The effect of selective decontamination on antimicrobial resistance in intensive care patients: a systematic review and meta-analysis

Frederique J C van Eerten; Joost D J Plate; Rolf H H Groenwold; Valentijn A Schweitzer; Jan A J W Kluytmans; Falco Hietbrink

doi:10.1038/s41598-026-57127-8

. 2026 Jun 14;16:27195. doi: 10.1038/s41598-026-57127-8

The effect of selective decontamination on antimicrobial resistance in intensive care patients: a systematic review and meta-analysis

Frederique J C van Eerten ^1,^✉, Joost D J Plate ², Rolf H H Groenwold ^3,⁴, Valentijn A Schweitzer ⁵, Jan A J W Kluytmans ⁵, Falco Hietbrink ¹

PMCID: PMC13526849 PMID: 42289535

Abstract

Selective Digestive Decontamination (SDD) and Selective Oropharyngeal Decontamination (SOD) are applied to prevent infections amongst Intensive Care Unit (ICU) patients and have proven to reduce mortality and infection rates. However, concerns about the development of antimicrobial resistance persists, specifically after ICU discharge. The aim of this study was to assess the occurrence of antimicrobial resistance during ICU stay and after ICU discharge in patients who had received SDD, or SOD compared to control, explicitly at individual-patient level. A previous systematic review, which included studies on antimicrobial resistance after SDD or SOD published before 01-02-2012, was updated. All studies analyzing antimicrobial resistance during and after ICU stay, were included. All outcomes related to resistant pathogens, whether detected through colonization or infection, were included. Pooled odds ratios and 95% confidence intervals were calculated using the Mantel-Haenszel method with random effects. Analyses were done separately for SDD and SOD. Twenty-seven studies were included in the meta-analysis on the occurrence of antimicrobial resistance during ICU stay, yielding a protective association in patients receiving SDD; OR 0.73 (95%-CI 0.54;0.98, I² 75%), which consisted of significant heterogeneity. Four studies investigated antimicrobial resistance after ICU discharge, of which two demonstrated protective results and two observed an increase in resistance in patients who had received SDD or SOD. A prospective long-term follow-up study is required to investigate the long-term effect of SDD and SOD on antimicrobial resistance. During ICU stay, SDD was not associated with increased antimicrobial resistance to specific antibiotics, consistent with previous findings, although study heterogeneity was considerable. This current review emphasizes the limited amount of data on the long-term effect of antimicrobial decontamination strategies on antimicrobial resistance, without addressing the population level effects on resistance rates and changes in gut-microbiome. Understanding this long-term effect is essential when deciding whether to implement preventative antibiotics.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1038/s41598-026-57127-8.

Keywords: Intensive care medicine, Infections, Antimicrobial resistance, Selective digestive decontamination

Subject terms: Antimicrobials, Bacteria, Health care

Introduction

Infections are a major cause of mortality and morbidity in patients admitted to Intensive Care Units (ICUs)¹. A substantial part of these infections is hospital-acquired and can therefore potentially be prevented¹.

Selective Digestive Decontamination (SDD) and Selective Oropharyngeal Decontamination (SOD) are applied to prevent infections among ICU patients. These two approaches have been extensively studied and demonstrate a reduction in mortality, infection rates, and duration of mechanical ventilation². SDD consists of the application of nonabsorbable antimicrobial agents in the oropharyngeal and gastrointestinal tract. Systemic antimicrobial prophylaxis is administered in addition to SDD during the first four days of ICU admission^2–4.

SOD consists of the application of nonabsorbable antimicrobial agents in the oropharynx. SOD and SDD were introduced to prevent endogenous infections caused by pathogens colonizing the oropharynx or gastrointestinal tract of ICU patients⁴. The choice of antibiotics is targeted against potential pathogens and should avoid targeting the anaerobic part of the flora⁴.

Despite the effect of SDD on ICU mortality, there is a persistent concern about the risk of antimicrobial resistance⁵. Bacterial antimicrobial resistance is a major cause of mortality⁶. Therefore, standardized preventative antibiotic administration should be critically reviewed. The resistance occurring after SDD and SOD may arise after ICU discharge. Thus, the main aim of this research was to assess the occurrence of antimicrobial resistance after ICU discharge. Antimicrobial resistance during ICU admission was also investigated, as new studies have been performed since the last systematic review in 2013^7–10.

Methods

Protocol and registration

The study protocol was registered in the PROSPERO International prospective register of systematic reviews under the ID CRD42019128143¹¹. Because of substantial heterogeneity in study designs and outcome measures, several sensitivity analyses were added to the initial protocol to assess the impact of this heterogeneity. Moreover, the analyses were conducted separately for SDD and SOD. The reporting of this article followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline¹². This study received no financial support and the authors declare no competing interests.

Information sources

A comprehensive literature search in Medline, Embase, and Cochrane was performed, see Fig. S1 for the search terms that were used. A previously performed systematic review by Daneman et al., which included all articles on antimicrobial resistance after SDD or SOD published before 01-02-2012, was taken as the basis^7,13. A search string was developed and tested for the 2010–2012 period. This yielded complete agreement with the studies found by Daneman et al.⁷ for this period. All studies identified by Daneman et al. were reviewed to determine whether they met the eligibility criteria for this current study. The search was expanded with studies from after 2012. Moreover, a cross-reference check of all included articles was performed. No additional studies were found. The last search was conducted on 08-05-24.

Study selection

All studies that analyzed the antimicrobial resistance of bacteria in ICU patients who received SDD or SOD were included, regardless of whether infections or colonization was studied. SDD and SOD regimens were defined as the application of topical regimens to the oropharyngeal and or the digestive tract. Studies were included regardless of which antimicrobial agents were used in the topical paste and whether systemic antimicrobial agents were administered. The primary outcome was the occurrence of antimicrobial resistance after ICU discharge, and the secondary outcome was the occurrence of antimicrobial resistance during ICU stay. Both routine samples and samples used for diagnosing infectious complications, which were tested on antimicrobial resistance, were included. Studies investigating both antimicrobial resistance after ICU discharge and during ICU stay were included. There were no restrictions regarding study design, country, publication status, date of publication, or study quality. Studies investigating only non-antimicrobial interventions (i.e. only washing with chlorhexidine), or only eradication rates rather than occurrence of new colonization with resistant bacteria were excluded. Only publications in English were included. When studies used overlapping data, the study which commenced first, or which investigated the most relevant outcomes was included. Study selection was performed by two reviewers (F.E. and J.P.). A third and fourth reviewer (F.H. and V.S) were consulted when consensus could not be reached. Eventually, consensus was reached through discussion.

Data extraction

The following information was extracted from each study: author, year of publication, years of study population inclusion, country, study design, number of participating ICUs, number of patients, duration of ICU stay, nature of topical agents and systemic antibiotics, total duration of decontamination, total duration of follow-up after ICU discharge, antimicrobial resistance outcome, definitions of antimicrobial resistance, and whether surveillance samples were performed routinely. A structured data extraction form was used. Authors of the reviewed articles were contacted for additional information if necessary. Data that were unclear or not apparent were considered missing. Where possible, unreported information was derived from available data, for example by calculating absolute numbers from percentage of patients colonized with antimicrobial resistant pathogens.

Risk of bias assessment

Two reviewers (F.E. and J.P.) assessed risk of bias using the MINORS checklist¹⁴. A third and fourth reviewer were consulted when consensus could not be reached (F.H. and V.S.). Consensus was reached on all studies. The MINORS checklist allowed assessment of the risk of bias of interventional studies, both observational studies and randomized trials.

Data synthesis of studies assessing the antimicrobial resistance during ICU admission

The analyses of resistance development during ICU admission were conducted separately for studies using SOD and SDD. All studies assessing the antimicrobial resistance rates of bacteria in individual patients after ICU discharge were included in the meta-analysis. Only studies with a control group not receiving SDD or SOD, and reporting outcomes as the proportion of patients with new colonization or infection with an antimicrobial resistant pathogen relative to total number of patients, were pooled (details below). Studies presenting outcomes using isolates or pathogens numbers instead of patients were excluded from the meta-analysis, as patients could be colonized with multiple pathogens. Moreover, outcomes reported as the proportion of resistant pathogens relative to total positive isolates were excluded.

Analyses were performed using the “rmeta”, “metaviz”, “meta”, and “metafor” packages in R software for statistical computing (V.3.3.2.)¹⁵. The symmetry of the funnel plot was assessed independently by three researchers (F.E., J.P. and V.S.)^16,17. To evaluate the presence of publication bias, the trim-and-fill analysis was performed. This analysis estimated the number of studies, risk ratios, and standard errors needed to achieve symmetry of the funnel plot¹⁸. The impact of possible publication bias was assessed by randomly producing multiple funnel plots with null hypothesis of no publication bias and blindly assessing whether the true funnel plot could be distinguished from the other funnel plots^16,17.

Pooled odds ratios (OR) and 95% confidence intervals on the occurrence of antimicrobial resistance after SDD or SOD were calculated using the DerSimonian and Laird method with random effects. Random effects were used to account for variability in treatment effect across studies, for example due to different study populations¹⁹. A continuity correction of 0.5 was applied to cell counts with zero events. The heterogeneity of the effect estimates regarding the occurrence of antimicrobial resistance after SDD or SOD across studies was quantified by means of the I² statistic.

Data synthesis of studies assessing the antimicrobial resistance during ICU admission

Due to limited data, outcomes of studies investigating the occurrence of antimicrobial resistance after ICU discharge were described narratively rather than pooled in a meta-analysis.

Outcomes to specific antibiotic groups and per multi-resistant bacteria type

Moreover, outcomes on resistance to specific antibiotic groups (aminoglycosides, polymyxin B and E, fluoroquinolones, and third-generation cephalosporins) and per multi-resistant bacteria type (Methicillin-Resistant S aureus (MRSA), Vancomycin Resistant Enterococcus spp. (VRE), and multi-resistant bacteria) were separately investigated. Due to limited data, only outcomes on MRSA in the SDD group were pooled. The other outcomes (MRSA in SOD, VRE and multi-resistant bacteria in both SDD and SOD) were only described narratively. Definitions of multi-resistant bacteria used by the studies included in this sensitivity analysis are specified in Table S5. Resistance to third-generation cephalosporins also included extended-spectrum beta-lactamase (ESBL) producing bacteria.

Sensitivity analyses

To investigate the effect of methodology, three sensitivity analyses were performed, combining results of studies using SDD or SOD: (A) IV antibiotics as part of SDD or SOD versus no IV antibiotics as part of SDD or SOD; (B) To explore the possible effect of cross-over contamination in individually randomized trials, a sensitivity analysis on studies with an individually randomized versus cluster randomized and observational design was conducted; When patients were individually randomized on the same ICU units, risk of cross-over contamination was higher than when patients were randomized in clusters on different ICU wards, or in observational designs such as before- and after designs; and (C) follow-up ≥ 14 days versus a < 14 days of follow-up. When studies did not report median follow-up duration, median length of ICU stay was used for this analysis.

Results

The search

In total, 65 studies were identified^{3,4,8–10,20–79}, of which 33 studies were included in addition to the studies identified by Daneman et al.⁷. In total, 27 studies were included in the meta-analysis (Fig. 1), of which six were included in addition to Daneman et al.⁷. Of these 27 studies, there were 25 studies included in the meta-analysis on SDD, which included 181,052 patients in total. Moreover, four studies were included in the meta-analysis on SOD, including a total of 11,532 patients. Thirty-eight studies were excluded from the meta-analyses, because they had no control group or had overlapping data with previous studies (Table S1). Specific details on the reason for exclusion of studies can be found in Table S2.

