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Hurley J. Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay. Antibiotics (Basel) 2024; 13:316. [PMID: 38666992 PMCID: PMC11047347 DOI: 10.3390/antibiotics13040316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, VIC 3052, Australia;
- Ballarat Health Services, Grampians Health, Ballarat, VIC 3350, Australia
- Ballarat Clinical School, Deakin University, Ballarat, VIC 3350, Australia
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Hurley J. Indirect (herd) effects of topical antibiotic prophylaxis and oral care versus non-antimicrobial methods increase mortality among ICU patients: realigning Cochrane review data to emulate a three-tier cluster randomised trial. BMJ Open 2023; 13:e064256. [PMID: 38035749 PMCID: PMC10689355 DOI: 10.1136/bmjopen-2022-064256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE This study aimed to estimate the direct effects to recipients and indirect (herd) effects to non-recipients of each of topical antibiotic prophylaxis (TAP) and oral care methods on patient mortality within randomised concurrent controlled trials (RCCT) using Cochrane review data. DESIGN Control and intervention groups from 209 RCCTs of TAP (tier 3), oral care (tier 2) each versus non-antimicrobial (tier 1) ventilator-associated pneumonia (VAP) prevention interventions arranged to emulate a three-tiered cluster randomised trial (CRT). Eligible RCCTs were those including ICU patients with >50% of patients receiving >24 hours of mechanical ventilation (MV) with mortality data available as abstracted in 13 Cochrane reviews. EXPOSURES Direct and indirect exposures to either TAP or oral care within RCCTs versus non-antimicrobial VAP prevention interventions. MAIN OUTCOMES AND MEASURES The ICU mortality within control and intervention groups, respectively, within RCCTs of either TAP or oral care versus that within non-antimicrobial VAP prevention RCCTs serving as benchmark. RESULTS The ICU mortality was 23.9%, 23.0% and 20.3% for intervention groups and 28.7%, 25.5% and 19.5% for control groups of RCCTs of TAP (tier 1), oral care (tier 2) and non-antimicrobial (tier 3) methods of VAP prevention, respectively. In a random effects meta-regression including late mortality data and adjusting for group mean age, year of study publication and MV proportion, the direct effect of TAP and oral care versus non-antimicrobial methods were 1.04 (95% CI 0.78 to 1.30) and 1.1 (95% CI 0.77 to 1.43) whereas the indirect effects were 1.39 (95% CI 1.03 to 1.74) and 1.26 (95% CI 0.89 to 1.62), respectively. CONCLUSIONS Indirect (herd) effects from TAP and oral care methods on mortality are stronger than the direct effects as made apparent by the three-tiered CRT. These indirect effects, being harmful to concurrent control groups by increasing mortality, perversely inflate the appearance of benefit within RCCTs.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Internal Medicine Service, Ballarat Health Services, Grampians Health, Ballarat, Victoria, Australia
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Hurley JC. Length of intensive care unit stay and the apparent efficacy of antimicrobial-based versus non-antimicrobial-based ventilator pneumonia prevention interventions within the Cochrane review database. J Hosp Infect 2023; 140:46-53. [PMID: 37544366 DOI: 10.1016/j.jhin.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/17/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND The risk of acquiring ventilator-associated pneumonia (VAP) increases with intensive care unit (ICU) length of stay (LOS). The objectives here are to estimate, using data derived from randomized concurrent control trials (RCCTs) of non-antimicrobial versus antimicrobial interventions, the relation of LOS with firstly, apparent VAP prevention effect, and secondly, with VAP incidence in control and intervention groups. METHODS Control and intervention group data derived from 13 Cochrane reviews of 78 RCCTs of antimicrobial-based interventions versus 111 RCCTs of various non-antimicrobial-based VAP prevention interventions. RESULTS In meta-regression models of VAP prevention effect versus group mean LOS, the effect size of non-antimicrobial-based interventions regress towards the null (+0.028; +0.002 to +0.054) whereas antimicrobial-based interventions regress away from the null (-0.043; -0.08 to -0.004). The day 9-10 VAP incidence increase is 1.28 (0.97-1.6) percentage points among the control groups of antimicrobial interventions per day. By contrast, these increases among antimicrobial- (0.45; 0.19-0.71) and non-antimicrobial- (0.58; 0.29-0.87) intervention groups and in control groups of non-antimicrobial- (0.76; 0.46-1.05) interventions are all similar. CONCLUSIONS Antimicrobial-based versus non-antimicrobial-based interventions show overall greater apparent VAP prevention which is most apparent with longer group mean LOS. The basis for this surprising relationship with LOS resides, paradoxically, within the control rather than the intervention groups. This discrepancy implicates indirect (spill-over) effects, inapparent within individual antimicrobial-based RCCTs, which could spuriously conflate the appearance of VAP prevention.
