Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial

E.A.N. Oostdijk; J. Kesecioglu; M.J. Schultz; C.E. Visser; E. de Jonge; E.H.R. van Essen; A.T. Bernards; I. Purmer; R. Brimicombe; D. Bergmans; F. van Tiel; F.H. Bosch; E. Mascini; A. van Griethuysen; A. Bindels; A. Jansz; F.A.L. van Steveninck; W.C. van der Zwet; J.W. Fijen; S. Thijsen; R. de Jong; J. Oudbier; A. Raben; E. van der Vorm; M. Koeman; P. Rothbarth; A. Rijkeboer; P. Gruteke; H. Hart-Sweet; P. Peerbooms; LJ. Winsser; A.M.W. van Elsacker-Niele; K. Demmendaal; A. Brandenburg; A.M.G.A. de Smet; M.J.M. Bonten

doi:10.1001/jama.2014.7247

Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial

E.A.N. Oostdijk^*, J. Kesecioglu, M.J. Schultz, C.E. Visser, E. de Jonge, E.H.R. van Essen, A.T. Bernards, I. Purmer, R. Brimicombe, D. Bergmans, F. van Tiel, F.H. Bosch, E. Mascini, A. van Griethuysen, A. Bindels, A. Jansz, F.A.L. van Steveninck, W.C. van der Zwet, J.W. Fijen, S. ThijsenR. de Jong, J. Oudbier, A. Raben, E. van der Vorm, M. Koeman, P. Rothbarth, A. Rijkeboer, P. Gruteke, H. Hart-Sweet, P. Peerbooms, LJ. Winsser, A.M.W. van Elsacker-Niele, K. Demmendaal, A. Brandenburg, A.M.G.A. de Smet, M.J.M. Bonten

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.

OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.

DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively.

INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD.

MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.

RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6%(95% CI, 4.6%-6.7%) during SDD and 11.8%(95% CI, 10.3%-13.2%) during SOD (P <.001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77).

CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria.

Original language	English
Pages (from-to)	1429-1437
Number of pages	9
Journal	JAMA-Journal of the American Medical Association
Volume	312
Issue number	14
DOIs	https://doi.org/10.1001/jama.2014.7247
Publication status	Published - 8 Oct 2014

Keywords

SELECTIVE DIGESTIVE DECONTAMINATION
INTENSIVE-CARE UNITS
GRAM-NEGATIVE BACTERIA
ANTIMICROBIAL RESISTANCE
COLISTIN RESISTANCE
METAANALYSIS
EMERGENCE

Access to Document

10.1001/jama.2014.7247

1 Erratum / corrigendum / retractions

Notice of Retraction and Replacement: Oostdijk et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014;312(14):1429-1437.
Oostdijk, E. A. N., Kesecioglu, J., Schultz, M. J., Visser, C. E., de Jonge, E., van Essen, E. H. R., Bernards, A. T., Purmer, I., Brimicombe, R., Bergmans, D., van Tiel, F., Bosch, F. H., Mascini, E., van Griethuysen, A., Bindels, A., Jansz, A., van Steveninck, F. A. L., van der Zwet, W. C., Fijen, J. W., Thijsen, S., & 16 othersde Jong, R., Oudbier, J., Raben, A., van der Vorm, E., Koeman, M., Rothbarth, P., Rijkeboer, A., Gruteke, P., Hart, H., Peerbooms, P., Winsser, L. J., van Elsacker-Niele, A-M., Demmendaal, K., Brandenburg, A., de Smet, A. M. G. A. & Bonten, M. J. M., 18 Apr 2017, In: JAMA-Journal of the American Medical Association. 317, 15, p. 1583-1584 2 p.
Research output: Contribution to journal › Erratum / corrigendum / retractions › Academic

Cite this

Oostdijk, E. A. N., Kesecioglu, J., Schultz, M. J., Visser, C. E., de Jonge, E., van Essen, E. H. R., Bernards, A. T., Purmer, I., Brimicombe, R., Bergmans, D., van Tiel, F., Bosch, F. H., Mascini, E., van Griethuysen, A., Bindels, A., Jansz, A., van Steveninck, F. A. L., van der Zwet, W. C., Fijen, J. W., ... Bonten, M. J. M. (2014). Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA-Journal of the American Medical Association, 312(14), 1429-1437. https://doi.org/10.1001/jama.2014.7247