Fig. 1 — Flowchart of systematic review on antibiotic resistance after SSD/SOD in ICU patients.

Lastly, four studies reported follow-up after ICU discharge.

Characteristics of included studies

Study characteristics are reported in Tables 1 and 2. Characteristics of the 27 studies that were included in the meta-analysis are described in Table 1. Most studies were conducted in in France (22.2%), Spain (18.5%), and in Germany, the Netherlands and the USA (all 11.1%). Study designs included individually randomized (37.0%), before-after design (25.9%), observational (18.5%) and cluster randomized (18.5%). The majority of the studies analyzed data collected from before 2012 (77.8%), and 6 (22.2%) studies investigated data collected after 2012. Aminoglycosides (96.3% of the studies) and Polymyxin B and E (81.5% of the studies) were the most frequently used topical antibiotics. Third-generation cephalosporins was the most frequently used systemic antibiotics (44.4% of the studies). Eleven (40.7%) studies did not use additional systemic antibiotics in their decontamination regimen (Table S3-4). SDD was used in 23 (85.2%), SOD in 2 (7.4%) studies, and both interventions in 2 (7.4%) studies. Seven (25.9%) of the studies used additional chlorhexidine body wash, and one (3.7%) used chlorhexidine mouthwash. Of these, five (18.5%) also administered chlorhexidine body wash in the control group, and one (3.7%) chlorhexidine mouthwash. Finally, 13 (48.1%) studies reported a follow-up of ≥ 14 days.

Table 1.

Characteristics of studies included in systematic review and meta-analysis on antimicrobial resistance after SSD/SOD in ICU patients.

Study	Country	Study design	Study years	Routinely swab regimen	Systemic antibiotics	Number of ICUs	Number of patients				Outcome gram + or - bacteria	Antimicrobial resistance as primary outcome	Endpoint colonization or infection	Intention to Treat (ITT) vs. Per Protocol (PP)
Study	Country	Study design	Study years	Routinely swab regimen	Systemic antibiotics	Number of ICUs	Total	SOD	SDD	Control	Outcome gram + or - bacteria	Antimicrobial resistance as primary outcome	Endpoint colonization or infection	Intention to Treat (ITT) vs. Per Protocol (PP)
Brun-Buisson 1989²⁴	France	Individual randomization	1987 - 1987	Every 4 days	No	1	86	0	36	50	-	Yes	Colonization****	PP
de la Cal 2004²⁶	Spain	Before and after	1997 - 2000	1x/week	Yes	1	659	0	401	258	+	Yes	Both
Camus 2005²⁸	France	Cluster randomization	1996 - 1998	1x/2weeks	No	3	256	130	0	126	+/-	No	Infection	ITT
Camus 2014³⁰	France	Before and after	2006 - 2008	1x/week	No	1	1947	0	1022	925	+/-	No	Infection
Canter 2014³²	UK	Observational	2008 - 2011	-	Yes	199	284,690	0	12,270	272,420	-	Yes	Infection
Dahms 2000³³	USA	Observational	1996 - 1999	No	No	1	596	0	54	542	+	Yes	Both
Ferrer 1994³⁵	Spain	Individual randomization	12 months	3x/week	Yes	1	79	0	39	40	+	No	Colonization****	PP
Flaherty 1990³⁶	USA	Individual randomization	8 months	2x/week	No	1	107	0	51	56	-	No	Infection****	ITT
Garcin 2012³⁷	France	Observational	-	No	Yes	1	218	0	146	125	+	No	Infection
Hammond 1992⁴⁰	South Africa	Individual randomization	1989 - 1990	2x/week	Yes	1	239	0	114	125	-	No	Colonization	PP
de Jonge 2003³	Netherlands	Cluster randomization	1999 - 2001	1x/week	Yes	1	773	0	378	395	+/-	Yes	Colonization	ITT
Katchman 2014⁴⁶	Canada	During and after	2007 - 2011	1x/week	No	1	148	0	111	37	+/-	No	Both
Krueger 2002⁴⁷	Germany	Individual randomization	2.5 years	2x/week	Yes	2	454	0	265	262	+/-	No	Colonization	PP
Perez-Granda 2018⁶¹	Spain	Before and after	2012 - 2015	No	No	1	1746	0	892	854	+/-	Yes	Colonization****
Quinio 1996⁶³	France	Individual randomization	-	2x/week	No	1	148	0	76	72	+/-	No	Colonization	ITT
Reizine 2023⁶⁴	France	Observational	2017 - 2023	-	Yes	220	5862	0	2931	2931	+/-	No	Both
Righi 2014⁶⁵	Italy	Before and after	2004 - 2010	No	Yes	1	1372	0	674	698	+/-	No	Infection
Sánchez García 1998⁶⁸	Spain	Individual randomization	-	2x/week	Yes	1	271	0	131	140	+	No	Infection****	ITT
Sánchez-Ramîrez 2018¹⁰	Spain	Before and after	2010 - 2015	1x/week	Yes	1	2992	0	1998	994	+/-	Yes	Infection****
de Smet 2011⁶⁹	Netherlands	Cluster randomization	2004 - 2006	2x/week	Yes	13	2595	886	828	881	+/-	Yes	Colonization	PP
SuDDICU 2022⁷⁰	Australia	Cluster randomization	2017-2021	1week/ month	Yes	19	5982	0	2791	3191	+/-	No	Both	ITT
Unertl 1987⁷³	Germany	Individual randomization	1984 - 1985	1x/day	No	1	39	0	19	20	+/-	No	Colonization****	ITT
Verwaest 199⁷⁴	Belgium	Individual randomization	19 months	2x/week	Yes	1	578	0	393	185	+/-	Yes	Infection	PP
van der Voort 2004⁷⁵	Netherlands	Before and after	2 years	2x/week	Yes	1	732	0	219	513	+/-	Yes	Colonization
Wang 2022⁷⁶	Germany	Case control	2012-2016	Routinely **	No	11	5034	3340	0	1694	+/-	Yes	Both
Wiener 1995⁷⁷	USA	Individual randomization	8 months	1x/week	No	1	61	0	30	31	+/-	Yes	Infection****	PP
Wittekamp 2018⁹	Multi^*	Cluster randomization	2013 - 2017	2x/week	No	13	8665	2224	2082	4359	+/-	Yes	Infection	ITT

Open in a new tab

* Belgium, Spain, Portugal, Italy, Slovenia and UK ** Frequency unknown ***Multi drug resistant, unspecified gram positive or negative **** Studies investigated both infection and colonization, but only the outcome reported in the table was used in the meta-analysis N/A. Not applicable -. Missing data (except for column depicting gram negative or positive outcome where – indicates gram negative).

Table 2.

Characteristics of studies included only in systematic review on antimicrobial resistance after SSD/SOD in ICU patients.

Study	Country	Study design	Study years	Routinely swab regimen	Systemic antibiotics	Number of ICUs	Number of patients				Outcome gram + or - bacteria	Antimicrobial resistance as primary outcome	Endpoint colonization or infection	Intention to Treat (ITT) vs. Per Protocol (PP)
Study	Country	Study design	Study years	Routinely swab regimen	Systemic antibiotics	Number of ICUs	Total	SOD	SDD	Control	Outcome gram + or - bacteria	Antimicrobial resistance as primary outcome	Endpoint colonization or infection	Intention to Treat (ITT) vs. Per Protocol (PP)
Abele-Horn 1997²⁰	Germany	Individual randomization	-	2x/week	Yes	1	85	58	0	30	+	Yes	Colonization	PP
Benus 2010²¹	Netherlands	Observational	2004 - 2006	no	Yes	1	57	19	17	21	+	No	Colonization
Bergmans 2001²²	Netherlands	Individual randomization	1994 - 1996	2x/week	No	3	226	87	0	139	+/-	No	Both	PP
van der Bij 2016²³	Netherlands	Observational	2008 - 2013	-	Yes	42	-	-	-	-	+	Yes	Both
Buitinck 2019²⁵	Multi^*	Observational	1997 - 2017	2x/week Aspirates 3x/week	Yes	1	12,054	0	12,054	0	-	Yes	Both
de la Cal 2005²⁷	Spain	Individual randomization	1997 - 2000	2x/week	Yes	1	107	0	53	54	+	No	Infection	PP
Camus 2014²⁹	France	Cluster randomization	1996 - 1999	1x/week	No	3	515	259	0	256	+	Yes	Both	ITT
Camus 2016³¹	France	Observational	2008 - 2012	1x/week	No	1	6175	0	5250	925	+/-	Yes	Both
Dautzenberg 2018³⁴	Netherlands	Observational	2005 - 2014	2x/week	Yes	2	2448	0	2448	0	-	Yes	Both
Godard 1990³⁸	France	Cluster randomization	1988	1x/week	No	1	181	0	97	84	-	No	Both	PP
Halaby 2013³⁹	Netherlands	Before and after	2001 - 2008	2x/week	No	1	134	0	106	28	-	Yes	Both
Hammond 1995⁴¹	South Africa	Before and after	1988 – 1991	2x/week	Yes	1	1528	0	719	809	+/-	Yes	Infection
Heininger 2006⁴²	Germany	Observational	2000 - 2004	2x/week	No	34	7270	0	1913	-	+/-	Yes	Both
Houben 2014⁴³	Netherlands	Observational	2008 - 2012	-	Yes	38	-	-	-	-	-	Yes	Both
Humphreys 1992⁴⁴	UK	Individual randomization	17 months	3x/week	Yes	1	267	0	92	175	+	Yes	Colonization	ITT
Janssen 2020⁴⁵	Netherlands	Observational	2018 - 2019	2x/week	Yes	1	428	0	428	0	-	Yes	Colonization
de Jonge 2018⁸	Netherlands	Observational	2010 - 2013	4x after ICU discharge	Yes	3	835	409	426	0	-	Yes	Colonization
Landelle 2018⁴⁸	Switzerland	Pre, during and after	2014 - 2016	No	No	1	1060	769	0	291	-	No	Both
Lendingham 1988⁴⁹	Scotland	Before and after	1985 - 1986	3x/week	Yes	1	324	0	163	161	-	No	Both
Leone 2003⁵⁰	France	Case control	6 years	2x/week	Yes	1	5987	0	360	360	+/-	Yes	Both
Lloréns-Villar 2019⁵¹	Spain	Before and after	1998 - 2013	No	Yes	8	-	-	0	-	+/-	Yes	Both
Massart 2022⁵²	France	Observational	2020-2021	1x/week	No	15	461	0	89	372	+/-	No	Infection
Massart 2023⁵³	France	Observational	2017-2021	1x/week	No	3	241	0	69	172	+/-	No	Colonization
Mathieu 2020⁵⁴	France	Before and after	2014 - 2018	No	Yes	1	447	0	447	0	MDR^**	No	Both
Muruzabal -Lecumberri 2015⁵⁵	Spain	Observational	2010 - 2011	2x/week	Yes	1	24	0	24	0	+	Yes	Both
Noteboom 2015⁵⁶	Netherlands	Observational	2009 - 2013	2x/week	Yes	16	8067	8067		0	-	Yes	Colonization
Ochoa-Ardila 2011⁵⁷	Spain	Observational	2002 - 2007	1x/week	Yes	1	1588	0	1588	0	+/-	Yes	Both
Oostdijk 2010⁵⁸	Netherlands	Cluster randomization	2004 - 2006	2x/week	Yes	13	-	-		-	-	Yes	Colonization	ITT
Oostdijk 2013⁵⁹	Netherlands	Cluster randomization	2004 - 2009	2x/week	Yes	13	1246	476	455	315	-	Yes	Colonization	ITT
Oostdijk 2014⁶⁰	Netherlands	Cluster randomization	2009 - 2013	2x/week	Yes	16	11,997	5957	6040	0	+/-	Yes	Colonization	PP
Plantinga 2020⁶²	Netherlands	Cluster randomization	2013 - 2017	2x/week	No	13	8665	-	-	-	-	Yes	Colonization	ITT
Rocha 1992⁶⁶	Spain	Individual randomization	14 months	2x/week	Yes	1	101	0	47	54	+/-	Yes	Both	PP
Rodríguez-Gascón 2024⁶⁷	Spain	Observational	2014-2018	2x/week	Yes	2	-	0	-	-	+/-	Yes	Both
de Smet 2009⁴	Netherlands	Cluster randomization	2004 - 2006	2x/week	Yes	13	5939	1904	2045	1990	-	No	Colonization	ITT
Tetteroo 1993⁷¹	Netherlands	Observational	18 months	1x/week	Yes	1	97	0	97	0	+	No	Colonization
Ulrich 1989⁷²	Netherlands	Individual randomization	1986 - 1987	2x/week	Yes	1	100	0	48	52	+/-	No	Colonization	PP
Wittekamp 2015⁷⁸	Netherlands	Cluster randomization	2004 - 2013	1x/month	Yes	5	1865	-		-	+/-	Yes	Colonization	ITT
Young 2024⁷⁹	Australia	Cluster randomization	2017 - 2021	1x/month	Yes	19	2061	0	968	1093	+/-	No	Both	ITT

Open in a new tab

* Belgium, Spain, Portugal, Italy, Slovenia and UK **Multi drug resistant, unspecified gram positive or negative N/A. Not applicable -. Missing data (except for column depicting gram negative or positive outcome where – indicates gram negative).