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Affiliation(s)
- J C Hurley
- Melbourne Medical School, Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Internal Medicine Service, Ballarat Health Services, Ballarat, Vic, Australia.
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Hurley JC. Establishing the safety of selective digestive decontamination within the ICU population: a bridge too far? Trials 2023; 24:337. [PMID: 37198636 DOI: 10.1186/s13063-023-07356-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Infection prevention interventions within the intensive care unit (ICU) setting, whether studied within quality improvement projects or cluster randomized trials (CRT), are seen as low risk and grounded in an ethical imperative. Selective digestive decontamination (SDD) appears highly effective at preventing ICU infections within randomized concurrent control trials (RCCTs) prompting mega-CRTs with mortality as the primary endpoint. FINDINGS Surprisingly, the summary results of RCCTs versus CRTs differ strikingly, being respectively, a 15-percentage-point versus a zero-percentage-point ICU mortality difference between control versus SDD intervention groups. Multiple other discrepancies are equally puzzling and contrary to both prior expectations and the experience within population-based studies of infection prevention interventions using vaccines. Could spillover effects from SDD conflate the RCCT control group event rate differences and represent population harm? Evidence that SDD is fundamentally safe to concurrent non-recipients in ICU populations is absent. A postulated CRT to realize this, the SDD Herd Effects Estimation Trial (SHEET), would require > 100 ICUs to achieve sufficient statistical power to find a two-percentage-point mortality spillover effect. Moreover, as a potentially harmful population-based intervention, SHEET would pose novel and insurmountable ethical issues including who is the research subject; whether informed consent is required and from whom; whether there is equipoise; the benefit versus the risk; considerations of vulnerable groups; and who should be the gatekeeper? CONCLUSION The basis for the mortality difference between control and intervention groups of SDD studies remains unclear. Several paradoxical results are consistent with a spillover effect that would conflate the inference of benefit originating from RCCTs. Moreover, this spillover effect would constitute to herd peril.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Division of Internal Medicine, Grampians Health Services, Ballarat, VIC, Australia.
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Hurley JC. Selective digestive decontamination, a seemingly effective regimen with individual benefit or a flawed concept with population harm? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:323. [PMID: 34470654 PMCID: PMC8408564 DOI: 10.1186/s13054-021-03744-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Abstract
Selective digestive decontamination (SDD) regimens, variously constituted with topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP), appear highly effective for preventing ICU-acquired infections but only within randomized concurrent control trials (RCCT's). Confusingly, SDD is also a concept which, if true, implies population benefit. The SDD concept can finally be reified in humans using the broad accumulated evidence base, including studies of TAP and PPAP that used non-concurrent controls (NCC), as a natural experiment. However, this test implicates overall population harm with higher event rates associated with SDD use within the ICU context.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia. .,Division of Internal Medicine, Ballarat Health Services, PO Box 577, Ballarat, VIC, 3353, Australia.
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Bernts LHP, Dekker SEI, Soonawala D, Brüggemann RJM, Wertheim HFL, de Fijter JW, Drenth JPH, Lantinga MA. Efficacy and safety of selective decontamination of the digestive tract (SDD) to prevent recurrent hepatic cyst infections in polycystic liver disease: a retrospective case series. J Antimicrob Chemother 2021; 75:2666-2669. [PMID: 32437580 PMCID: PMC7443730 DOI: 10.1093/jac/dkaa186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/03/2020] [Accepted: 04/15/2020] [Indexed: 12/27/2022] Open
Abstract
Background Hepatic cyst infection is a complication of polycystic liver disease (PLD) that causes substantial morbidity. Repetitive infection is frequent and is increasingly difficult to treat. As translocated gut bacteria are considered the cause, we hypothesize that selective decontamination of the digestive tract (SDD) reduces recurrence of hepatic cyst infection. Methods We performed a retrospective, observational study in two referral centres. All patients with PLD treated with SDD for hepatic cyst infection were included. Efficacy was determined by calculating the infection incidence (hepatic cyst infections per month) before and during SDD therapy. Adverse events were scored according to the Common Terminology Criteria for Adverse Events (CTCAE). Results We identified eight patients who received SDD (88% female, 88% polycystic kidney disease). The median age was 65 years (IQR: 51–74 years). SDD lowered the median incidence from 0.09 episodes per month (IQR: 0.06–0.25 episodes per month) to 0.01 episodes per month (IQR: 0.00–0.05 episodes per month) (P = 0.12). Discontinuation of SDD led to rapid recurrence of cyst infection (71% within 6 weeks). SDD consisted of polymyxins with/without aminoglycosides. The median SDD treatment duration was 20 months (range: 3–89 months). Six patients (75%) developed adverse events [CTCAE Grade 1 (gastrointestinal: n = 3) or Grade 3 (ototoxicity: n = 1; fungal infection: n = 1)], mostly attributable to aminoglycosides; one patient developed polymyxin E resistance. Conclusions SDD prophylaxis provides a novel strategy for limiting recurrent hepatic cyst infection in PLD patients. However, adverse events are frequent and curtail its use. As most were attributable to aminoglycosides, polymyxin E is considered the preferred therapy.