@article{6047c68282cd4efaac270a27e4197bb4,

title = "Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial",

abstract = "IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively.INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD.MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6%(95% CI, 4.6%-6.7%) during SDD and 11.8%(95% CI, 10.3%-13.2%) during SOD (P <.001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77).CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria.",

keywords = "SELECTIVE DIGESTIVE DECONTAMINATION, INTENSIVE-CARE UNITS, GRAM-NEGATIVE BACTERIA, ANTIMICROBIAL RESISTANCE, COLISTIN RESISTANCE, METAANALYSIS, EMERGENCE",

author = "E.A.N. Oostdijk and J. Kesecioglu and M.J. Schultz and C.E. Visser and {de Jonge}, E. and {van Essen}, E.H.R. and A.T. Bernards and I. Purmer and R. Brimicombe and D. Bergmans and {van Tiel}, F. and F.H. Bosch and E. Mascini and {van Griethuysen}, A. and A. Bindels and A. Jansz and {van Steveninck}, F.A.L. and {van der Zwet}, W.C. and J.W. Fijen and S. Thijsen and {de Jong}, R. and J. Oudbier and A. Raben and {van der Vorm}, E. and M. Koeman and P. Rothbarth and A. Rijkeboer and P. Gruteke and H. Hart-Sweet and P. Peerbooms and LJ. Winsser and {van Elsacker-Niele}, A.M.W. and K. Demmendaal and A. Brandenburg and {de Smet}, A.M.G.A. and M.J.M. Bonten",

year = "2014",

month = oct,

day = "8",

doi = "10.1001/jama.2014.7247",

language = "English",

volume = "312",

pages = "1429--1437",

journal = "JAMA-Journal of the American Medical Association",

issn = "0098-7484",

publisher = "American Medical Association",

number = "14",

}

Oostdijk, EAN, Kesecioglu, J, Schultz, MJ, Visser, CE, de Jonge, E, van Essen, EHR, Bernards, AT, Purmer, I, Brimicombe, R, Bergmans, D, van Tiel, F, Bosch, FH, Mascini, E, van Griethuysen, A, Bindels, A, Jansz, A, van Steveninck, FAL, van der Zwet, WC, Fijen, JW, Thijsen, S, de Jong, R, Oudbier, J, Raben, A, van der Vorm, E, Koeman, M, Rothbarth, P, Rijkeboer, A, Gruteke, P, Hart-Sweet, H, Peerbooms, P, Winsser, LJ, van Elsacker-Niele, AMW, Demmendaal, K, Brandenburg, A, de Smet, AMGA & Bonten, MJM 2014, 'Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial', JAMA-Journal of the American Medical Association, vol. 312, no. 14, pp. 1429-1437. https://doi.org/10.1001/jama.2014.7247

TY - JOUR

T1 - Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial

AU - Oostdijk, E.A.N.

AU - Kesecioglu, J.

AU - Schultz, M.J.

AU - Visser, C.E.

AU - de Jonge, E.

AU - van Essen, E.H.R.

AU - Bernards, A.T.

AU - Purmer, I.

AU - Brimicombe, R.

AU - Bergmans, D.

AU - van Tiel, F.

AU - Bosch, F.H.

AU - Mascini, E.

AU - van Griethuysen, A.

AU - Bindels, A.

AU - Jansz, A.

AU - van Steveninck, F.A.L.

AU - van der Zwet, W.C.

AU - Fijen, J.W.

AU - Thijsen, S.

AU - de Jong, R.

AU - Oudbier, J.

AU - Raben, A.

AU - van der Vorm, E.

AU - Koeman, M.

AU - Rothbarth, P.

AU - Rijkeboer, A.

AU - Gruteke, P.

AU - Hart-Sweet, H.

AU - Peerbooms, P.

AU - Winsser, LJ.

AU - van Elsacker-Niele, A.M.W.

AU - Demmendaal, K.

AU - Brandenburg, A.

AU - de Smet, A.M.G.A.

AU - Bonten, M.J.M.

PY - 2014/10/8

Y1 - 2014/10/8

N2 - IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively.INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD.MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6%(95% CI, 4.6%-6.7%) during SDD and 11.8%(95% CI, 10.3%-13.2%) during SOD (P <.001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77).CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria.

AB - IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively.INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD.MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6%(95% CI, 4.6%-6.7%) during SDD and 11.8%(95% CI, 10.3%-13.2%) during SOD (P <.001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77).CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria.

KW - SELECTIVE DIGESTIVE DECONTAMINATION

KW - INTENSIVE-CARE UNITS

KW - GRAM-NEGATIVE BACTERIA

KW - ANTIMICROBIAL RESISTANCE

KW - COLISTIN RESISTANCE

KW - METAANALYSIS

KW - EMERGENCE

U2 - 10.1001/jama.2014.7247

DO - 10.1001/jama.2014.7247

M3 - Article

C2 - 25271544

SN - 0098-7484

VL - 312

SP - 1429

EP - 1437

JO - JAMA-Journal of the American Medical Association

JF - JAMA-Journal of the American Medical Association

IS - 14

ER -

Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial

Abstract

Keywords

Access to Document

Research output

Notice of Retraction and Replacement: Oostdijk et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014;312(14):1429-1437.

Cite this