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Sánchez-Ramírez C, Hípola-Escalada S, Cabrera-Santana M, Hernández-Viera MA, Caipe-Balcázar L, Saavedra P, Artiles-Campelo F, Sangil-Monroy N, Lübbe-Vázquez CF, Ruiz-Santana S. Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance. Crit Care 2018; 22:141. [PMID: 29843808 PMCID: PMC5975678 DOI: 10.1186/s13054-018-2057-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin-, tobramycin-, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB). METHODS In this cohort study, which was conducted in a 30-bed medical-surgical ICU, clinical outcomes before (1 year, non-SDD group) and after (4 years) implementation of SDD were compared. ICU patients who were expected to require tracheal intubation for > 48 hours were given a standard prophylactic SDD regimen. Oropharyngeal and rectal swabs were obtained on admission and once weekly thereafter. RESULTS ICU-acquired infections occurred in 110 patients in the non-SDD group and in 258 in the SDD group. A significant (P < 0.001) reduction of infections caused by MDRB (risk ratio [RR], 0.31; 95% CI, 0.23-0.41) was found after SDD and was associated with low rates of colistin- and tobramycin-resistant colonization. Colistin- and tobramycin-acquired increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at admission, was nonsignificant (0.82; 95% CI, 0.56 to 1.95; 1.13; 95% CI, 0.75 to 1.70, respectively). SDD was also a protective factor for ICU-acquired infections caused by MDR gram-negative pathogens and Acinetobacter baumannii in the multivariate analysis. In addition, a significant (P < 0.001) reduction of ventilator-associated pneumonia (VAP) (RR, 0.43; 95% CI, 0.32-0.59) and secondary bloodstream infection (BSI) (RR, 0.35; 95% CI, 0.24-0.52) was found. A decrease in antibiotic consumption was also observed. CONCLUSIONS Treatment with SDD during 4 years was effective in an ICU setting with a high level of resistance, with clinically relevant reductions of infections caused by MDRB, and with low rates of colistin- and tobramycin-resistant colonization with nonsignificant increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at ICU admission. In addition, VAP and secondary BSI rates were significantly lower after SDD. Notably, a decrease in antimicrobial consumption was also observed.
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Affiliation(s)
- Catalina Sánchez-Ramírez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Silvia Hípola-Escalada
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Miriam Cabrera-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - María Adela Hernández-Viera
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Liliana Caipe-Balcázar
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Pedro Saavedra
- Mathematics Department, Universidad de las Palmas de Gran Canaria, Las Palmas, Spain
| | - Fernando Artiles-Campelo
- Microbiology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Nayra Sangil-Monroy
- Pharmacy Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Carlos Federico Lübbe-Vázquez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Sergio Ruiz-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
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Polyclonality among clinical strains of non-pigmented rapidly growing mycobacteria: phenotypic and genotypic differences and their potential implications. Clin Microbiol Infect 2015; 21:348.e1-4. [DOI: 10.1016/j.cmi.2014.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/17/2014] [Accepted: 12/06/2014] [Indexed: 11/24/2022]
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Silvestri L, de la Cal MA, van Saene HKF. Selective decontamination of the digestive tract: the mechanism of action is control of gut overgrowth. Intensive Care Med 2012; 38:1738-50. [PMID: 23001446 DOI: 10.1007/s00134-012-2690-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/03/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Gut overgrowth is the pathophysiological event in the critically ill requiring intensive care. In relation to the risk of developing a clinically important outcome, gut overgrowth is defined as ≥10(5) potential pathogens including 'abnormal' aerobic Gram-negative bacilli (AGNB), 'normal' bacteria and yeasts, per mL of digestive tract secretion. Surveillance samples of throat and gut are the only samples to detect overgrowth. Gut overgrowth is the crucial event which precedes both primary and secondary endogenous infection, and a risk factor for the development of de novo resistance. Selective decontamination of the digestive tract (SDD) is an antimicrobial prophylaxis designed to control overgrowth. METHODS There have been 65 randomised controlled trials of SDD in 15,000 patients over 25 years and 11 meta-analyses, which are reviewed. RESULTS AND CONCLUSIONS These trials demonstrate that the full SDD regimen using parenteral and enteral antimicrobials reduces lower airway infection by 72 %, blood stream infection by 37 %, and mortality by 29 %. Resistance is also controlled. Parenteral cefotaxime which reaches high salivary and biliary concentrations eradicates overgrowth of 'normal' bacteria such as Staphylococcus aureus in the throat. Enteral polyenes control 'normal' Candida species. Enteral polymyxin and tobramycin, eradicate, or prevent gut overgrowth of 'abnormal' AGNB. Enteral vancomycin controls overgrowth of 'abnormal' methicillin-resistant S. aureus. SDD controls overgrowth by achieving high antimicrobial concentrations effective against 'normal' and 'abnormal' potential pathogens rather than by selectivity.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170, Gorizia, Italy
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Silvestri L, van Saene HKF, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother 2012; 13:1113-29. [PMID: 22533385 DOI: 10.1517/14656566.2012.681778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) has been proposed to prevent endogenous and exogenous infections and to reduce mortality in critically ill patients. Although the efficacy of SDD has been confirmed by randomized controlled trials (RCTs) and systematic reviews, SDD has been the subject of intense controversy, based mainly on an insufficient evidence of efficacy and on concerns about resistance. AREAS COVERED This article reviews the philosophy, the current evidence on the efficacy of SDD and the issue of emergence of resistance. All SDD RCTs were searched using Embase and Medline, with no restriction of language, gender or age. Personal archives were also explored, including abstracts from major scientific meetings; references in papers and published meta-analyses on SDD were crosschecked. Up-to-date evidence of the impact of SDD on carriage, infections and mortality is presented, and the efficacy of SDD in selected patient groups was investigated, along with the problem of the emergence of resistance. EXPERT OPINION SDD significantly reduces the number of infections of the lower respiratory tract and bloodstream, multiple organ failure and mortality. It also controls resistance, particularly when the full protocol of parenteral and enteral antimicrobials is used.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170 Gorizia, Italy.