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Affiliation(s)
- Lucas H P Bernts
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Shosha E I Dekker
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Darius Soonawala
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Heiman F L Wertheim
- Department of Medical Microbiology and Radboudumc Center for Infectious Diseases, Radboudumc, Nijmegen, The Netherlands
| | - Johan W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Marten A Lantinga
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboudumc, Nijmegen, The Netherlands
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Abstract
Antibiotic resistance is a major global health challenge and, worryingly, several key Gram negative pathogens can become resistant to most currently available antibiotics. Polymyxins have been revived as a last-line therapeutic option for the treatment of infections caused by multidrug-resistant Gram negative bacteria, in particular Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacterales. Polymyxins were first discovered in the late 1940s but were abandoned soon after their approval in the late 1950s as a result of toxicities (e.g., nephrotoxicity) and the availability of "safer" antibiotics approved at that time. Therefore, knowledge on polymyxins had been scarce until recently, when enormous efforts have been made by several research teams around the world to elucidate the chemical, microbiological, pharmacokinetic/pharmacodynamic, and toxicological properties of polymyxins. One of the major achievements is the development of the first scientifically based dosage regimens for colistin that are crucial to ensure its safe and effective use in patients. Although the guideline has not been developed for polymyxin B, a large clinical trial is currently being conducted to optimize its clinical use. Importantly, several novel, safer polymyxin-like lipopeptides are developed to overcome the nephrotoxicity, poor efficacy against pulmonary infections, and narrow therapeutic windows of the currently used polymyxin B and colistin. This review discusses the latest achievements on polymyxins and highlights the major challenges ahead in optimizing their clinical use and discovering new-generation polymyxins. To save lives from the deadly infections caused by Gram negative "superbugs," every effort must be made to improve the clinical utility of the last-line polymyxins. SIGNIFICANCE STATEMENT: Antimicrobial resistance poses a significant threat to global health. The increasing prevalence of multidrug-resistant (MDR) bacterial infections has been highlighted by leading global health organizations and authorities. Polymyxins are a last-line defense against difficult-to-treat MDR Gram negative pathogens. Unfortunately, the pharmacological information on polymyxins was very limited until recently. This review provides a comprehensive overview on the major achievements and challenges in polymyxin pharmacology and clinical use and how the recent findings have been employed to improve clinical practice worldwide.
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Affiliation(s)
- Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Mohammad A K Azad
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Tony Velkov
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Qi Tony Zhou
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
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Hurley JC. Structural equation modeling the "control of gut overgrowth" in the prevention of ICU-acquired Gram-negative infection. Crit Care 2020; 24:189. [PMID: 32366267 PMCID: PMC7199305 DOI: 10.1186/s13054-020-02906-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conceptually, the "control of gut overgrowth" (COGO) is key in mediating prevention against infection with Gram-negative bacilli by topical antibiotic prophylaxis, a common constituent of selective digestive decontamination (SDD) regimens. However, the relative importance of the other SDD components, enteral and protocolized parenteral antibiotic prophylaxis, versus other methods of infection prevention and versus other contextual exposures cannot be resolved within individual studies. METHODS Seven candidate generalized structural equation models founded on COGO concepts were confronted with Pseudomonas and Acinetobacter bacteremia as well as ventilator-associated pneumonia data derived from > 200 infection prevention studies. The following group-level exposures were included in the models: use and mode of antibiotic prophylaxis, anti-septic and non-decontamination methods of infection prevention; proportion receiving mechanical ventilation; trauma ICU; mean length of ICU stay; and concurrency versus non-concurrency of topical antibiotic prophylaxis study control groups. RESULTS In modeling Pseudomonas and Acinetobacter gut overgrowth as latent variables, anti-septic interventions had the strongest negative effect against Pseudomonas gut overgrowth but no intervention was significantly negative against Acinetobacter gut overgrowth. Strikingly, protocolized parenteral antibiotic prophylaxis and concurrency each have positive effects in the model, enteral antibiotic prophylaxis is neutral, and Acinetobacter bacteremia incidences are high within topical antibiotic prophylaxis studies, moreso with protocolized parenteral antibiotic prophylaxis exposure. Paradoxically, topical antibiotic prophylaxis (moreso with protocolized parenteral antibiotic prophylaxis) appears to provide the strongest summary prevention effects against overall bacteremia and overall VAP. CONCLUSIONS Structural equation modeling of published Gram-negative bacillus infection data enables a test of the COGO concept. Paradoxically, Acinetobacter and Pseudomonas bacteremia incidences are unusually high among studies of topical antibiotic prophylaxis.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Internal Medicine Service, Ballarat Health Services, PO Box 577, Ballarat, Victoria, 3353, Australia.
