Effects of decontamination of the digestive tract and oropharynx in intensive care unit patients on 1-year survival

Selective decontamination of the digestive tract and oropharynx: after 30 years of debate is the definitive answer in sight?

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.

Considerations About Antimicrobial Stewardship in Settings with Epidemic Extended-Spectrum β-Lactamase-Producing or Carbapenem-Resistant Enterobacteriaceae

Infections caused by gram-negative bacteria (GNB) resistant to multiple classes of antibiotics are increasing in many hospitals. Extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant Enterobacteriaceae in particular are now endemic in many parts of the world and represent a serious public health threat. In this era, antimicrobial stewardship programs are essential as targeted and responsible use of antibiotics improves patient outcomes and hopefully limits the selective pressure that drives the further emergence of resistance. However, some stewardship strategies aimed at promoting carbapenem-sparing regimens remain controversial and are difficult to implement when resistance rates to non-carbapenem antibiotics are increasing. Coordinated efforts between stewardship programs and infection control are essential for reversing conditions that favor the emergence and dissemination of multidrug-resistant GNB within the hospital and identifying extra-institutional "feeder reservoirs" of resistant strains such as long-term care facilities, where colonization is common despite limited numbers of serious infections. In settings where ESBL resistance is endemic, the cost-effectiveness of expanded infection control efforts and antimicrobial stewardship is still unknown. Once a patient has been colonized, selective oral or digestive decontamination may be considered, but evidence supporting its effectiveness is limited in patients who are already colonized or in centers with high rates of resistance. Moreover, temporary success at decolonization may be associated with a higher risk of relapse with strains that are resistant to the decolonizing antibiotics.

The views of health care professionals about selective decontamination of the digestive tract: an international, theoretically informed interview study

PURPOSE

Selective decontamination of the digestive tract (SDD) as a prophylactic intervention improves hospital-acquired infection and survival rates. Uptake of SDD is low and remains controversial. This study applied the theoretical domains framework to assess intensive care unit clinicians' views about SDD in regions with limited or no adoption of SDD.

MATERIALS AND METHODS

Participants were health professionals with "decisional authority" for the adoption of SDD. Semistructured interviews were conducted as the first round of a Delphi study. Views about SDD adoption, delivery, and further SDD research were explored. Directed content analysis of interview data identified subthemes, which informed item development for subsequent Delphi rounds. Linguistic features of interview data were also explored.

RESULTS

One hundred forty-one participants provided interview data. Fifty-six subthemes were identified; 46 were common across regions. Beliefs about consequences were the most widely elaborated theme. Linguistic features of how participants discussed SDD included caution expressed when discussing the risks and benefits and words such as "worry," "anxiety," and "fear" when discussing potential antibiotic resistance associated with SDD.

CONCLUSIONS

We identified salient beliefs, barriers, and facilitators to SDD adoption and delivery. What participants said about SDD and the way in which they said it demonstrated the degree of clinical caution, uncertainty, and concern that SDD evokes.