Surviving Sepsis Campaign Guidelines: Selective Decontamination of the Digestive Tract Still Neglected

Highlights from the 2008 Surviving Sepsis Campaign: Part 2

Previously, 1 key issues surrounding the 2008 Surviving Sepsis Campaign (SSC) were examined, 2 including evidence-based ratings, initial resuscitation, antimicrobial therapy, vasopressor support, and the role of the pharmaceutical industry in the SSC. In part 2 of this series, the recommendations for corticotherapy, intensive insulin therapy, activated protein C, blood transfusions, and selective digestive tract decontamination are discussed.

[Selective digestive decontamination. Why don't we apply the evidence in the clinical practice?]

Selective digestive decontamination (SDD) is a prophylactic strategy whose objective is to reduce the incidence of infections, mainly mechanical ventilation associated pneumonia in patients who require intensive cares, preventing or eradicating the oropharyngeal and gastrointestinal carrier state of potentially pathogenic microorganisms. Fifty-four randomized clinical trials (RCTs) and 9 meta-analysis have evaluated SDD. Thirty eight RCTs show a significant reduction of the infections and 4 of mortality. All the meta-analyses show a significant reduction of the infections and 5 out of the 9 meta-analyses report a significant reduction in mortality. Thus, 5 patients from the ICU with SDD must be treated to prevent pneumonia and 12 patients from the ICU should be treated to prevent one death. The data that show benefit of the SDD on mortality have an evidence grade 1 or recommendation grade A (supported by at least two level 1 investigations). The aim of this review is to explain the pathogeny of infections in critical patients, describe selective digestive decontamination, analyze the evidence available on it efficacy and the potential adverse effects and discuss the reasons published by the experts who advise against the use of SDD, even though it is recognized as the best intervention evaluated in intensive cares to reduce morbidity and mortality of the infections.

Management of severe sepsis and septic shock: challenges and recommendations

Sepsis and related aspects has become an area of active and intense research, leading to important advances for an early diagnosis and appropriate management useful to improve patient outcome. The septic response is an extremely complex cascade of events, including proinflammatory, anti-inflammatory, humoral, cellular, and circulatory involvement. The pathophysiology of this syndrome, its various and changing clinical aspects, and the vast variety of therapeutic options available, not always of well-proved efficacy, make its management a goal difficult to achieve.

The intensive care unit as a research laboratory: developing strategies to prevent antimicrobial resistance

OBJECTIVE

To assemble the available clinical data on the prevention of antimicrobial resistance in the intensive care unit (ICU) setting.

DATA SOURCE

A MEDLINE database search and references from identified articles were employed to obtain the literature relating to the prevention of antimicrobial resistance in the ICU.

CONCLUSIONS

The ICU presents a unique environment for the conduct of clinical research. The closed physical space with centralized patient management and efficient data recovery allows important clinical questions to be evaluated in a timely manner. Antimicrobial resistance has emerged as an important determinant of mortality for patients in the ICU. Additionally, there is currently a limited pipeline of new agents for the treatment of emerging bacteria with new resistance genes that pose an increasing threat to the ICU patient. Effective strategies for the prevention of antimicrobial resistance within ICUs are available and should be implemented aggressively. These strategies can be divided into non-pharmacologic infection- control strategies (e.g., routine hand hygiene, infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotics, narrowing of the antimicrobial spectrum on the basis of culture results). Additional studies conducted in ICUs are needed urgently to identify the optimal approaches for the management of antibiotics in order to balance the need for efficacy with the ability to minimize resistance.

Strategies to prevent antimicrobial resistance in the intensive care unit

OBJECTIVE

To assemble the available clinical data for the prevention of antimicrobial resistance into practical recommendations for clinicians.

DATA SOURCE

A Medline database and references from identified articles were employed to perform a literature search relating to the prevention of antimicrobial resistance.

CONCLUSIONS

Antimicrobial resistance has emerged as an important determinant of mortality for patients in the intensive care unit. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents, resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. These strategies can be divided into nonpharmacologic infection control strategies (e.g., routine hand hygiene, implementation of infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotic treatment, narrowing of antimicrobial spectrum based on culture results). Increasing current efforts aimed at the prevention of antimicrobial resistance is especially important given the limited availability of new antimicrobial drug classes for the foreseeable future.