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Buelow E, Bello González TDJ, Fuentes S, de Steenhuijsen Piters WAA, Lahti L, Bayjanov JR, Majoor EAM, Braat JC, van Mourik MSM, Oostdijk EAN, Willems RJL, Bonten MJM, van Passel MWJ, Smidt H, van Schaik W. Comparative gut microbiota and resistome profiling of intensive care patients receiving selective digestive tract decontamination and healthy subjects. MICROBIOME 2017; 5:88. [PMID: 28803549 PMCID: PMC5554972 DOI: 10.1186/s40168-017-0309-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 07/13/2017] [Indexed: 05/13/2023]
Abstract
BACKGROUND The gut microbiota is a reservoir of opportunistic pathogens that can cause life-threatening infections in critically ill patients during their stay in an intensive care unit (ICU). To suppress gut colonization with opportunistic pathogens, a prophylactic antibiotic regimen, termed "selective decontamination of the digestive tract" (SDD), is used in some countries where it improves clinical outcome in ICU patients. Yet, the impact of ICU hospitalization and SDD on the gut microbiota remains largely unknown. Here, we characterize the composition of the gut microbiota and its antimicrobial resistance genes ("the resistome") of ICU patients during SDD and of healthy subjects. RESULTS From ten patients that were acutely admitted to the ICU, 30 fecal samples were collected during ICU stay. Additionally, feces were collected from five of these patients after transfer to a medium-care ward and cessation of SDD. Feces from ten healthy subjects were collected twice, with a 1-year interval. Gut microbiota and resistome composition were determined using 16S rRNA gene phylogenetic profiling and nanolitre-scale quantitative PCRs. The microbiota of the ICU patients differed from the microbiota of healthy subjects and was characterized by lower microbial diversity, decreased levels of Escherichia coli and of anaerobic Gram-positive, butyrate-producing bacteria of the Clostridium clusters IV and XIVa, and an increased abundance of Bacteroidetes and enterococci. Four resistance genes (aac(6')-Ii, ermC, qacA, tetQ), providing resistance to aminoglycosides, macrolides, disinfectants, and tetracyclines, respectively, were significantly more abundant among ICU patients than in healthy subjects, while a chloramphenicol resistance gene (catA) and a tetracycline resistance gene (tetW) were more abundant in healthy subjects. CONCLUSIONS The gut microbiota of SDD-treated ICU patients deviated strongly from the gut microbiota of healthy subjects. The negative effects on the resistome were limited to selection for four resistance genes. While it was not possible to disentangle the effects of SDD from confounding variables in the patient cohort, our data suggest that the risks associated with ICU hospitalization and SDD on selection for antibiotic resistance are limited. However, we found evidence indicating that recolonization of the gut by antibiotic-resistant bacteria may occur upon ICU discharge and cessation of SDD.
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Affiliation(s)
- Elena Buelow
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Université Limoges, INSERM, CHU Limoges, UMR 1092, Limoges, France
| | | | - Susana Fuentes
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
- Center for Immunology of Infectious Diseases and Vaccines, Bilthoven, The Netherlands
| | - Wouter A A de Steenhuijsen Piters
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatric Immunology and Infectious Diseases, The Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo Lahti
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
- Department of Mathematics and Statistics, University of Turku, Turku, Finland
| | - Jumamurat R Bayjanov
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eline A M Majoor
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna C Braat
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maaike S M van Mourik
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob J L Willems
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark W J van Passel
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
- Center of Infectious Disease Control, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Willem van Schaik
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
- Institute of Microbiology and Infection, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
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Selective decontamination of the digestive tract and oropharynx: after 30 years of debate is the definitive answer in sight? Curr Opin Crit Care 2016; 22:161-6. [PMID: 26766392 DOI: 10.1097/mcc.0000000000000281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Selective digestive or oropharyngeal decontamination has been being used as a means to prevent infections and death in intensive care patients for the past 30 years. It remains controversial and its use is limited. In this review, we summarize the recently published data on efficacy of selective decontamination and effects on antibiotic resistances. RECENT FINDINGS The most recent meta-analysis shows a reduced mortality when selective digestive or oropharyngeal decontamination are compared with either standard care or oropharyngeal chlorhexidine. Selective decontamination is associated with reduced bacteraemia, and although this effect is greater with selective digestive decontamination compared with selective oropharyngeal decontamination, there is not a mortality difference between these two interventions. Reanalysis of infection data suggests, however, that selective decontamination may also have effects on concurrent control groups. Current evidence generally shows that antibiotic resistance is decreased although much of these data come from the Netherlands (an area with low endemic antibiotic resistance rates). There are currently two huge cluster randomized clinical trials, one in early recruitment, one in development, which will hopefully provide definitive answers in the years to come. SUMMARY Current evidence suggests that selective decontamination reduces mortality without increasing antibiotic resistances; this will be tested again in two huge international trials.
