Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study

A.M. de Smet, J.A. Kluytmans, H.E. Blok, E.M. Mascini, R.F. Benus, A.T. Bernards, E.J. Kuijper, M.A. Leverstein van Hall, A.R. Jansz, B.M. de Jongh, G.J. van Asselt, I.H. Frenay, S.F. Thijsen, S.N. Conijn, J.A. Kaan, J.P. Arends, P.D. Sturm, M.C.J. Bootsma, M.J. Bonten

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Abstract

BACKGROUND: Previously, we assessed selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) on survival and prevention of bacteraemia in patients in intensive-care units. In this analysis, we aimed to assess effectiveness of these interventions for prevention of respiratory tract colonisation and bacteraemia with highly resistant microorganisms acquired in intensive-care units. METHODS: We did an open-label, clustered group-randomised, crossover study in 13 intensive-care units in the Netherlands between May, 2004, and July, 2006. Participants admitted to intensive-care units with an expected duration of mechanical ventilation of more than 48 h or an expected stay of more than 72 h received SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx), SDD (SOD antibiotics in the oropharynx and stomach plus 4 days' intravenous cefotaxime), or standard care. The computer-randomised order of study regimens was applied by an independent clinical pharmacist who was masked to intensive-care-unit identity. We calculated crude odds ratios (95% CI) for rates of bacteraemia or respiratory tract colonisation with highly resistant microorganisms in patients who stayed in intensive-care units for more than 3 days (ie, acquired infection). This trial is registered at http://isrctn.org, number ISRCTN35176830. FINDINGS: Data were available for 5927 (>99%) of 5939 patients, of whom 5463 (92%) were in intensive-care units for more than 3 days. 239 (13%) of 1837 patients in standard care acquired bacteraemia after 3 days, compared with 158 (9%) of 1758 in SOD (odds ratio 0.66, 95% CI 0.53-0.82), and 124 (7%) of 1868 in SDD (0.48, 0.38-0.60). Eight patients acquired bacteraemia with highly resistant microorganisms during SDD, compared with 18 patients (with 19 episodes) during standard care (0.41, 0.18-0.94; rate reduction [RR] 59%, absolute risk reduction [ARR] 0.6%) and 20 during SOD (0.37, 0.16-0.85; RR 63%, ARR 0.7%). Of the patients staying in intensive-care units for more than 3 days, we obtained endotracheal aspirate cultures for 881 (49%) patients receiving standard care, 886 (50%) receiving SOD, and 828 (44%) receiving SDD. 128 (15%) patients acquired respiratory tract colonisation with highly resistant microorganisms during standard care, compared with 74 (8%) during SDD (0.58, 0.43-0.78; RR 38%, ARR 5.5%) and 88 (10%) during SOD (0.65, 0.49-0.87; RR 32%, ARR 4.6%). Acquired respiratory tract colonisation with Gram-negative bacteria or cefotaxime-resistant and colistin-resistant pathogens was lowest during SDD. INTERPRETATION: Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified. FUNDING: None.
Original languageEnglish
Pages (from-to)372-380
JournalLancet Infectious Diseases
Volume11
Issue number5
DOIs
Publication statusPublished - 1 Jan 2011

Cite this

de Smet, A. M., Kluytmans, J. A., Blok, H. E., Mascini, E. M., Benus, R. F., Bernards, A. T., Kuijper, E. J., Leverstein van Hall, M. A., Jansz, A. R., de Jongh, B. M., van Asselt, G. J., Frenay, I. H., Thijsen, S. F., Conijn, S. N., Kaan, J. A., Arends, J. P., Sturm, P. D., Bootsma, M. C. J., & Bonten, M. J. (2011). Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study. Lancet Infectious Diseases, 11(5), 372-380. https://doi.org/10.1016/S1473-3099(11)70035-4