Six (22.2%) studies presented usable data on antimicrobial resistance as resistance to aminoglycosides, 5 (18.5%) studies as resistance to polymyxin B and E, 3 (11.1%) studies as resistance to fluoroquinolones, and 4 (14.8%) as resistance to third-generation cephalosporins. Antimicrobial resistance was defined as infection or colonization with MRSA in 16 (59.3%) studies, VRE in 5 (18.5%) studies, and multi-resistant bacteria in 6 (22.2%) studies. In total, 11 (40.7%) studies presented usable data for ≥ 1 of these definitions of antimicrobial resistance. The occurrence of antimicrobial resistance was the primary outcome in 13 (48.1%) studies.

One author was contacted for additional information; however, no response was received. In case of Hammond et al. (1992)⁴⁰, de Jonge et al. (2003)³, Quinio et al. (1996)⁶³, and Verwaest et al. (1997)⁷⁴, unreported information derived from available data. Absolute numbers of outcomes were calculated using reported percentages of patients with acquired antimicrobial resistant pathogens.

Risk of bias assessment

The risk of bias assessment is illustrated in Fig. S2. All studies were deemed of sufficient quality to be included in the analyses.

The funnel plot was asymmetrical (Fig. 2). When conducting the trim-and-fill analysis, two missing studies were added, one in the lower left section and one in the upper left section (Fig. S3). This indicated that two studies which found lower antimicrobial resistance after SDD or SOD were missing, which means a possible reporting bias was present. The true funnel plot was not identified as outstanding in the visual inference plot (Fig. S4). This indicated that a possible bias did not significantly influence the outcome of the forest plot. In case of reporting bias, the true effect might have been less protective than what was found in the meta-analyses (Fig. 2).

Antimicrobial resistance during ICU admission

All 27 studies which were described above were included in the meta-analysis on the occurrence of resistance during ICU stay. Of these, 25 studies were included in the analysis on SDD and four studies were included in the analysis on SOD. A significant association between SDD and the development of antimicrobial resistance during ICU admission was found; OR 0.72 (95%-CI 0.53;0.98, I² 75% n = 25, p < 0.01). The four studies included in the analysis on SOD yielded no significant association between SOD and developing antimicrobial resistance during ICU admission; OR 0.89 (95%-CI 0.48;1.64, I² 67%, n = 4, p = 0.03) (Fig. 3).

Fig. 3 — Occurrence of colonization of- or infection with resistant bacteria during ICU stay in patients receiving SDD, or SOD versus placebo or control group. Studies are divided into SDD or SOD as decontamination regimen. An odds ratio <1 suggests a protective effect and an odds ratio >1 suggests a risk-inducing effect.

Antimicrobial resistance after ICU discharge

There were four studies that investigated antimicrobial resistance both during ICU stay and after discharge in individual patients after receiving SDD or SOD^3,8,40,44. The study performed by Hammond et al. (1992) was conducted in South Africa and comprised 239 patients, of whom 114 (48%) patients received SDD⁴⁰. Hammond et al. (1992) found higher antimicrobial resistance rates until 4 weeks after first admission; 13% in the intervention group, versus 5% in the control group (p < 0.05)⁴⁰. The study of Humphreys et al. (1992) was conducted in the UK and included 267 patients, of which 92 (34%) received SDD, but did not include a control group⁴⁴. Humphreys et al. (1992) found no difference in minimal inhibitory concentrations (MIC) of bacteria to antibiotics up to four days after ICU discharge among patients who had received SDD⁴⁴. De Jonge et al. (2003) investigated 773 patients in a Dutch ICU, of which 378 (49%) received SDD³. De Jonge et al. (2003) found lower antimicrobial resistance until 10 days after discharge; 16% in the intervention group, versus 26% in the control group (p = 0.001)³. De Jonge et al. (2018) investigated 835 patients from a Dutch ICU, of whom 409 (49%) patients received SOD and 426 (51%) received SDD⁸. De Jonge et al. (2018) compared SDD group to SOD group. The study found slightly more rectal carriage with resistant gram-negative bacteria in patients who received SOD (13%), versus patients who received SDD (11%) until 10 days after ICU discharge, however, this difference was statistically significant (p = 0.7)⁸.

Resistance to specific antimicrobial agents

There were ten studies that reported analyses on the occurrence of resistance to specific antimicrobial agents^{3,10,28,36,47,61,69,73,76,77}. Five studies investigating the occurrence of resistance to aminoglycosides after SDD or SOD found no significant difference between the groups^{28,36,69,73,77}. The study of de Jonge et al. (2003) found occurrence of tobramycin resistance in gram-negative bacteria in 5% in the SDD group, and 12% in the control group, with a relative risk (RR) of 0.4 (95%-CI; 0.3;0.7)³.

Four studies found no significant difference in the occurrence of resistance to polymyxin B and E after administration of SDD or SOD^3,28,36,73. Whereas the study of de Smet et al. (2011) found significantly lower resistance to polymyxin B and E after SDD, 7% versus 15% respectively (crude OR; 0.41 (95%-CI; 0.29;0.57))⁶⁹.

Two studies did not find significant differences in the occurrence of resistance to fluoroquinolones after SDD or SOD^47,76. De Jonge et al. (2003) found significantly lower resistance to ciprofloxacin in gram-negative bacteria in the SDD group (2%) versus the control group (8%) (RR; 0.3 (95%-CI 0.1;0.6))³.

Lastly, de Smet et al. (2011) found lower resistance to third-generation cephalosporins in the SDD group (2%) versus the control group (6%) (crude OR; 0.36 (95%-CI; 0.22;0·0.1))⁶⁹. Wang et al. (2022) found a lower incidence density / 1000 days with versus without SOD of colonization with ESBL-producing K. pneumonia; 0.22 versus 0.56 (p < 0.01)⁷⁶. The two other studies investigating this specific occurrence of antimicrobial resistance did not find significant differences between SDD or SOD and the control group^10,61.

Occurrence of VRE, MRSA and multi-resistant pathogens

Fourteen studies investigated the acquisition of MRSA in patients who received SDD. Pooling of these studies yielded no significant result; OR 1.02 (95%-CI 0.76;1.38, I² 42%, p = 0.05) (Fig. 4). Three studies investigated the acquisition of MRSA after SOD, with no significant differences between intervention and control group^9,28,76.

Fig. 4 — Additional analysis on the occurrence of colonization of-, or infection of MRSA. An odds ratio <1 suggests a protective effect and an odds ratio > 1 suggests a risk-inducing effect.

Four studies investigated the occurrence of VRE after SDD or SOD, with no significant differences between SDD or SOD and control group^3,9,32,33. However, Wang et al. (2022) found a higher incidence density / 1000 days with versus without SOD of colonization with VRE; 0.72 versus 0.31 (p < 0.01)⁷⁶.

Lastly, six studies investigated the occurrence of multi-resistant bacteria other than MRSA or VRE, of which two studies described less multi-resistant bacteria in the SDD group versus control group^{9,30,61,64,65,75}. These studies included Camus et al. (2014); (1% vs. 2%, respectively. Adjusted OR; 0.33 (95%-CI 0.15–0.74; p = 0.008))³⁰, and Reizine et al. (2023); (1% vs. 5%, respectively, p < 0.001)⁶⁴. Definitions of multi-resistant bacteria used by the studies are specified in Table S5.

Sensitivity analyses

All 27 studies that were included in the meta-analysis were subdivided in the sensitivity analyses on different study characteristics. In total, 15 (55%) studies included IV antibiotics in their study regimen, and 12 (45%) studies did not. Studies using IV antibiotics in their regimen yielded a significant association with lower antimicrobial resistance in patients receiving SDD, while no significant association was found in studies not using IV antibiotics; respectively OR 0.70 (95%-CI 0.52;0.96, I² 76%, p < 0.0001) and OR 0.86 (95%-CI 0.47;1.57, I² 75%, p < 0.01) (Figure S5).

There were 10 (37%) studies with individual randomization, i.e. studies with patients who received SDD or SOD and control patients in the same ICU. There were 17 (63%) studies with cluster randomization or an observational design, i.e. studies where intervention patients were in separate ICUs than control patients. When observational and cluster-randomized design studies were pooled together, there was a significant protective effect of SDD and SOD to the occurrence of antimicrobial resistance, OR 0.61 (95%-CI 0.49;0.75, I² 67%, p < 0.01). No such effect was found in individually randomized studies, OR 1.31 (95%-CI 0.66;2.61, I² 63%, p < 0.01) (Fig. S6).

Of all 27 meta-analyzed studies, 14 (52%) had a follow-up < 14 days, which showed lower antimicrobial resistance in the intervention group; OR 0.57 (95%-CI 0.42;0.78, I² 61%, p < 0.01). The other studies with a follow-up ≥ 14 days (12 (44%) studies) found no such association; OR 1.11 (95%-CI 0.66;1.87, I² 82%, p < 0.01) (Fig. S7). The study of the SuDDICU Investigators et al. (2022) did not specify median days of follow-up of microbiological cultures and was therefore not included in this sensitivity analysis⁷⁰.

Discussion

In total, four studies investigated the occurrence of antimicrobial resistance after SDD or SOD and after ICU discharge. One study found lower, and one study found higher antimicrobial resistance after SDD^3,40. One study found no difference in MICs for bacteria after ICU discharge in patients who had received SDD and one study found more rectal carriage of resistant gram-negative bacteria in patients who received SOD versus patients who received SDD^8,44.

Moreover, 27 studies investigated the occurrence of antimicrobial resistance during ICU stay. There were significantly fewer patients during ICU stay with antimicrobial resistance after receiving SDD, based on studies with a median length of ICU stay of < 14 days and administering IV antibiotics as part of the SDD or SOD regimen. However, there was significant heterogeneity, which is reflected in the wide variation in outcome incidences across studies. This heterogeneity should be considered when interpreting the meta-analysis results, as it limits the generalizability of the results and indicates extensive inter-study variability. There were only four studies investigating SOD, and they yielded no significant association between SOD and developing antimicrobial resistance during ICU stay.