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Niederman MS. New Strategies to Prevent Ventilator-Associated Pneumonia: What to Do for Your Patients. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2016. [DOI: 10.1007/s40506-016-0067-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kesecioglu J, Eggimann P. What is new in selective decontamination of the digestive tract? Intensive Care Med 2015; 42:1270-5. [PMID: 26280933 PMCID: PMC4930457 DOI: 10.1007/s00134-015-4009-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/26/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Philippe Eggimann
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Abstract
PURPOSE OF REVIEW This review explores the usefulness of surveillance cultures in healthcare-associated pneumonia (HCAP). RECENT FINDINGS The definition of HCAP is controversial. Causative micro-organisms of HCAP resemble those found in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Some types of surveillance cultures have proven useful in hospitalized patients. Whereas numerous studies have investigated the role of surveillance cultures in VAP, one may wonder whether surveillance culture implementation should belong in HCAP management guidelines. SUMMARY Studies exploring the usefulness of obtaining surveillance cultures in VAP are numerous, but are mostly retrospective, observational and/or quasi-experimental in nature. Surveillance cultures may be useful for antibiotic guidance, but positive predictive value and specificity of surveillance cultures are low, obviously negatively impacting on cost effectiveness, especially in the large population at risk for HCAP. On the other hand, multidrug-resistance is increasing and surveillance cultures for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci in ICU-admitted patients appeared useful and cost-effective. Furthermore, surveillance cultures for the presence of multidrug-resistant Gram-negative bacilli might be useful for antibiotic guidance. Currently, neither community-acquired pneumonia, HCAP, HAP nor VAP guidelines incorporate surveillance cultures. In the future, surveillance cultures in populations at risk for HCAP may be able to differentiate HCAP from other kinds of pneumonia and authorize its reason for existence.
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Ramírez P, Gordón M. Microbiota intestinal en el paciente crítico. Una aproximación positiva mediante el aporte de simbióticos. Med Clin (Barc) 2014; 143:161-2. [DOI: 10.1016/j.medcli.2013.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 12/11/2013] [Accepted: 12/16/2013] [Indexed: 01/28/2023]
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Qu X, Xie H, Zhang Q, Zhou X, Shi Z. A survey on oral care practices for ventilator-assisted patients in intensive care units in 3A hospitals of mainland China. Int J Nurs Pract 2014; 21:699-708. [PMID: 24689526 DOI: 10.1111/ijn.12282] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Oral hygiene is a critical element of patient care, particularly among patients who need ventilator-assisted equipment. The objective of this study was to explore the current status of oral care practices, attitudes, education and knowledge among intensive care unit (ICU) nurses caring for ventilator-assisted patients in 3A hospitals in mainland China. To achieve this aim, an 18-item self-assessment questionnaire was mailed to head ICU nurses in 189 Grade 3A hospitals. Additional data were collected through in-person interviews at 38 ICUs throughout Sichuan, Shanxi, Jiangsu provinces, as well as Chongqing and Beijing. We found that most ICUs conducted oral examinations at patient admission, and that this care was largely provided by nurses. The most common oral care methods were foam swabs and mouth rinse containing antibiotics or disinfectants. Although the majority of ICUs provided continuing training for oral care, and most training was conducted by head nurses, the content and scope of training were not consistent among the hospitals in the study. The most popular sources of oral care knowledge were academic journals, Internet and professional books. Overall, it is clear that an evidence-based oral care standard manual is urgently needed for oral practice in ICUs in mainland China.
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Affiliation(s)
- Xing Qu
- Hospital Management Department, School of Business, Sichuan University, Chengdu, Sichuan, China.,West China Hospital of Stomatology, Chengdu, Sichuan, China
| | - Huixu Xie
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Xuedong Zhou
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Zongdao Shi
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
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Philippart F, Max A, Couzigou C, Misset B. Reanimación y prevención de las infecciones nosocomiales. EMC - ANESTESIA-REANIMACIÓN 2013. [PMCID: PMC7147915 DOI: 10.1016/s1280-4703(12)63970-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Los servicios de reanimación deben organizar de forma minuciosa la prevención de infecciones en sus enfermos, ya que éstos suelen estar inmunodeprimidos, están sometidos a múltiples procedimientos invasivos realizados por un personal sanitario variado, a menudo en situaciones de urgencia y a cualquier hora del día o de la noche. Las principales infecciones que hay que tratar de prevenir son las neumonías bacterianas adquiridas asociadas a ventilación mecánica (NAVM), las infecciones relacionadas con catéteres intravasculares y las infecciones urinarias asociadas al sondeo vesical. La incidencia de estas infecciones ha disminuido en la mayoría de los servicios que realizan un control cifrado, sobre todo gracias a la implantación de programas de mejora de la calidad. Las técnicas de prevención son múltiples y deben aplicarse simultáneamente. Incluyen medidas globales, como las modalidades de prevención de la transmisión cruzada (higiene de las manos, sobre todo) o de uso de antibióticos, concebidas para reducir la presión de selección de bacterias resistentes a éstos, así como medidas específicas relativas a la colocación y uso de cada uno de los dispositivos invasivos. Numerosas técnicas han demostrado su eficacia en estudios de buen nivel metodológico (higiene de las manos, apósitos para catéteres, etc.), mientras que otras siguen siendo objeto de controversias, por lo que las recomendaciones nacionales e internacionales se actualizan regularmente de acuerdo con los nuevos datos científicos. Estas medidas, implantadas de manera razonada en el marco de programas de mejora de la calidad, permiten obtener tasas muy bajas de infecciones relacionadas con el uso de catéteres vasculares y resultados menos satisfactorios con las NAVM, que justifican la necesidad de proseguir la investigación en este campo.