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Selective digestive decontamination and antibiotic resistance. THE LANCET. INFECTIOUS DISEASES 2012; 12:181; author reply 181-2. [PMID: 22361428 DOI: 10.1016/s1473-3099(11)70276-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Silvestri L, de la Cal MA, Zandstra DF, Taylor N, van Saene HKF. Fluoroquinolones are not a blanket cover for gram-negative bacilli. Liver Transpl 2012; 18:496-7; author reply 498. [PMID: 22467551 DOI: 10.1002/lt.23373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Reply to Petros et al.: Gut overgrowth harms the critically ill. Intensive Care Med 2011. [DOI: 10.1007/s00134-011-2288-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: a 5-year prospective cohort study. Intensive Care Med 2011; 37:1458-65. [DOI: 10.1007/s00134-011-2307-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 06/27/2011] [Indexed: 10/18/2022]
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Gut overgrowth harms the critically ill. Intensive Care Med 2011; 37:1560; author reply 1561-2. [PMID: 21710115 DOI: 10.1007/s00134-011-2287-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2011] [Indexed: 10/18/2022]
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Al Sweih N, Salama MF, Jamal W, Al Hashem G, Rotimi VO. An outbreak of CTX-M-15-producing Klebsiella pneumoniae isolates in an intensive care unit of a teaching hospital in Kuwait. Indian J Med Microbiol 2011; 29:130-5. [DOI: 10.4103/0255-0857.81791] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abecasis F, Sarginson RE, Kerr S, Taylor N, van Saene HK. Is Selective Digestive Decontamination Useful in Controlling Aerobic Gram-Negative Bacilli Producing Extended Spectrum Beta-Lactamases? Microb Drug Resist 2011; 17:17-23. [DOI: 10.1089/mdr.2010.0060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Francisco Abecasis
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Richard E. Sarginson
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Steve Kerr
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Nia Taylor
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
| | - Hendrik K.F. van Saene
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
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Petros AJ, Taylor N, Damjanovic V, Saene HV, Abecasis F, Silvestri L, de la Cal MA. Worlds apart: Proof that SDD works. Am J Respir Crit Care Med 2011; 182:1564; author reply 1564-5. [PMID: 21159906 DOI: 10.1164/ajrccm.182.12.1564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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van Saene HK, Silvestri L, de la Cal MA, Gullo A. Outbreaks of Infection in the ICU: What’s up at the Beginning of the Twenty-First Century? INFECTION CONTROL IN THE INTENSIVE CARE UNIT 2011. [PMCID: PMC7120292 DOI: 10.1007/978-88-470-1601-9_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Hendrick K.F. van Saene
- , Institute of Aging and Chronic Diseases, University Liverpool, Daulby Street, Liverpool, L69 3GA United Kingdom
| | - Luciano Silvestri
- , Dept. Emergency, Hospital Gorizia, Via Vittorio Veneto 171, Gorizia, 34170 Italy
| | - Miguel A. de la Cal
- , Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo km 12.5, Getafe, 28045 Spain
| | - Antonino Gullo
- Policlinico di Catania, UCO di Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria, Via Santa Sofia 78, Catania, 95100 Italy
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Selective decontamination of the digestive tract in burn patients: an evidence-based maneuver that reduces mortality. J Burn Care Res 2010; 31:372-3; author reply 374. [PMID: 20182385 DOI: 10.1097/bcr.0b013e3181d1b61f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Damjanovic V, Damjanovic C, Taylor N, van Saene H. Comment on reply of Miranda et al., Re: ‘Is the endogenous pathogenesis of Candida parapsilosis infection underreported?’. J Hosp Infect 2010; 74:187-8; author reply 188-9. [DOI: 10.1016/j.jhin.2009.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Accepted: 09/21/2009] [Indexed: 10/20/2022]
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Silvestri L, van Saene HKF, de la Cal MA, De Gaudio AR. Carriage classification of pneumonia rather than time improves survival. Chest 2009; 136:1188-1189. [PMID: 19809078 DOI: 10.1378/chest.08-2910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Damjanovic V, Taylor N, van Saene HKF. Origin of epidemic clones of acinetobacter in the critically ill. J Hosp Infect 2009; 73:285-6; author reply 286-7. [PMID: 19788949 DOI: 10.1016/j.jhin.2009.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 07/14/2009] [Indexed: 10/20/2022]
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Is the endogenous pathogenesis of Candida parapsilosis infection underreported? J Hosp Infect 2009; 73:93-4. [DOI: 10.1016/j.jhin.2009.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 05/21/2009] [Indexed: 11/17/2022]
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García-Hierro P, de la Cal MA, van Saene HK, Silvestri L. Un nuevo ensayo clínico con descontaminación digestiva selectiva. Med Intensiva 2009; 33:297-300. [DOI: 10.1016/s0210-5691(09)72198-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Accepted: 04/20/2009] [Indexed: 10/20/2022]
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