Selective digestive tract decontamination in critically ill patients

Is Selective Digestive Decontamination Useful for Critically Ill Patients?

In this study we review the rationale for using selective digestive decontamination (SDD) in critically ill patients, and its effects on clinical outcomes and rates of infection with antimicrobial-resistant microorganisms. SDD consists of the application of nonabsorbable antibiotics to the oropharynx and through a nasogastric or nasoenteral tube, in association with a 4-day course of an intravenous third-generation cephalosporin. The enteral component aims at preventing oral and rectal colonization with potentially pathogenic nosocomial aerobic gram-negative bacilli and yeasts while preserving normal protective anaerobic enteral flora. The short-course systemic component aims at eradicating oral endogenous gram-positive bacteria. SDD decreases the risk of nosocomial infections, and reduces by one-quarter the mortality of patients on mechanical ventilation in settings with low prevalence of antibiotic resistance. Evidence from randomized trials suggests that SDD does not increase rates of antimicrobial-resistant microorganisms, and may reduce resistance rates to some antibiotics. However, several limitations decrease our confidence on these data, particularly for settings with high baseline rates of antimicrobial-resistant microorganisms. Although SDD has a clear potential to improve clinical outcomes of critically patients, its long-term ecologic effects on rates of antimicrobial resistant require appropriate assessment by large multinational cluster randomized trials. Before these results are available, the use of SDD cannot be recommended in most parts of the world, except in settings with very low baseline prevalence of antibiotic resistance.

The pros, cons, and unknowns of search and destroy for carbapenem-resistant enterobacteriaceae

Antibiotic drug discovery has not kept pace with the development of microbial resistance to these agents. There are ever increasing reports where the causative agents of serious infections are multi-drug resistant and in some cases resistant to all known antibiotics. The emergence and spread of carbapenemase-producing Enterobacteriaceae has heightened awareness regarding antibiotic stewardship programs and infection prevention and control measures. There has been much controversy regarding the utility of the "search and destroy" strategy to prevent the spread of carbapenem-resistant Enterobacteriaceae. These controversies center on screening and management of carriers, including decontamination and isolation. It is however clear that a functional infection prevention and control program is fundamental to any strategy that serves to address the spread of microbes within a healthcare facility.

Implementing selective digestive tract decontamination in the intensive care unit: A qualitative analysis of nurse-identified considerations

OBJECTIVE

To describe factors senior critical care nurses identify as being important to address when introducing selective digestive tract decontamination (SDD) in the clinical setting.

BACKGROUND

Critically ill patients are at risk of developing ventilator-associated pneumonia (VAP). SDD is one strategy shown to prevent VAP and possibly improve survival in the critically ill.

METHODS

We performed a secondary analysis of qualitative data obtained from 20 interviews. An inductive thematic analysis approach was applied to data obtained from senior critical care nurses during phase two of a multi-methods study.

RESULTS

There were four primary considerations identified that should be addressed or considered prior to implementation of SDD. These considerations included education of health care professionals, patient comfort, compatibility of SDD with existing practices, and cost.

CONCLUSIONS

Despite a lack of experience with, or knowledge of SDD, nurses were able to articulate factors that may influence its implementation and delivery. Organizations or researchers considering implementation of SDD should include nurses as key members of the implementation team.