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Affiliation(s)
- F. Philippart
- Service de réanimation, Groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
- Université Paris Descartes, 12, rue de l’École-de-Médecine, 75270 Paris cedex 06, France
- Unité cytokines et inflammation, Institut Pasteur, 25-28, rue du Docteur-Roux, 75015 Paris, France
| | - A. Max
- Service de réanimation, Groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - C. Couzigou
- Unité d’hygiène, Groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - B. Misset
- Université Paris Descartes, 12, rue de l’École-de-Médecine, 75270 Paris cedex 06, France
- Chef du service de réanimation, Groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
- Auteur correspondant.
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Rianimazione e prevenzione delle infezioni nosocomiali. EMC - ANESTESIA-RIANIMAZIONE 2013. [PMCID: PMC7148748 DOI: 10.1016/s1283-0771(12)63945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
I servizi di rianimazione devono organizzare la prevenzione delle infezioni nei loro pazienti in modo minuzioso, in quanto i pazienti sono spesso immunodepressi e subiscono gesti invasivi molteplici, realizzati da personale differente, spesso in situazioni di urgenza e a qualsiasi ora del giorno o della notte. Le principali infezioni che bisogna tentare di prevenire sono le polmoniti batteriche acquisite sotto ventilazione meccanica (PAVM), le infezioni su cateteri intravascolari e le infezioni urinarie su catetere vescicale. L’incidenza di queste infezioni è diminuita nella maggior parte dei servizi che ne effettuano un monitoraggio su base numerica, in particolare nel quadro di programmi di miglioramento della qualità. Le tecniche di prevenzione sono molteplici e devono essere applicate simultaneamente. Esse riguardano delle misure globali, come le modalità di prevenzione della trasmissione crociata (igiene delle mani, in particolare) o di utilizzo degli antibiotici nella prospettiva di ridurre la pressione di selezione di batteri resistenti agli antibiotici, così come delle misure specifiche relative al posizionamento e all’utilizzo di ciascuno dei dispositivi invasivi. Numerose tecniche si sono dimostrate efficaci in studi di buon livello metodologico (igiene delle mani, medicazioni dei cateteri, ecc.) mentre altre sono ancora oggetto di controversie, portando a raccomandazioni nazionali e internazionali regolarmente aggiornate in funzione dei nuovi dati scientifici. Queste misure, implementate in modo ragionato nel quadro di programmi di miglioramento della qualità, consentono di ottenere dei tassi molto bassi per quanto riguarda le infezioni dei cateteri vascolari e dei risultati meno buoni per le PAVM, illustrando la necessità di proseguire la ricerca in questo settore.