Antimicrobial resistance after ICU discharge

The few studies investigating the occurrence of antimicrobial resistance after ICU discharge yielded conflicting results. The two studies that included a control group showed different results. The study of De Jonge et al. (2003) was conducted in the Netherlands and did not find an increase in MRSA in both groups, whereas Hammond et al. (1992) in South Africa found more MRSA in the SDD or SOD group than in the control group^3,44. The resistance rates in South Africa are higher than in the Netherlands, which makes the occurrence of MRSA more common in South Africa than in the Netherlands^80,81. As MRSA is practically absent in the Netherlands it is a priori unlikely that MRSA acquisition occurs under any antibiotic regimen. Moreover, the studies also included data of antimicrobial resistance during ICU stay, therefore these outcomes do not reflect resistance rates occurring exclusively after ICU discharge. Only the study of Hammond et al. had a follow-up after ICU discharge > 2 weeks and showed an increasing colonization rate of 10% at week 2 and 13% at week 4⁴⁰.

Clinical relevance

To decide whether to apply preventative antibiotics, advantages and disadvantages must be weighed against each other. In case of SDD and SOD, mortality rates, infection rates, costs and short-term occurrence of resistance have all been extensively studied and have shown positive results^7,82–84. Moreover, overall total antibiotic consumption when using SDD or SOD versus control was comparable to lower than in control in 20 of the 21 studies investigating this^{3,4,10,22,30,31,36,41,44,46–48,53,63,67,68,72,77–79}. Only one study found a higher intravenous antibiotic consumption rate in patients receiving SOD versus control⁷⁶.

However, the occurrence of antibiotic resistance on the long term should also be a factor in the consideration on whether to apply preventative antibiotics. Antimicrobial resistance on the long term, e.g., after ICU discharge, is important as it could lead to increased morbidity by complicating treatment of infections⁶. Currently, there is little knowledge on the long-term effect of preventative antibiotics in general on antimicrobial resistance. This could possibly be explained by the fact that long -term investigation is costly and prone to loss of follow-up. It should be noted that this is specifically about the long-term effect at the level of individual patients rather than population-level long-term effect. For example, an ecological study found that resistance rates in an ICU did not increase significantly during SDD administration over a period of 21 years, however this study did not analyze the long-term in patients i.e. after ICU discharge²⁵. In the short term, it is known that preventative antibiotics influence the composition of the gut-microbiome⁸⁵. Interestingly, the gut-microbiome has the capacity to recover several days after exposure to antibiotics^86,87. Whether this recovery is accompanied by antimicrobial resistance remains uncertain⁸⁸. However, both Hammond et al. and de Jonge et al. showed that it is possible to obtain antibiotic resistance after ICU discharge^8,40.

To investigate this possible long-term effect of preventative antibiotics, one must discriminate clearly between the effect of preventative and therapeutic antibiotics. The specific patient population in which this is possible consists of trauma patients or elective complex surgery patients who receive SDD or SOD. Trauma and elective complex surgery patients are mainly a healthy population without excessive hospitalization and treatments before being admitted to the ICU³⁷. Hence, the SDD or SOD administration is usually the first exposure to antibiotics in a previously unaffected microbiome³⁷. Therefore, it is recommended to investigate the long-term effect of SDD or SOD on the occurrence of antimicrobial resistance specifically in trauma and elective complex surgery patients. As SDD and SOD have been extensively studied to be beneficial for outcomes on mortality and infection rates in ICU patients, it would be ethically preferable to investigate long-term occurrence of antimicrobial resistance observationally rather than initiating a randomized controlled trial.

Such a study would preferably be conducted prospectively with rectal baseline swabs at admission, followed by routine swabs during ICU stay and lastly follow-up at 6 weeks and 1 year after ICU discharge. Secondly, the outcomes of these swabs should be combined with outcomes of cultures from clinically relevant infections to gain insight into the possible risks associated with the acquisition of antimicrobial-resistant bacteria. Such prospective long-term follow-up study would provide insights regarding rectal colonization, antimicrobial resistance occurrence and its relation to the occurrence of infections with different pathogens. This information together could contribute to a patient-specific consideration on whether to administer preventative antimicrobial agents.

Antimicrobial resistance during ICU stay

The significantly lower resistance during ICU stay in studies using SDD, especially in studies also administrating IV antibiotics as part of the SDD regimen, can be explained by the eradication of bacteria from the digestive tract or by the potentially reduction in the use of other antibiotics⁷⁹. It is unlikely that the decrease in antimicrobial resistance is due to reduced external acquisition. However, most of the included studies investigated occurrence of multi-resistant bacteria and MRSA (80% of studies), and it is important to acknowledge the inter-country differences in prevalence of these bacteria^80,81. In countries with a low prevalence of multi-resistant bacteria or MRSA, resistance to antimicrobial agents used in the SDD regimen may be a more clinically relevant outcome than MRSA occurrence, given the higher anticipated risk of resistance developing to these agents. Moreover, it should be noted that SDD and SOD are not intended to eradicate MRSA or bacteria intrinsically resistant to SDD or SOD components, and therefore the emergence of resistance due to SDD and SOD is unlikely. Rather, the increased occurrence of MRSA is likely due to selection under antibiotic pressure and therefore a reflection of the underlying baseline prevalence in that setting.

Moreover, the heterogeneity of 75% (^I2) was considerable and should be taken into account in interpreting the results. This heterogeneity was not only reflected in the I² value itself, but also in the wide variation in endpoint incidences across studies (ranging from 1% to 49%). Such variation is explained by between-study differences in antibiotic use, ICU settings and study design. The sensitivity analyses further demonstrated the impact of these study characteristics on the pooled estimates.

Firstly, studies with IV antibiotics in their SDD or SOD regimen found significantly lower resistance during ICU stay in patients who received SDD or SOD as opposed to studies not using IV antibiotics as part of the SDD or SOD regimen. This may be caused by a more systemic eradication of bacteria in patients receiving IV antibiotics in comparison to no IV antibiotics.

Secondly, studies conducted in countries with low antimicrobial resistance rates showed significant reduction in antimicrobial resistance during ICU stay. This is in line with previous studies^4,89. This is possibly because in countries with lower resistance rates, antimicrobial resistant bacteria are less likely to be selected through SDD or SOD.

Thirdly, studies with a cluster randomized and observational design pooled together yielded a significant protective effect versus no protective effect in studies with an individually randomized design. This can be explained by risk of cross-contamination in an individually randomized design, where intervention and control patients may be admitted at the same ICU. This could cause cross-contamination of pathogens from intervention group to the control group.

Lastly, studies in which the length of stay on the ICU was a mean or median of < 14 days yielded significantly lower antimicrobial resistance as opposed to studies in which the length of stay on the ICU was a mean or median of > 14 days. It is tempting to speculate that if antimicrobial resistance occurs, it would do so after two weeks. This can be explained by time needed to develop resistance as well as a prolonged period of possible external acquisition of bacteria such as MRSA for example due to prolonged ICU stay, possible interventions and foreign bodies.

Strengths and limitations

Strengths of this study are the addition of 33 new studies to Daneman et al.⁷, the focus on antimicrobial resistance after ICU discharge, the clear distinction between effect of SDD and SOD, and the transparency of our research process. Limitations are substantial heterogeneity in study countries, the variations in SDD and SOD regimens used, local antimicrobial resistance rates, and standard hygiene measures. Therefore, the generalizability of the results is limited. The funnel plot was asymmetrical as it seemed few studies that reported lower antimicrobial resistance after SDD or SOD were missing, indicating a possible minor reporting bias. In case of minimal reporting bias, the actual protective effect of SDD on the occurrence of antimicrobial resistance might be lower than the result from this meta-analysis.

Beyond this, it remains uncertain to what extent the observed effects reflect preventive benefits versus population-level influences. Concerns include that the apparent effects are mainly observed in studies with high event rates⁹⁰. In addition, as mentioned above, reported incidence rates vary widely (1%–49%). This suggests that the effect on antimicrobial resistance may partly be driven by underlying population-level dynamics rather than a direct effect of the interventions alone⁹⁰. These potential population-level effects remain insufficiently studied and warrant further investigation.

Moreover, mortality could be considered a competing event for the occurrence of antimicrobial resistance. However, conducting a sensitivity analysis on mortality as competing event would require detailed patient-level data. This sensitivity analysis was not performed as these data were not available. Lastly, correction for multiple testing was not done, yielding an increased risk of false-positive outcomes. However, this methodology was deliberately chosen, given the explorative nature of this study.

Conclusion

During ICU stay, SDD was not significantly associated with increased antimicrobial resistance to specific antibiotics, more specifically when an IV component is added, which is in line with previous reviews. This was not observed for SOD. Moreover, this current review shows there were limited data available on the long-term effect of SDD and SOD on antimicrobial resistance. Knowledge of the long-term effect of SDD and SOD on antimicrobial resistance, the potential population effect, and the effect on the gut microbiome is a fundamental contributor in the consideration of whether to apply SDD or SOD.

Therefore, it is recommended to enlarge the data on the occurrence of antimicrobial resistance after ICU discharge by conducting an observational prospective long-term follow-up study in patients receiving SDD or SOD without prior exposure to antibiotics, such as trauma and elective surgery patients.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1^{(1.4MB, docx)}

Abbreviations

ICU: Intensive Care Unit
IV: Intravenous
MRSA: Methicillin-Resistant S. aureus
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
SDD: Selective Digestive Decontamination
SOD: Selective Oropharyngeal Decontamination
VRE: Vancomycin Resistant Enterococcus spp.

Author contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by F.J.C. van Eerten, J.D.J. Plate and V.A. Schweitzer. The first draft of the manuscript was written by F.J.C. van Eerten and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

There are no financial, or non-financial conflicts of interest to declare for all authors.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

