian randomized controlled trials 3,4 have demonstrated that the classical selective intestinal decontamination regimen of polymyxin and tobramycin does cover nonfermenting gram-negative bacilli (apart from Enterobacteriaceae). 5 The partial efficacy of selective intestinal decontamination with fluoroquinolones can be explained by the observation that fluoroquinolones eradicate gut overgrowth of Enterobacteriaceae after intestinal excretion via the gut mucosa 6 but not the overgrowth of nonfermenting gram-negative bacilli, which is subsequently followed by polyclonality and resistance.…”