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Daneman N, Sarwar S, Fowler RA, Cuthbertson BH. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2013; 13:328-41. [PMID: 23352693 DOI: 10.1016/s1473-3099(12)70322-5] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many meta-analyses have shown reductions in infection rates and mortality associated with the use of selective digestive decontamination (SDD) or selective oropharyngeal decontamination (SOD) in intensive care units (ICUs). These interventions have not been widely implemented because of concerns that their use could lead to the development of antimicrobial resistance in pathogens. We aimed to assess the effect of SDD and SOD on antimicrobial resistance rates in patients in ICUs. METHODS We did a systematic review of the effect of SDD and SOD on the rates of colonisation or infection with antimicrobial-resistant pathogens in patients who were critically ill. We searched for studies using Medline, Embase, and Cochrane databases, with no limits by language, date of publication, study design, or study quality. We included all studies of selective decontamination that involved prophylactic application of topical non-absorbable antimicrobials to the stomach or oropharynx of patients in ICUs, with or without additional systemic antimicrobials. We excluded studies of interventions that used only antiseptic or biocide agents such as chlorhexidine, unless antimicrobials were also included in the regimen. We used the Mantel-Haenszel model with random effects to calculate pooled odds ratios. FINDINGS We analysed 64 unique studies of SDD and SOD in ICUs, of which 47 were randomised controlled trials and 35 included data for the detection of antimicrobial resistance. When comparing data for patients in intervention groups (those who received SDD or SOD) versus data for those in control groups (who received no intervention), we identified no difference in the prevalence of colonisation or infection with Gram-positive antimicrobial-resistant pathogens of interest, including meticillin-resistant Staphylococcus aureus (odds ratio 1·46, 95% CI 0·90-2·37) and vancomycin-resistant enterococci (0·63, 0·39-1·02). Among Gram-negative bacilli, we detected no difference in aminoglycoside-resistance (0·73, 0·51-1·05) or fluoroquinolone-resistance (0·52, 0·16-1·68), but we did detect a reduction in polymyxin-resistant Gram-negative bacilli (0·58, 0·46-0·72) and third-generation cephalosporin-resistant Gram-negative bacilli (0·33, 0·20-0·52) in recipients of selective decontamination compared with those who received no intervention. INTERPRETATION We detected no relation between the use of SDD or SOD and the development of antimicrobial-resistance in pathogens in patients in the ICU, suggesting that the perceived risk of long-term harm related to selective decontamination cannot be justified by available data. However, our study indicates that the effect of decontamination on ICU-level antimicrobial resistance rates is understudied. We recommend that future research includes a non-crossover, cluster randomised controlled trial to assess long-term ICU-level changes in resistance rates. FUNDING None.
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Affiliation(s)
- Nick Daneman
- Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada.
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Abstract
PURPOSE OF REVIEW Endotracheal intubation and mechanical ventilation are lifesaving measures in critically ill patients. However, these interventions increase the risk of respiratory infections, particularly ventilator-associated pneumonia (VAP). VAP constitutes a serious burden for the healthcare system and worsens the patient's outcomes; thus, several preventive strategies have been implemented. This communication reviews the current knowledge on VAP pathogenesis and the latest preventive measures. RECENT FINDINGS Pathogen-laden oropharyngeal secretions leak across the endotracheal tube (ETT) cuff; thus, a continuous control of the internal cuff pressure and cuffs made of polyurethane improve sealing effectiveness and associated risks of infections. Subglottic secretions aspiration prevents VAP, and the latest evidence demonstrated a reduction in the incidence of late-onset VAP. The role of ETT biofilm in the pathogenesis of VAP is not fully elucidated. Nevertheless, antimicrobial-coated ETTs have showed beneficial effects in VAP incidence. Recent experimental evidence has challenged the benefits associated with the use of the semirecumbent position; yet, these findings need to be corroborated in clinical trials. The latest results from trials testing the effects of selective digestive decontamination (SDD) showed beneficial effects on patients' outcomes, but concerns remain regarding the emergence of bacterial resistance, specifically upon digestive tract re-colonization. The use of oropharyngeal decontamination with antiseptics and the use of probiotics are potential alternatives to SDD. SUMMARY There is consistent evidence that strategies affecting the primary mechanisms of VAP pathogenesis efficiently reduce the occurrence of the disease. Preventive measures should be implemented grouped into bundles to improve overall efficacy.
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Westendorp WF, Vermeij JD, Vermeij F, Den Hertog HM, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic therapy for preventing infections in patients with acute stroke. Cochrane Database Syst Rev 2012; 1:CD008530. [PMID: 22258987 DOI: 10.1002/14651858.cd008530.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Stroke is the main cause of disability in high income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce infections and improve outcome. OBJECTIVES 1. To assess whether preventive antibiotic therapy in patients with acute stroke reduces the risk of dependency and death at follow-up. 2. To assess whether preventive antibiotic therapy in patients with acute stroke reduces infection rate. SEARCH METHODS We searched the Cochrane Stroke Group's Trials Register (October 2010); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3); MEDLINE (1950 to October 2010) and EMBASE (1980 to October 2010). In an effort to identify further published, unpublished and ongoing trials we searched trials and research registers, scanned reference lists and contacted authors, colleagues and researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in patients with acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS Two authors independently selected articles and performed data extraction; we discussed and resolved discrepancies in a consensus meeting with a third observer. We contacted the study authors to obtain missing data when required. An independent observer assessed methodological quality. We calculated relative risks (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies and performed subgroup analyses on study quality. MAIN RESULTS We included five studies involving 506 patients. Study population, study design, type of antibiotic and definition of infection differed considerably. The number of patients who died in the preventive antibiotic group was non-significantly reduced (33/248 (13%) versus 38/258 (15%), RR 0.85, 95% confidence interval (CI) 0.47 to 1.51); the number of dependent patients in the preventive antibiotic therapy group was also non-significantly reduced (97/208 (47%) versus 127/208 (61%), RR 0.67, 95% CI 0.32 to 1.43). Preventive antibiotic therapy did reduce the incidence of infections in patients with acute stroke from 36% to 22% (36/166 (22%) versus 61/169 (36%), RR 0.58, 95% CI 0.43 to 0.79). No major side-effects of preventive antibiotic therapy were reported. AUTHORS' CONCLUSIONS In this meta-analysis, preventive antibiotic therapy seemed to reduce the risk of infection, but did not reduce the number of dependent or deceased patients. However, the included studies were small and heterogeneous. Large randomised trials are urgently needed.