1.Vincent, J-L. et al. International study of the prevalence and outcomes of infection in intensive care u. JAMA302, 2323–2329. 10.1001/jama.2009.1754 (2009). [DOI] [PubMed] [Google Scholar]
2.Hammond, N. E. et al. Association between selective decontamination of the digestive tract and in-hospital mortality in intensive care unit patients receiving mechanical ventilation: a systematic review and meta-analysis. JAMA Am. Med. Assoc.328, 1922–1934. 10.1001/jama.2022.19709 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
3.de Jonge, E. et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet362, 1011–1016. 10.1016/s0140-6736(03)14409-1 (2003). [DOI] [PubMed] [Google Scholar]
4.de Smet, A. M. G. A., Kluytmans, J. A. W. J. & Cooper, B. S. Decontamination of the digestive tract and oropharynx in ICU patients. New. Engl. J. Med.360, 20–31. 10.1056/nejmoa0800394 (2009). [DOI] [PubMed] [Google Scholar]
5.Kesecioglu, J. & Eggimann, P. What is new in selective decontamination of the digestive tract? Intensive Care Med.42, 1270–1275. 10.1007/s00134-015-4009-5 (2016). [DOI] [PMC free article] [PubMed]
6.Antimicrobial Resistance Collaborators et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 399, 629–655. 10.1016/S0140-6736(21)02724-0 (2022). [DOI] [PMC free article] [PubMed]
7.Daneman, N., Sarwar, S., Fowler, R. A. & Cuthbertson, B. H. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. Lancet Infect. Dis.13, 328–341. 10.1016/S1473-3099(12)70322-5 (2013). [DOI] [PubMed] [Google Scholar]
8.de Jonge, E. et al. Carriage of antibiotic-resistant Gram-negative bacteria after discontinuation of selective decontamination of the digestive tract (SDD) or selective oropharyngeal decontamination (SOD). Crit. Care. 22, 1–10. 10.1186/s13054-018-2170-2 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Wittekamp, B. H. et al. Decontamination strategies and bloodstream infections with antibiotic-resistant microorganisms in ventilated patients: a randomized clinical trial. JAMA Am. Med. Assoc.320, 2087–2098. 10.1001/jama.2018.13765 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Sánchez-Ramírez, C. et al. Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance. Crit. Care 22, 141. 10.1186/s13054-018-2057-2 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
11.PROSPERO International prospective register of systematic reviews. [Internet]. https://www.crd.york.ac.uk/prospero (2024).
12.Liberati, A. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J. Clin. Epidemiol.62, e1–34. 10.1016/j.jclinepi.2009.06.006 (2009). [DOI] [PubMed] [Google Scholar]
13.Garner, P. et al. When and how to update systematic reviews: consensus and checklist. BMJ2016, 354. 10.1136/bmj.i3507 (2016). [DOI] [PMC free article] [PubMed]
14.Slim, K. et al. Methodological Index for Non-Randomized Studies (MINORS): development and validation of a new instrument. ANZ J. Surg.73, 712–716 (2003). [DOI] [PubMed] [Google Scholar]
15.R Core Team. A language and environment for statistical computing. R Foundation for Statistical Computing. Vienna, Austria (2017).
16.Sterne, J. A. C., Egger, M. & Moher, D. On behalf of the Cochrane Bias Methods Group. Addressing reporting biases. [Internet]. https://handbook-5-1.cochrane.org/chapter_10/10_addressing_reporting_biases.htm (2024).
17.Kossmeier, M., Tran, U. S. & Voracek, M. Visual inference for the funnel plot in meta-analysis. Z. Psychol.227, 83–89. 10.1027/2151-2604/a000358 (2019). [DOI]
18.Duval, S. & Tweedie, R. A nonparametric “Trim and Fill” method of accounting for publication bias in meta-analysis. J. Am. Stat. Assoc.95, 89–98. 10.1080/01621459.2000.10473905 (2000). [DOI] [Google Scholar]
19.Riley, R. D., Higgins, J. P. T. & Deeks, J. J. Interpretation of random effects meta-analyses. BMJ342, 964–967. 10.1136/bmj.d549 (2011). [DOI] [PubMed] [Google Scholar]
20.Abele-Horn, M. et al. Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD). Intensive Care Med.23, 187–195. 10.1007/s001340050314 (1997). [DOI] [PubMed] [Google Scholar]
21.Benus, R. F. et al. Impact of digestive and oropharyngeal decontamination on the intestinal microbiota in ICU patients. Intensive Care Med.36, 1394–1402. 10.1007/s00134-010-1826-4 (2010). [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Bergmans, D. C. J. J. et al. Prevention of ventilator-associated pneumonia by oral decontamination. Am. J. Respir Crit. Care Med.164, 382–388. 10.1164/ajrccm.164.3.2005003 (2001). [DOI] [PubMed] [Google Scholar]
23.van der Bij, A. K. et al. Gram-positive cocci in Dutch ICUs with and without selective decontamination of the oropharyngeal and digestive tract: a retrospective database analysis. J. Antimicrob. Chemother. 71, 816–820. 10.1093/jac/dkv396 (2016). [DOI] [PubMed] [Google Scholar]
24.Brun-Buisson, C. et al. Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Study of an outbreak in an intensive care unit. Ann. Intern. Med.110, 873–881. 10.7326/0003-4819-110-11-873 (1989). [DOI] [PubMed] [Google Scholar]
25.Buitinck, S. et al. The ecological effects of selective decontamination of the digestive tract (SDD) on antimicrobial resistance: a 21-year longitudinal single-centre study. Crit. Care 23, 208. 10.1186/s13054-019-2480-z (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
26.de la Cal, M. A. et al. Effectiveness and safety of enteral vancomycin to control endemicity of methicillin-resistant Staphylococcus aureus in a medical/surgical intensive care unit. J. Hosp. Infect.56, 175–183. 10.1016/j.jhin.2003.09.021 (2004). [DOI] [PubMed] [Google Scholar]
27.de La Cal, M. A. et al. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract. Ann. Surg.241, 424–430. 10.1097/01.sla.0000154148.58154.d5 (2005). [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Camus, C. et al. Prevention of acquired infections in intubated patients with the combination of two decontamination regimens. Crit. Care Med.33, 307–314. 10.1097/01.CCM.0000152224.01949.01 (2005). [DOI] [PubMed] [Google Scholar]
29.Camus, C. et al. Mupirocin/chlorexidine to prevent methicillin-resistant Staphylococcus aureus infections: Post hoc analysis of a placebo-controlled, randomized trial using mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired infections in intubated patients. Infection42, 493–502. 10.1007/s15010-013-0581-1 (2014). [DOI] [PubMed] [Google Scholar]
30.Camus, C. et al. Short-term decline in all-cause acquired infections with the routine use of a decontamination regimen combining topical polymyxin, tobramycin, and amphotericin B with mupirocin and chlorhexidine in the ICU: a single-center experience. Crit. Care Med. 42, 1121–1130. 10.1097/CCM.0000000000000140 (2014). [DOI] [PubMed] [Google Scholar]
31.Camus, C. et al. Decline of multidrug-resistant Gram negative infections with the routine use of a multiple decontamination regimen in ICU. J. Infect. 73, 200–209. 10.1016/j.jinf.2016.06.007 (2016). [DOI] [PubMed] [Google Scholar]
32.Canter, R. R. et al. Observational study of current use of selective decontamination of the digestive tract in UK Critical Care units. Br. J. Anaesth. 113, 610–617. 10.1093/bja/aeu108 (2014). [DOI] [PubMed] [Google Scholar]
33.Dahms, R., Carlson, M., Lohr, B. & Beilman, G. Selective digestive tract decontamination and vancomycin-resistant enterococcus isolation in the surgical intensive care unit. Shock14, 343–346. 10.1097/00024382-200014030-00018 (2000). [DOI] [PubMed] [Google Scholar]
34.Dautzenberg, M. J. D. et al. Dynamics of colistin and tobramycin resistance among Enterobacter cloacae during prolonged use of selective decontamination of the digestive tract. Antimicrob. Resist. Infect. Control 7, 67. 10.1186/s13756-018-0356-7 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Ferrer, M. et al. Utility of selective digestive decontamination general population of mechanically ventilated patients. Ann. Intern. Med.120, 389–395 (1994). [DOI] [PubMed] [Google Scholar]
36.Flaherty, J., Nathan, C., Kabins, S. A. & Weinstein, R. A. Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit. J. Infect. Dis.162, 1393–1397 (1990). [DOI] [PubMed] [Google Scholar]
37.Garcin, F. et al. Selective digestive decontamination and empirical antimicrobial therapy of late–onset ventilator–associated pneumonia in trauma. J. Acute Dis.1, 1–6. 10.1016/S2221-6189(13)60001-3 (2012). [DOI] [Google Scholar]
38.Godard, J., Guillaume, C., Reverdy, M. E., Herriot, E. & Received, F. Intestinal decontamination in a polyvalent ICU. A double-blind study. Intensive Care Med.16, 307–311 (1990). [DOI] [PubMed] [Google Scholar]
39.Halaby, T., Naiemi, N., Al, Kluytmans, J., Van Der Palen, J. & Vandenbroucke-Grauls, C. M. J. E. Emergence of colistin resistance in Enterobacteriaceae after the introduction of selective digestive tract decontamination in an intensive care unit. Antimicrob. Agents Chemother.57, 3224–3229. 10.1128/AAC.02634-12 (2013). [DOI] [PMC free article] [PubMed] [Google Scholar]
40.Hammond, J. M. J., Potgieter, P. D. & Hammond, J. M. J. Double-blind study of selective decontamination of the digestive tract in intensive care. JAMA340, 5–9. 10.1016/0140-6736(92)92422-c (1992). [DOI] [PubMed] [Google Scholar]
41.Hammond, J. M. & Potgieter, P. D. Long-term effects of selective decontamination on antimicrobial resistance. Crit. Care Med.23, 637–645 (1995). [DOI] [PubMed] [Google Scholar]
42.Heininger, A. et al. Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance. Intensive Care Med.32, 1569–1576. 10.1007/s00134-006-0304-5 (2006). [DOI] [PubMed] [Google Scholar]
43.Houben, A. J. M. et al. Selective decontamination of the oropharynx and the digestive tract, and antimicrobial resistance: a 4 year ecological study in 38 intensive care units in the Netherlands. J. Antimicrob. Chemother.69, 797–804. 10.1093/jac/dkt416 (2014). [DOI] [PubMed] [Google Scholar]
44.Humphreys, H., Winter, R. & Pick, A. The effect of selective decontamination of the digestive tract on gastrointestinal enterococcal colonization in ITU patients. Intensive Care Med.18, 459–463. 10.1007/BF01708581 (1992). [DOI] [PubMed] [Google Scholar]
45.Janssen, A. B., van Hout, D., Bonten, M. J. M., Willems, R. J. L. & van Schaik, W. Microevolution of acquired colistin resistance in enterobacteriaceae from ICU patients receiving selective decontamination of the digestive tract. J. Antimicrob. Chemother. 75, 3135–3143. 10.1093/jac/dkaa305 (2020). [DOI] [PubMed] [Google Scholar]
46.Katchman, E. et al. A comparative study of the use of selective digestive decontamination prophylaxis in living-donor liver transplant recipients. Transpl. Infect. Dis. 16, 539–547. 10.1111/tid.12235 (2014). [DOI] [PubMed] [Google Scholar]
47.Krueger, W. A. et al. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically III surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical tr. Am. J. Respir. Crit. Care Med.166, 1029–1037. 10.1164/rccm.2105141 (2002). [DOI] [PubMed] [Google Scholar]
48.Landelle, C. et al. Impact of a multifaceted prevention program on ventilator-associated pneumonia including selective oropharyngeal decontamination. Intensive Care Med. 44, 1777–1786. 10.1007/s00134-018-5227-4 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
49.Ledingham, I. M. et al. Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet331, 785–790 (1988). [DOI] [PubMed] [Google Scholar]
50.Leone, M., Albanese, J., Antonini, F., Nguyen-Michel, A. & Martin, C. Long-term (6-year) effect of selective digestive decontamination on antimicrobial resistance in intensive care, multiple-trauma patients. Crit. Care Med.31, 2090–2095. 10.1097/01.CCM.0000079606.16776.C5 (2003). [DOI] [PubMed] [Google Scholar]
51.Lloréns-Villar, Y. et al. Antibiotic susceptibility trend before and after long-term use of selective digestive decontamination: a 16 year ecological study. J. Antimicrob. Chemother. 74, 2289–2294. 10.1093/jac/dkz186 (2019). [DOI] [PubMed] [Google Scholar]
52.Massart, N. et al. Multiple-site decontamination regimen decreases acquired infection incidence in mechanically ventilated COVID-19 patients. Ann. Intensive Care 12, 84. 10.1186/s13613-022-01057-x (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
53.Massart, N. et al. Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO support. Ann. Intensive Care2023, 13. 10.1186/s13613-023-01120-1 (2023). [DOI] [PMC free article] [PubMed]
54.Mathieu, C. et al. Decreased duration of intravenous cephalosporins in intensive care unit patients with selective digestive decontamination: a retrospective before-and-after study. Eu J. Clin. Microbiol. Infect. Dis. 39, 2115–2120. 10.1007/s10096-020-03966-w (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
55.Muruzábal-Lecumberri, I., Girbau, C., Canut, A., Alonso, R. & Fernández-Astorga, A. Spread of an Enterococcus faecalis sequence type 6 (CC2) clone in patients undergoing selective decontamination of the digestive tract. APMIS123, 245–251. 10.1111/apm.12336 (2015). [DOI] [PubMed] [Google Scholar]
56.Noteboom, Y. et al. Antibiotic-induced within-host resistance development of gram-negative bacteria in patients receiving selective decontamination or standard care. Crit. Care Med. 43, 2582–2588. 10.1097/CCM.0000000000001298 (2015). [DOI] [PubMed] [Google Scholar]
57.Ochoa-Ardila, M. E. et al. Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: A 5-year prospective cohort study. Intensive Care Med.37, 1458–1465. 10.1007/s00134-011-2307-0 (2011). [DOI] [PubMed] [Google Scholar]
58.Oostdijk, E. A. N. et al. Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am. J. Respir Crit. Care Med.181, 452–457. 10.1164/rccm.200908-1210OC (2010). [DOI] [PubMed] [Google Scholar]
59.Oostdijk, E. A. N. et al. Colistin resistance in gram-negative bacteria during prophylactic topical colistin use in intensive care units. Intensive Care Med.39, 653–660. 10.1007/s00134-012-2761-3 (2013). [DOI] [PubMed] [Google Scholar]
60.Oostdijk, E. A. N. et al. Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in icus a randomized clinical trial. JAMA Am. Med. Assoc.312, 1429–1437. 10.1001/jama.2014.7247 (2014). [DOI] [PubMed] [Google Scholar]
61.Pérez-Granda, M. J. et al. Impact of selective digestive decontamination without systemic antibiotics in a major heart surgery intensive care unit. J. Thorac. Cardiovasc. Surg. 156, 685–693. 10.1016/j.jtcvs.2018.02.091 (2018). [DOI] [PubMed] [Google Scholar]
62.Plantinga, N. L. et al. The effects of topical antibiotics on eradication and acquisition of third-generation cephalosporin and carbapenem-resistant Gram-negative bacteria in ICU patients; a post hoc analysis from a multicentre cluster-randomized trial. Clin. Microbiol. Infect. 26, 485–491. 10.1016/j.cmi.2019.08.001 (2020). [DOI] [PubMed] [Google Scholar]
63.Quinio, B., Albanese, J., Bues, C. M., Viviand, X. & Martin, C. Selective decontamination of the digestive tract in multiple trauma patients. A prospective double-blind, randomized, placebo-controlled study. Chest109, 765–772 (1996). [DOI] [PubMed] [Google Scholar]
64.Reizine, F. et al. Association between selective digestive decontamination and decreased rate of acquired candidemia in mechanically ventilated ICU patients: a multicenter nationwide study. Crit. Care27, 494. 10.1186/s13054-023-04775-1 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]
65.Righi, E. et al. Trends in ventilator-associated pneumonia: impact of a ventilator care bundle in an Italian tertiary care hospital intensive care unit. Am. J. Infect. Control 42, 1312–1316. 10.1016/j.ajic.2014.08.009 (2014). [DOI] [PubMed] [Google Scholar]
66.Rocha, L. A. et al. Intensive care medicine prevention of nosocomial infection in critically ill patients by selective decontamination of the digestive tract a randomized, double blind, placebo-controlled study. Intensive Care Med.18, 398–404 (1992). [DOI] [PubMed] [Google Scholar]
67.Rodríguez-Gascón, A., Lloréns-Villar, Y., Solinís, M. Á., Barrasa, H. & Canut-Blasco, A. Does selective digestive decontamination (SDD) increase antibiotic resistance? Long-term comparison of two intensive care units (with and without SDD) of the same tertiary hospital. Eu J. Clin. Microbiol. Infect. Dis. 43, 885–893. 10.1007/s10096-024-04792-0 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]
68.Sánchez-García, M. et al. Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients. Am. J. Respir Crit. Care Med.158, 908–916. 10.1164/ajrccm.158.3.9712079 (1998). [DOI] [PubMed] [Google Scholar]
69.de Smet, A. M. G. A. et al. 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 Infect. Dis.11, 372–380. 10.1016/S1473-3099(11)70035-4 (2011). [DOI] [PubMed] [Google Scholar]
70.SuDDICU, I. et al. Effect of selective decontamination of the digestive tract on hospital mortality in critically ill patients receiving mechanical ventilation: a randomized clinical trial. JAMA Am. Med. Assoc.328, 1911–1921. 10.1001/jama.2022.17927 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
71.Tetteroo, G. W. M., Wagenvoort, J. H. T., Mulder, P. G. H., Ince, C. & Bruining, H. A. Decreased mortality rate and length of hospital stay in surgical intensive care unit patients with successful selective decontamination of the gut. Crit. Care Med.21, 1692–1698 (1993). [DOI] [PubMed] [Google Scholar]
72.Ulrich, C. et al. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study. Intensive Care Med.15, 424–431. 10.1007/BF00255597 (1989). [DOI] [PubMed] [Google Scholar]
73.Unertl, K. et al. Prevention of colonization and respiratory infections in long- term ventilated patients by local antimicrobial prophylaxis. Intensive Care Med.13, 106–113 (1987). [DOI] [PubMed] [Google Scholar]
74.Verwaest, C. et al. Randomised, controlled trial of selective digestive deconatmination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit. Care Med.25, 63–71 (1997). [DOI] [PubMed] [Google Scholar]
75.van der Voort, P. H. J. et al. A before-after study of multi-resistance and cost of selective decontamination of the digestive tract. Infection32, 271–277. 10.1007/s15010-004-3170-5 (2004). [DOI] [PubMed] [Google Scholar]
76.Wang, B. et al. Ecological effects of selective oral decontamination on multidrug-resistance bacteria acquired in the intensive care unit: a case–control study over 5 years. Intensive Care Med. . 48, 1165–1175. 10.1007/s00134-022-06826-7 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
77.Wiener, J. et al. A randomized, double-blind, placebo-controlled trial of selective digestive decontamination in a medical-surgical intensive-care unit. Clin. Infect. Dis.20, 861–867 (1995). [DOI] [PubMed] [Google Scholar]
78.Wittekamp, B. H. J., Oostdijk, E. A. N., De Smet, A. M. G. A. & Bonten, M. J. M. Colistin and tobramycin resistance during long- term use of selective decontamination strategies in the intensive care unit: a post hoc analysis. Crit. Care 2025, 19. 10.1186/s13054-015-0838-4 (2015). [DOI] [PMC free article] [PubMed]
79.Young, P. J. et al. Selective digestive tract decontamination in critically ill adults with acute brain injuries: a post hoc analysis of a randomized clinical trial. Intensive Care Med. 50, 56–67. 10.1007/s00134-023-07261-y (2024). [DOI] [PubMed] [Google Scholar]
80.Jurke, A. et al. Changing epidemiology of meticillin-resistant Staphylococcus aureus in 42 hospitals in the Dutch–German border region, 2012 to 2016: results of the search-and-follow-policy. Euro surveill. Eur. Centre Disease Prev. Control (ECDC). 24, 1800244. 10.2807/1560-7917.ES.2019.24.15.1800244 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
81.Perovic, O. et al. Prevalence and trends of staphylococcus aureus bacteraemia in hospitalized patients in South Africa, 2010 to 2012: laboratory-based surveillance mapping of antimicrobial resistance and molecular epidemiology. PLoS One 10, e0145429. 10.1371/journal.pone.0145429 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
82.Zhu, D. et al. Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses. J. Hosp. Infect. 145, 174–186. 10.1016/j.jhin.2023.12.017 (2024). [DOI] [PubMed] [Google Scholar]
83.Oostdijk, E. A. et al. Selective decontamination of the digestive tract and selective oropharyngeal decontamination in intensive care unit patients: a cost-effectiveness analysis. BMJ Open.3, e002529. 10.1136/bmjopen-2012 (2013). [DOI] [PMC free article] [PubMed] [Google Scholar]
84.Minozzi, S. et al. Topical antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving mechanical ventilation. Cochrane Database Syst. Rev. 1, CD000022. 10.1002/14651858.CD000022.pub4 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
85.Tan, G. et al. Gut microbiota modulation: implications for infection control and antimicrobial stewardship. Adv. Ther.37, 4054–4067. 10.6084/m9.figshare.12689891 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
86.Huttner, B. et al. Decolonization of intestinal carriage of extended-spectrum Β-lactamase-producing Enterobacteriaceae with oral colistin and neomycin: a randomized, double-blind, placebo-controlled trial. J. Antimicrob. Chemother.68, 2375–2382. 10.1093/jac/dkt174 (2013). [DOI] [PubMed] [Google Scholar]
87.Aardema, H. et al. Marked changes in gut microbiota in cardio-surgical intensive care patients: a longitudinal cohort study. Front. Cell. Infect. Microbiol. 9, 467. 10.3389/fcimb.2019.00467 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
88.Buelow, E. et al. Comparative gut microbiota and resistome profiling of intensive care patients receiving selective digestive tract decontamination and healthy subjects. Microbiome5, 88. 10.1186/s40168-017-0309-z (2017). [DOI] [PMC free article] [PubMed] [Google Scholar]
89.de Smet, A. M. G. A., Bonten, M. J. M. & Kluytmans, J. A. J. W. For whom should we use selective decontamination of the digestive tract? Curr. Opin. Infect. Dis.25, 211–217. 10.1097/QCO.0b013e3283507f8cLK (2012). [DOI] [PubMed]
90.Hurley, J. C. Selective digestive decontamination-Con. Intensive Care Med.49, 982–983. 10.1007/s00134-023-07146-0 (2023). [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