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Hennigs JK, Baumann HJ, Schmiedel S, Tennstedt P, Sobottka I, Bokemeyer C, Kluge S, Klose H. Characterization of Enterobacter cloacae Pneumonia: A Single-Center Retrospective Analysis. Lung 2011; 189:475-83. [DOI: 10.1007/s00408-011-9323-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 09/10/2011] [Indexed: 10/16/2022]
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Affiliation(s)
- S K Todi
- Director - Critical Care & Emergency Medicine, AMRI Hospitals, Kolkata, India
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Passing the bug—Translocation, bacteremia, and sepsis in the intensive care unit patient: Is intestinal decontamination the answer?*. Crit Care Med 2011; 39:1202-3. [DOI: 10.1097/ccm.0b013e31820e4625] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Wunderink R. Worlds Apart: Proof that SDD Works. Am J Respir Crit Care Med 2010. [DOI: 10.1164/ajrccm.182.12.1564a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Vermeij F, Nederkoorn PJ, Den Hertog HM, van de Beek D, Dippel DWJ. Antibiotic therapy for preventing infections in patients with acute stroke. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Palencia Herrejón E, Rico Cepeda P. [Decontamination. A treatment without indications]. Med Intensiva 2010; 34:334-44. [PMID: 20488583 DOI: 10.1016/j.medin.2010.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 04/12/2010] [Accepted: 04/12/2010] [Indexed: 11/30/2022]
Abstract
The prevention of ventilator-associated pneumonia (VAP) is a priority in the Intensive Care Unit (ICU). To achieve this goal, clinical practice guidelines recommend the simultaneous application of a heterogeneous group of preventive measures of proven effectiveness. That is why we are presently seeing a reduction in VAP incidence to values previously considered unreachable. Better compliance with clinical practice guidelines has resulted in VAP rates approaching zero in multiple studies. Faced with the measures recommended in these guidelines, selective digestive decontamination (SDD), used together with other infection control practices, has shown efficacy in hospitals with high baseline incidence of pneumonia. However, its effectiveness in hospitals with good compliance of clinical practice guidelines and lower rates of VAP is highly unlikely. A serious drawback of DDS is the risk of favoring the selection of resistant microorganisms that can spread easily through the ICU and the hospital. With current standards of infection prevention, DDS is an unnecessary and risky measure, which should not be used on a widespread basis. Those situations in which the DDS may increase the effectiveness of properly implemented standard measures are still unknown.
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Amaral SM, Côrtes ADQ, Pires FR. Authors' reply. J Bras Pneumol 2010. [DOI: 10.1590/s1806-37132010000200019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Sánchez García M. [Debates in intensive medicine: Pro: selective decontamination]. Med Intensiva 2010; 34:325-33. [PMID: 20219269 DOI: 10.1016/j.medin.2010.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 12/20/2009] [Accepted: 01/04/2010] [Indexed: 11/25/2022]
Abstract
Selective decontamination of the digestive tract (SDD) has been proven to prevent infections of endogenous development and reduce mortality in critically ill patients under prolonged mechanical ventilation. Historical arguments against its use, like the development of bacterial resistance or the selection of resistant microorganisms and the absence of influence on mortality have not been confirmed. Moreover, recent clinical trials designed to evaluate these variables, show remarkable reductions in the incidence of resistant bacteria and a significant beneficial effect on mortality. Furthermore, no increases in workload or costs have been documented. A few studies with post-trial and intermediate range follow-up periods didn't find increases in resistance. Implementation of SDD requires motivation and leadership in order to achieve cooperation of other related hospital specialists, training of several categories of healthcare professionals, and continuous monitoring of results. In order to facilitate the use of SDD in the critically ill, this preventive measure should be incorporated in guidelines of national and international scientific societies and working groups involved in the care of the critically ill patient. The general implementation of SDD in our intensive care units must be accompanied by a registry in order to be able to monitor the effect on the incidence of infection and bacterial resistance. For this purpose, the Spanish national ICU infection and resistance surveillance programme ENVIN-HELICS, active over the last 15 years, constitutes both a more than adequate tool, and the convenient reference data base.
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Affiliation(s)
- M Sánchez García
- Servicio de Medicina Intensiva, Hospital Clínico San Carlos, Madrid, Spain.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control. Intensive Care Med 2010; 36:196-209. [PMID: 20057995 PMCID: PMC2816797 DOI: 10.1007/s00134-009-1742-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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