[CR1] 1.Vincent, J-L. et al. International study of the prevalence and outcomes of infection in intensive care u. JAMA302, 2323–2329. 10.1001/jama.2009.1754 (2009). [DOI] [PubMed] [Google Scholar]

[CR2] 2.Hammond, N. E. et al. Association between selective decontamination of the digestive tract and in-hospital mortality in intensive care unit patients receiving mechanical ventilation: a systematic review and meta-analysis. JAMA Am. Med. Assoc.328, 1922–1934. 10.1001/jama.2022.19709 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR3] 3.de Jonge, E. et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet362, 1011–1016. 10.1016/s0140-6736(03)14409-1 (2003). [DOI] [PubMed] [Google Scholar]

[CR4] 4.de Smet, A. M. G. A., Kluytmans, J. A. W. J. & Cooper, B. S. Decontamination of the digestive tract and oropharynx in ICU patients. New. Engl. J. Med.360, 20–31. 10.1056/nejmoa0800394 (2009). [DOI] [PubMed] [Google Scholar]

[CR5] 5.Kesecioglu, J. & Eggimann, P. What is new in selective decontamination of the digestive tract? Intensive Care Med.42, 1270–1275. 10.1007/s00134-015-4009-5 (2016). [DOI] [PMC free article] [PubMed]

[CR6] 6.Antimicrobial Resistance Collaborators et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 399, 629–655. 10.1016/S0140-6736(21)02724-0 (2022). [DOI] [PMC free article] [PubMed]

[CR7] 7.Daneman, N., Sarwar, S., Fowler, R. A. & Cuthbertson, B. H. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. Lancet Infect. Dis.13, 328–341. 10.1016/S1473-3099(12)70322-5 (2013). [DOI] [PubMed] [Google Scholar]

[CR8] 8.de Jonge, E. et al. Carriage of antibiotic-resistant Gram-negative bacteria after discontinuation of selective decontamination of the digestive tract (SDD) or selective oropharyngeal decontamination (SOD). Crit. Care. 22, 1–10. 10.1186/s13054-018-2170-2 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR9] 9.Wittekamp, B. H. et al. Decontamination strategies and bloodstream infections with antibiotic-resistant microorganisms in ventilated patients: a randomized clinical trial. JAMA Am. Med. Assoc.320, 2087–2098. 10.1001/jama.2018.13765 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR10] 10.Sánchez-Ramírez, C. et al. Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance. Crit. Care 22, 141. 10.1186/s13054-018-2057-2 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR11] 11.PROSPERO International prospective register of systematic reviews. [Internet]. https://www.crd.york.ac.uk/prospero (2024).

[CR12] 12.Liberati, A. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J. Clin. Epidemiol.62, e1–34. 10.1016/j.jclinepi.2009.06.006 (2009). [DOI] [PubMed] [Google Scholar]

[CR13] 13.Garner, P. et al. When and how to update systematic reviews: consensus and checklist. BMJ2016, 354. 10.1136/bmj.i3507 (2016). [DOI] [PMC free article] [PubMed]

[CR14] 14.Slim, K. et al. Methodological Index for Non-Randomized Studies (MINORS): development and validation of a new instrument. ANZ J. Surg.73, 712–716 (2003). [DOI] [PubMed] [Google Scholar]

[CR15] 15.R Core Team. A language and environment for statistical computing. R Foundation for Statistical Computing. Vienna, Austria (2017).

[CR16] 16.Sterne, J. A. C., Egger, M. & Moher, D. On behalf of the Cochrane Bias Methods Group. Addressing reporting biases. [Internet]. https://handbook-5-1.cochrane.org/chapter_10/10_addressing_reporting_biases.htm (2024).

[CR17] 17.Kossmeier, M., Tran, U. S. & Voracek, M. Visual inference for the funnel plot in meta-analysis. Z. Psychol.227, 83–89. 10.1027/2151-2604/a000358 (2019). [DOI]

[CR18] 18.Duval, S. & Tweedie, R. A nonparametric “Trim and Fill” method of accounting for publication bias in meta-analysis. J. Am. Stat. Assoc.95, 89–98. 10.1080/01621459.2000.10473905 (2000). [DOI] [Google Scholar]

[CR19] 19.Riley, R. D., Higgins, J. P. T. & Deeks, J. J. Interpretation of random effects meta-analyses. BMJ342, 964–967. 10.1136/bmj.d549 (2011). [DOI] [PubMed] [Google Scholar]

[CR20] 20.Abele-Horn, M. et al. Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD). Intensive Care Med.23, 187–195. 10.1007/s001340050314 (1997). [DOI] [PubMed] [Google Scholar]

[CR21] 21.Benus, R. F. et al. Impact of digestive and oropharyngeal decontamination on the intestinal microbiota in ICU patients. Intensive Care Med.36, 1394–1402. 10.1007/s00134-010-1826-4 (2010). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR22] 22.Bergmans, D. C. J. J. et al. Prevention of ventilator-associated pneumonia by oral decontamination. Am. J. Respir Crit. Care Med.164, 382–388. 10.1164/ajrccm.164.3.2005003 (2001). [DOI] [PubMed] [Google Scholar]

[CR23] 23.van der Bij, A. K. et al. Gram-positive cocci in Dutch ICUs with and without selective decontamination of the oropharyngeal and digestive tract: a retrospective database analysis. J. Antimicrob. Chemother. 71, 816–820. 10.1093/jac/dkv396 (2016). [DOI] [PubMed] [Google Scholar]

[CR24] 24.Brun-Buisson, C. et al. Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Study of an outbreak in an intensive care unit. Ann. Intern. Med.110, 873–881. 10.7326/0003-4819-110-11-873 (1989). [DOI] [PubMed] [Google Scholar]

[CR25] 25.Buitinck, S. et al. The ecological effects of selective decontamination of the digestive tract (SDD) on antimicrobial resistance: a 21-year longitudinal single-centre study. Crit. Care 23, 208. 10.1186/s13054-019-2480-z (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR26] 26.de la Cal, M. A. et al. Effectiveness and safety of enteral vancomycin to control endemicity of methicillin-resistant Staphylococcus aureus in a medical/surgical intensive care unit. J. Hosp. Infect.56, 175–183. 10.1016/j.jhin.2003.09.021 (2004). [DOI] [PubMed] [Google Scholar]

[CR27] 27.de La Cal, M. A. et al. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract. Ann. Surg.241, 424–430. 10.1097/01.sla.0000154148.58154.d5 (2005). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR28] 28.Camus, C. et al. Prevention of acquired infections in intubated patients with the combination of two decontamination regimens. Crit. Care Med.33, 307–314. 10.1097/01.CCM.0000152224.01949.01 (2005). [DOI] [PubMed] [Google Scholar]

[CR29] 29.Camus, C. et al. Mupirocin/chlorexidine to prevent methicillin-resistant Staphylococcus aureus infections: Post hoc analysis of a placebo-controlled, randomized trial using mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired infections in intubated patients. Infection42, 493–502. 10.1007/s15010-013-0581-1 (2014). [DOI] [PubMed] [Google Scholar]

[CR30] 30.Camus, C. et al. Short-term decline in all-cause acquired infections with the routine use of a decontamination regimen combining topical polymyxin, tobramycin, and amphotericin B with mupirocin and chlorhexidine in the ICU: a single-center experience. Crit. Care Med. 42, 1121–1130. 10.1097/CCM.0000000000000140 (2014). [DOI] [PubMed] [Google Scholar]

[CR31] 31.Camus, C. et al. Decline of multidrug-resistant Gram negative infections with the routine use of a multiple decontamination regimen in ICU. J. Infect. 73, 200–209. 10.1016/j.jinf.2016.06.007 (2016). [DOI] [PubMed] [Google Scholar]

[CR32] 32.Canter, R. R. et al. Observational study of current use of selective decontamination of the digestive tract in UK Critical Care units. Br. J. Anaesth. 113, 610–617. 10.1093/bja/aeu108 (2014). [DOI] [PubMed] [Google Scholar]

[CR33] 33.Dahms, R., Carlson, M., Lohr, B. & Beilman, G. Selective digestive tract decontamination and vancomycin-resistant enterococcus isolation in the surgical intensive care unit. Shock14, 343–346. 10.1097/00024382-200014030-00018 (2000). [DOI] [PubMed] [Google Scholar]

[CR34] 34.Dautzenberg, M. J. D. et al. Dynamics of colistin and tobramycin resistance among Enterobacter cloacae during prolonged use of selective decontamination of the digestive tract. Antimicrob. Resist. Infect. Control 7, 67. 10.1186/s13756-018-0356-7 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR35] 35.Ferrer, M. et al. Utility of selective digestive decontamination general population of mechanically ventilated patients. Ann. Intern. Med.120, 389–395 (1994). [DOI] [PubMed] [Google Scholar]

[CR36] 36.Flaherty, J., Nathan, C., Kabins, S. A. & Weinstein, R. A. Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit. J. Infect. Dis.162, 1393–1397 (1990). [DOI] [PubMed] [Google Scholar]

[CR37] 37.Garcin, F. et al. Selective digestive decontamination and empirical antimicrobial therapy of late–onset ventilator–associated pneumonia in trauma. J. Acute Dis.1, 1–6. 10.1016/S2221-6189(13)60001-3 (2012). [DOI] [Google Scholar]

[CR38] 38.Godard, J., Guillaume, C., Reverdy, M. E., Herriot, E. & Received, F. Intestinal decontamination in a polyvalent ICU. A double-blind study. Intensive Care Med.16, 307–311 (1990). [DOI] [PubMed] [Google Scholar]

[CR39] 39.Halaby, T., Naiemi, N., Al, Kluytmans, J., Van Der Palen, J. & Vandenbroucke-Grauls, C. M. J. E. Emergence of colistin resistance in Enterobacteriaceae after the introduction of selective digestive tract decontamination in an intensive care unit. Antimicrob. Agents Chemother.57, 3224–3229. 10.1128/AAC.02634-12 (2013). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR40] 40.Hammond, J. M. J., Potgieter, P. D. & Hammond, J. M. J. Double-blind study of selective decontamination of the digestive tract in intensive care. JAMA340, 5–9. 10.1016/0140-6736(92)92422-c (1992). [DOI] [PubMed] [Google Scholar]

[CR41] 41.Hammond, J. M. & Potgieter, P. D. Long-term effects of selective decontamination on antimicrobial resistance. Crit. Care Med.23, 637–645 (1995). [DOI] [PubMed] [Google Scholar]

[CR42] 42.Heininger, A. et al. Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance. Intensive Care Med.32, 1569–1576. 10.1007/s00134-006-0304-5 (2006). [DOI] [PubMed] [Google Scholar]

[CR43] 43.Houben, A. J. M. et al. Selective decontamination of the oropharynx and the digestive tract, and antimicrobial resistance: a 4 year ecological study in 38 intensive care units in the Netherlands. J. Antimicrob. Chemother.69, 797–804. 10.1093/jac/dkt416 (2014). [DOI] [PubMed] [Google Scholar]

[CR44] 44.Humphreys, H., Winter, R. & Pick, A. The effect of selective decontamination of the digestive tract on gastrointestinal enterococcal colonization in ITU patients. Intensive Care Med.18, 459–463. 10.1007/BF01708581 (1992). [DOI] [PubMed] [Google Scholar]

[CR45] 45.Janssen, A. B., van Hout, D., Bonten, M. J. M., Willems, R. J. L. & van Schaik, W. Microevolution of acquired colistin resistance in enterobacteriaceae from ICU patients receiving selective decontamination of the digestive tract. J. Antimicrob. Chemother. 75, 3135–3143. 10.1093/jac/dkaa305 (2020). [DOI] [PubMed] [Google Scholar]

[CR46] 46.Katchman, E. et al. A comparative study of the use of selective digestive decontamination prophylaxis in living-donor liver transplant recipients. Transpl. Infect. Dis. 16, 539–547. 10.1111/tid.12235 (2014). [DOI] [PubMed] [Google Scholar]

[CR47] 47.Krueger, W. A. et al. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically III surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical tr. Am. J. Respir. Crit. Care Med.166, 1029–1037. 10.1164/rccm.2105141 (2002). [DOI] [PubMed] [Google Scholar]

[CR48] 48.Landelle, C. et al. Impact of a multifaceted prevention program on ventilator-associated pneumonia including selective oropharyngeal decontamination. Intensive Care Med. 44, 1777–1786. 10.1007/s00134-018-5227-4 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR49] 49.Ledingham, I. M. et al. Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet331, 785–790 (1988). [DOI] [PubMed] [Google Scholar]

[CR50] 50.Leone, M., Albanese, J., Antonini, F., Nguyen-Michel, A. & Martin, C. Long-term (6-year) effect of selective digestive decontamination on antimicrobial resistance in intensive care, multiple-trauma patients. Crit. Care Med.31, 2090–2095. 10.1097/01.CCM.0000079606.16776.C5 (2003). [DOI] [PubMed] [Google Scholar]

[CR51] 51.Lloréns-Villar, Y. et al. Antibiotic susceptibility trend before and after long-term use of selective digestive decontamination: a 16 year ecological study. J. Antimicrob. Chemother. 74, 2289–2294. 10.1093/jac/dkz186 (2019). [DOI] [PubMed] [Google Scholar]

[CR52] 52.Massart, N. et al. Multiple-site decontamination regimen decreases acquired infection incidence in mechanically ventilated COVID-19 patients. Ann. Intensive Care 12, 84. 10.1186/s13613-022-01057-x (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR53] 53.Massart, N. et al. Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO support. Ann. Intensive Care2023, 13. 10.1186/s13613-023-01120-1 (2023). [DOI] [PMC free article] [PubMed]

[CR54] 54.Mathieu, C. et al. Decreased duration of intravenous cephalosporins in intensive care unit patients with selective digestive decontamination: a retrospective before-and-after study. Eu J. Clin. Microbiol. Infect. Dis. 39, 2115–2120. 10.1007/s10096-020-03966-w (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR55] 55.Muruzábal-Lecumberri, I., Girbau, C., Canut, A., Alonso, R. & Fernández-Astorga, A. Spread of an Enterococcus faecalis sequence type 6 (CC2) clone in patients undergoing selective decontamination of the digestive tract. APMIS123, 245–251. 10.1111/apm.12336 (2015). [DOI] [PubMed] [Google Scholar]

[CR56] 56.Noteboom, Y. et al. Antibiotic-induced within-host resistance development of gram-negative bacteria in patients receiving selective decontamination or standard care. Crit. Care Med. 43, 2582–2588. 10.1097/CCM.0000000000001298 (2015). [DOI] [PubMed] [Google Scholar]

[CR57] 57.Ochoa-Ardila, M. E. et al. Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: A 5-year prospective cohort study. Intensive Care Med.37, 1458–1465. 10.1007/s00134-011-2307-0 (2011). [DOI] [PubMed] [Google Scholar]

[CR58] 58.Oostdijk, E. A. N. et al. Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am. J. Respir Crit. Care Med.181, 452–457. 10.1164/rccm.200908-1210OC (2010). [DOI] [PubMed] [Google Scholar]

[CR59] 59.Oostdijk, E. A. N. et al. Colistin resistance in gram-negative bacteria during prophylactic topical colistin use in intensive care units. Intensive Care Med.39, 653–660. 10.1007/s00134-012-2761-3 (2013). [DOI] [PubMed] [Google Scholar]

[CR60] 60.Oostdijk, E. A. N. et al. Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in icus a randomized clinical trial. JAMA Am. Med. Assoc.312, 1429–1437. 10.1001/jama.2014.7247 (2014). [DOI] [PubMed] [Google Scholar]

[CR61] 61.Pérez-Granda, M. J. et al. Impact of selective digestive decontamination without systemic antibiotics in a major heart surgery intensive care unit. J. Thorac. Cardiovasc. Surg. 156, 685–693. 10.1016/j.jtcvs.2018.02.091 (2018). [DOI] [PubMed] [Google Scholar]

[CR62] 62.Plantinga, N. L. et al. The effects of topical antibiotics on eradication and acquisition of third-generation cephalosporin and carbapenem-resistant Gram-negative bacteria in ICU patients; a post hoc analysis from a multicentre cluster-randomized trial. Clin. Microbiol. Infect. 26, 485–491. 10.1016/j.cmi.2019.08.001 (2020). [DOI] [PubMed] [Google Scholar]

[CR63] 63.Quinio, B., Albanese, J., Bues, C. M., Viviand, X. & Martin, C. Selective decontamination of the digestive tract in multiple trauma patients. A prospective double-blind, randomized, placebo-controlled study. Chest109, 765–772 (1996). [DOI] [PubMed] [Google Scholar]

[CR64] 64.Reizine, F. et al. Association between selective digestive decontamination and decreased rate of acquired candidemia in mechanically ventilated ICU patients: a multicenter nationwide study. Crit. Care27, 494. 10.1186/s13054-023-04775-1 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR65] 65.Righi, E. et al. Trends in ventilator-associated pneumonia: impact of a ventilator care bundle in an Italian tertiary care hospital intensive care unit. Am. J. Infect. Control 42, 1312–1316. 10.1016/j.ajic.2014.08.009 (2014). [DOI] [PubMed] [Google Scholar]

[CR66] 66.Rocha, L. A. et al. Intensive care medicine prevention of nosocomial infection in critically ill patients by selective decontamination of the digestive tract a randomized, double blind, placebo-controlled study. Intensive Care Med.18, 398–404 (1992). [DOI] [PubMed] [Google Scholar]

[CR67] 67.Rodríguez-Gascón, A., Lloréns-Villar, Y., Solinís, M. Á., Barrasa, H. & Canut-Blasco, A. Does selective digestive decontamination (SDD) increase antibiotic resistance? Long-term comparison of two intensive care units (with and without SDD) of the same tertiary hospital. Eu J. Clin. Microbiol. Infect. Dis. 43, 885–893. 10.1007/s10096-024-04792-0 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR68] 68.Sánchez-García, M. et al. Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients. Am. J. Respir Crit. Care Med.158, 908–916. 10.1164/ajrccm.158.3.9712079 (1998). [DOI] [PubMed] [Google Scholar]

[CR69] 69.de Smet, A. M. G. A. et al. 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 Infect. Dis.11, 372–380. 10.1016/S1473-3099(11)70035-4 (2011). [DOI] [PubMed] [Google Scholar]

[CR70] 70.SuDDICU, I. et al. Effect of selective decontamination of the digestive tract on hospital mortality in critically ill patients receiving mechanical ventilation: a randomized clinical trial. JAMA Am. Med. Assoc.328, 1911–1921. 10.1001/jama.2022.17927 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR71] 71.Tetteroo, G. W. M., Wagenvoort, J. H. T., Mulder, P. G. H., Ince, C. & Bruining, H. A. Decreased mortality rate and length of hospital stay in surgical intensive care unit patients with successful selective decontamination of the gut. Crit. Care Med.21, 1692–1698 (1993). [DOI] [PubMed] [Google Scholar]

[CR72] 72.Ulrich, C. et al. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study. Intensive Care Med.15, 424–431. 10.1007/BF00255597 (1989). [DOI] [PubMed] [Google Scholar]

[CR73] 73.Unertl, K. et al. Prevention of colonization and respiratory infections in long- term ventilated patients by local antimicrobial prophylaxis. Intensive Care Med.13, 106–113 (1987). [DOI] [PubMed] [Google Scholar]

[CR74] 74.Verwaest, C. et al. Randomised, controlled trial of selective digestive deconatmination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit. Care Med.25, 63–71 (1997). [DOI] [PubMed] [Google Scholar]

[CR75] 75.van der Voort, P. H. J. et al. A before-after study of multi-resistance and cost of selective decontamination of the digestive tract. Infection32, 271–277. 10.1007/s15010-004-3170-5 (2004). [DOI] [PubMed] [Google Scholar]

[CR76] 76.Wang, B. et al. Ecological effects of selective oral decontamination on multidrug-resistance bacteria acquired in the intensive care unit: a case–control study over 5 years. Intensive Care Med. . 48, 1165–1175. 10.1007/s00134-022-06826-7 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR77] 77.Wiener, J. et al. A randomized, double-blind, placebo-controlled trial of selective digestive decontamination in a medical-surgical intensive-care unit. Clin. Infect. Dis.20, 861–867 (1995). [DOI] [PubMed] [Google Scholar]

[CR78] 78.Wittekamp, B. H. J., Oostdijk, E. A. N., De Smet, A. M. G. A. & Bonten, M. J. M. Colistin and tobramycin resistance during long- term use of selective decontamination strategies in the intensive care unit: a post hoc analysis. Crit. Care 2025, 19. 10.1186/s13054-015-0838-4 (2015). [DOI] [PMC free article] [PubMed]

[CR79] 79.Young, P. J. et al. Selective digestive tract decontamination in critically ill adults with acute brain injuries: a post hoc analysis of a randomized clinical trial. Intensive Care Med. 50, 56–67. 10.1007/s00134-023-07261-y (2024). [DOI] [PubMed] [Google Scholar]

[CR80] 80.Jurke, A. et al. Changing epidemiology of meticillin-resistant Staphylococcus aureus in 42 hospitals in the Dutch–German border region, 2012 to 2016: results of the search-and-follow-policy. Euro surveill. Eur. Centre Disease Prev. Control (ECDC). 24, 1800244. 10.2807/1560-7917.ES.2019.24.15.1800244 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR81] 81.Perovic, O. et al. Prevalence and trends of staphylococcus aureus bacteraemia in hospitalized patients in South Africa, 2010 to 2012: laboratory-based surveillance mapping of antimicrobial resistance and molecular epidemiology. PLoS One 10, e0145429. 10.1371/journal.pone.0145429 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR82] 82.Zhu, D. et al. Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses. J. Hosp. Infect. 145, 174–186. 10.1016/j.jhin.2023.12.017 (2024). [DOI] [PubMed] [Google Scholar]

[CR83] 83.Oostdijk, E. A. et al. Selective decontamination of the digestive tract and selective oropharyngeal decontamination in intensive care unit patients: a cost-effectiveness analysis. BMJ Open.3, e002529. 10.1136/bmjopen-2012 (2013). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR84] 84.Minozzi, S. et al. Topical antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving mechanical ventilation. Cochrane Database Syst. Rev. 1, CD000022. 10.1002/14651858.CD000022.pub4 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR85] 85.Tan, G. et al. Gut microbiota modulation: implications for infection control and antimicrobial stewardship. Adv. Ther.37, 4054–4067. 10.6084/m9.figshare.12689891 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR86] 86.Huttner, B. et al. Decolonization of intestinal carriage of extended-spectrum Β-lactamase-producing Enterobacteriaceae with oral colistin and neomycin: a randomized, double-blind, placebo-controlled trial. J. Antimicrob. Chemother.68, 2375–2382. 10.1093/jac/dkt174 (2013). [DOI] [PubMed] [Google Scholar]

[CR87] 87.Aardema, H. et al. Marked changes in gut microbiota in cardio-surgical intensive care patients: a longitudinal cohort study. Front. Cell. Infect. Microbiol. 9, 467. 10.3389/fcimb.2019.00467 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR88] 88.Buelow, E. et al. Comparative gut microbiota and resistome profiling of intensive care patients receiving selective digestive tract decontamination and healthy subjects. Microbiome5, 88. 10.1186/s40168-017-0309-z (2017). [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR89] 89.de Smet, A. M. G. A., Bonten, M. J. M. & Kluytmans, J. A. J. W. For whom should we use selective decontamination of the digestive tract? Curr. Opin. Infect. Dis.25, 211–217. 10.1097/QCO.0b013e3283507f8cLK (2012). [DOI] [PubMed]

[CR90] 90.Hurley, J. C. Selective digestive decontamination-Con. Intensive Care Med.49, 982–983. 10.1007/s00134-023-07146-0 (2023). [DOI] [PubMed] [Google Scholar]

PERMALINK

The effect of selective decontamination on antimicrobial resistance in intensive care patients: a systematic review and meta-analysis

Frederique J C van Eerten

Joost D J Plate

Rolf H H Groenwold

Valentijn A Schweitzer

Jan A J W Kluytmans

Falco Hietbrink

Abstract

Supplementary Information

Introduction

Methods

Protocol and registration

Information sources

Study selection

Data extraction

Risk of bias assessment

Data synthesis of studies assessing the antimicrobial resistance during ICU admission

Data synthesis of studies assessing the antimicrobial resistance during ICU admission

Outcomes to specific antibiotic groups and per multi-resistant bacteria type

Sensitivity analyses

Results

The search

Fig. 1.

Characteristics of included studies

Table 1.

Table 2.

Risk of bias assessment

Fig. 2.

Antimicrobial resistance during ICU admission

Fig. 3.

Antimicrobial resistance after ICU discharge

Resistance to specific antimicrobial agents

Occurrence of VRE, MRSA and multi-resistant pathogens

Fig. 4.

Sensitivity analyses

Discussion

Antimicrobial resistance after ICU discharge

Clinical relevance

Antimicrobial resistance during ICU stay

Strengths and limitations

Conclusion

Supplementary Information

Abbreviations

Author contributions

Funding

Data availability

Competing interests

Footnotes

References

Associated Data

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases