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. 1995 Apr;39(4):941–947. doi: 10.1128/aac.39.4.941

Prophylaxis with enteral antibiotics in ventilated patients: selective decontamination or selective cross-infection?

J C Hurley 1
PMCID: PMC162658  PMID: 7786000

Abstract

Selective decontamination of the digestive tract (SDD) has been evaluated as a method to prevent colonization and infection in ventilated patients in 40 trials. On the basis of an assumption that cross-infection would be reduced as a consequence of SDD and that this would distort the results of SDD studies that used concurrent controls, 14 studies used historic controls. To test this assumption, three observations from the two types of studies were compared. (i) The differences between observed and expected event rates for each study were used to perform a meta-analysis. This revealed that the summary odds ratios for bacteremia and respiratory infection were marked by significant heterogeneity (P > 0.95) and inconsistencies between those derived from studies with concurrent versus studies with historic controls. (ii) Where the data were available, the rates of acquisition of colonization in control groups were higher in studies with concurrent controls than in studies with historic controls. (iii) At least four studies with concurrent controls have shown a pattern of pathogenic isolates consistent with cross-infection between groups. These results are contrary to the initial assumption and suggest the possibility that SDD represents a major cross-infection hazard.

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Selected References

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  1. Aerdts S. J., van Dalen R., Clasener H. A., Festen J., van Lier H. J., Vollaard E. J. Antibiotic prophylaxis of respiratory tract infection in mechanically ventilated patients. A prospective, blinded, randomized trial of the effect of a novel regimen. Chest. 1991 Sep;100(3):783–791. doi: 10.1378/chest.100.3.783. [DOI] [PubMed] [Google Scholar]
  2. Armstrong P. J., Barr J. G., Webb C. H., Blair P. H., Rowlands B. J. Epidemiology of Pseudomonas aeruginosa in an intensive care unit using selective decontamination of the digestive tract. J Hosp Infect. 1992 Mar;20(3):199–208. doi: 10.1016/0195-6701(92)90088-4. [DOI] [PubMed] [Google Scholar]
  3. Bion J. F., Badger I., Crosby H. A., Hutchings P., Kong K. L., Baker J., Hutton P., McMaster P., Buckels J. A., Elliott T. S. Selective decontamination of the digestive tract reduces gram-negative pulmonary colonization but not systemic endotoxemia in patients undergoing elective liver transplantation. Crit Care Med. 1994 Jan;22(1):40–49. doi: 10.1097/00003246-199401000-00011. [DOI] [PubMed] [Google Scholar]
  4. Blair P., Rowlands B. J., Lowry K., Webb H., Armstrong P., Smilie J. Selective decontamination of the digestive tract: a stratified, randomized, prospective study in a mixed intensive care unit. Surgery. 1991 Aug;110(2):303–310. [PubMed] [Google Scholar]
  5. Bonten M. J., Gaillard C. A., van der Geest S. Selective decontamination of the digestive tract. Benefit remains unproved. BMJ. 1993 Dec 11;307(6918):1559–1560. doi: 10.1136/bmj.307.6918.1559-c. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Boukadida J., de Montalembert M., Gaillard J. L., Gobin J., Grimont F., Girault D., Véron M., Berche P. Outbreak of gut colonization by Pseudomonas aeruginosa in immunocompromised children undergoing total digestive decontamination: analysis by pulsed-field electrophoresis. J Clin Microbiol. 1991 Sep;29(9):2068–2071. doi: 10.1128/jcm.29.9.2068-2071.1991. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brun-Buisson C., Legrand P., Rauss A., Richard C., Montravers F., Besbes M., Meakins J. L., Soussy C. J., Lemaire F. Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Study of an outbreak in an intensive care unit. Ann Intern Med. 1989 Jun 1;110(11):873–881. doi: 10.7326/0003-4819-110-11-873. [DOI] [PubMed] [Google Scholar]
  8. Cerra F. B., Maddaus M. A., Dunn D. L., Wells C. L., Konstantinides N. N., Lehmann S. L., Mann H. J. Selective gut decontamination reduces nosocomial infections and length of stay but not mortality or organ failure in surgical intensive care unit patients. Arch Surg. 1992 Feb;127(2):163–169. doi: 10.1001/archsurg.1992.01420020045007. [DOI] [PubMed] [Google Scholar]
  9. Cockerill F. R., 3rd, Muller S. R., Anhalt J. P., Marsh H. M., Farnell M. B., Mucha P., Gillespie D. J., Ilstrup D. M., Larson-Keller J. J., Thompson R. L. Prevention of infection in critically ill patients by selective decontamination of the digestive tract. Ann Intern Med. 1992 Oct 1;117(7):545–553. doi: 10.7326/0003-4819-117-7-545. [DOI] [PubMed] [Google Scholar]
  10. Cook D. J., Laine L. A., Guyatt G. H., Raffin T. A. Nosocomial pneumonia and the role of gastric pH. A meta-analysis. Chest. 1991 Jul;100(1):7–13. doi: 10.1378/chest.100.1.7. [DOI] [PubMed] [Google Scholar]
  11. Craven D. E., Steger K. A., Barber T. W. Preventing nosocomial pneumonia: state of the art and perspectives for the 1990s. Am J Med. 1991 Sep 16;91(3B):44S–53S. doi: 10.1016/0002-9343(91)90343-v. [DOI] [PubMed] [Google Scholar]
  12. Fagon J. Y., Chastre J., Domart Y., Trouillet J. L., Pierre J., Darne C., Gibert C. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis. 1989 Apr;139(4):877–884. doi: 10.1164/ajrccm/139.4.877. [DOI] [PubMed] [Google Scholar]
  13. Ferrer M., Torres A., González J., Puig de la Bellacasa J., el-Ebiary M., Roca M., Gatell J. M., Rodriguez-Roisin R. Utility of selective digestive decontamination in mechanically ventilated patients. Ann Intern Med. 1994 Mar 1;120(5):389–395. doi: 10.7326/0003-4819-120-5-199403010-00006. [DOI] [PubMed] [Google Scholar]
  14. 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. 1990 Dec;162(6):1393–1397. doi: 10.1093/infdis/162.6.1393. [DOI] [PubMed] [Google Scholar]
  15. Flynn D. M., Weinstein R. A., Nathan C., Gaston M. A., Kabins S. A. Patients' endogenous flora as the source of "nosocomial" Enterobacter in cardiac surgery. J Infect Dis. 1987 Aug;156(2):363–368. doi: 10.1093/infdis/156.2.363. [DOI] [PubMed] [Google Scholar]
  16. Fox M. A., Peterson S., Fabri B. M., van Saene H. K. Selective decontamination of the digestive tract in cardiac surgical patients. Crit Care Med. 1991 Dec;19(12):1486–1490. doi: 10.1097/00003246-199112000-00008. [DOI] [PubMed] [Google Scholar]
  17. Gastinne H., Wolff M., Delatour F., Faurisson F., Chevret S. A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract. N Engl J Med. 1992 Feb 27;326(9):594–599. doi: 10.1056/NEJM199202273260903. [DOI] [PubMed] [Google Scholar]
  18. George D. L. Epidemiology of nosocomial ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 1993 Mar;14(3):163–169. doi: 10.1086/646705. [DOI] [PubMed] [Google Scholar]
  19. Godard J., Guillaume C., Reverdy M. E., Bachmann P., Bui-Xuan B., Nageotte A., Motin J. Intestinal decontamination in a polyvalent ICU. A double-blind study. Intensive Care Med. 1990;16(5):307–311. doi: 10.1007/BF01706355. [DOI] [PubMed] [Google Scholar]
  20. Hammond J. M., Potgieter P. D., Saunders G. L., Forder A. A. Double-blind study of selective decontamination of the digestive tract in intensive care. Lancet. 1992 Jul 4;340(8810):5–9. doi: 10.1016/0140-6736(92)92422-c. [DOI] [PubMed] [Google Scholar]
  21. Hartenauer U., Thülig B., Diemer W., Lawin P., Fegeler W., Kehrel R., Ritzerfeld W. Effect of selective flora suppression on colonization, infection, and mortality in critically ill patients: a one-year, prospective consecutive study. Crit Care Med. 1991 Apr;19(4):463–473. doi: 10.1097/00003246-199104000-00003. [DOI] [PubMed] [Google Scholar]
  22. Hurley J. C. Concordance of endotoxemia with gram-negative bacteremia in patients with gram-negative sepsis: a meta-analysis. J Clin Microbiol. 1994 Sep;32(9):2120–2127. doi: 10.1128/jcm.32.9.2120-2127.1994. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hünefeld G. Klinische Studie zur selektiven Darmdekolonisation bei 204 langzeitbeatmeten abdominal- und unfallchirurgischen Intensivpatienten. Anaesthesiol Reanim. 1989;14(3):131–153. [PubMed] [Google Scholar]
  24. Johanson W. G., Jr, Pierce A. K., Sanford J. P., Thomas G. D. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med. 1972 Nov;77(5):701–706. doi: 10.7326/0003-4819-77-5-701. [DOI] [PubMed] [Google Scholar]
  25. Kerver A. J., Rommes J. H., Mevissen-Verhage E. A., Hulstaert P. F., Vos A., Verhoef J., Wittebol P. Prevention of colonization and infection in critically ill patients: a prospective randomized study. Crit Care Med. 1988 Nov;16(11):1087–1093. doi: 10.1097/00003246-198811000-00001. [DOI] [PubMed] [Google Scholar]
  26. Kollef M. H. The role of selective digestive tract decontamination on mortality and respiratory tract infections. A meta-analysis. Chest. 1994 Apr;105(4):1101–1108. doi: 10.1378/chest.105.4.1101. [DOI] [PubMed] [Google Scholar]
  27. Konrad F., Schwalbe B., Heeg K., Wagner H., Wiedeck H., Kilian J., Ahnefeld F. W. Kolonisations-, Pneumoniefrequenz und Resistenzentwicklung bei langzeitbeatmeten Intensivpatienten unter selektiver Dekontamination des Verdauungstraktes. Anaesthesist. 1989 Mar;38(3):99–109. [PubMed] [Google Scholar]
  28. Korinek A. M., Laisne M. J., Nicolas M. H., Raskine L., Deroin V., Sanson-Lepors M. J. Selective decontamination of the digestive tract in neurosurgical intensive care unit patients: a double-blind, randomized, placebo-controlled study. Crit Care Med. 1993 Oct;21(10):1466–1473. doi: 10.1097/00003246-199310000-00013. [DOI] [PubMed] [Google Scholar]
  29. Ledingham I. M., Alcock S. R., Eastaway A. T., McDonald J. C., McKay I. C., Ramsay G. Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet. 1988 Apr 9;1(8589):785–790. doi: 10.1016/s0140-6736(88)91656-x. [DOI] [PubMed] [Google Scholar]
  30. Mackie D. P., van Hertum W. A., Schumburg T., Kuijper E. C., Knape P. Prevention of infection in burns: preliminary experience with selective decontamination of the digestive tract in patients with extensive injuries. J Trauma. 1992 May;32(5):570–575. [PubMed] [Google Scholar]
  31. McClelland P., Murray A. E., Williams P. S., van Saene H. K., Gilbertson A. A., Mostafa S. M., Bone J. M. Reducing sepsis in severe combined acute renal and respiratory failure by selective decontamination of the digestive tract. Crit Care Med. 1990 Sep;18(9):935–939. doi: 10.1097/00003246-199009000-00006. [DOI] [PubMed] [Google Scholar]
  32. McClelland P., Murray A., Yaqoob M., Van Saene H. K., Bone J. M., Mostafa S. M. Prevention of bacterial infection and sepsis in acute severe pancreatitis. Ann R Coll Surg Engl. 1992 Sep;74(5):329–334. [PMC free article] [PubMed] [Google Scholar]
  33. Potgieter P. D., Linton D. M., Oliver S., Forder A. A. Nosocomial infections in a respiratory intensive care unit. Crit Care Med. 1987 May;15(5):495–498. doi: 10.1097/00003246-198705000-00008. [DOI] [PubMed] [Google Scholar]
  34. Preston G. A., Larson E. L., Stamm W. E. The effect of private isolation rooms on patient care practices, Colonization and infection in an intensive care unit. Am J Med. 1981 Mar;70(3):641–645. doi: 10.1016/0002-9343(81)90588-x. [DOI] [PubMed] [Google Scholar]
  35. Prod'hom G., Leuenberger P., Koerfer J., Blum A., Chiolero R., Schaller M. D., Perret C., Spinnler O., Blondel J., Siegrist H. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. Ann Intern Med. 1994 Apr 15;120(8):653–662. doi: 10.7326/0003-4819-120-8-199404150-00005. [DOI] [PubMed] [Google Scholar]
  36. Pugin J., Auckenthaler R., Lew D. P., Suter P. M. Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia. A randomized, placebo-controlled, double-blind clinical trial. JAMA. 1991 May 22;265(20):2704–2710. [PubMed] [Google Scholar]
  37. Rello J., Ausina V., Ricart M., Castella J., Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest. 1993 Oct;104(4):1230–1235. doi: 10.1378/chest.104.4.1230. [DOI] [PubMed] [Google Scholar]
  38. Rocha L. A., Martín M. J., Pita S., Paz J., Seco C., Margusino L., Villanueva R., Durán M. T. 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. 1992;18(7):398–404. doi: 10.1007/BF01694341. [DOI] [PubMed] [Google Scholar]
  39. Rodríguez-Roldán J. M., Altuna-Cuesta A., López A., Carrillo A., Garcia J., León J., Martínez-Pellús A. J. Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial pharyngeal nonabsorbable paste. Crit Care Med. 1990 Nov;18(11):1239–1242. doi: 10.1097/00003246-199011000-00011. [DOI] [PubMed] [Google Scholar]
  40. Rolando N., Gimson A., Wade J., Philpott-Howard J., Casewell M., Williams R. Prospective controlled trial of selective parenteral and enteral antimicrobial regimen in fulminant liver failure. Hepatology. 1993 Feb;17(2):196–201. [PubMed] [Google Scholar]
  41. Sacks H., Chalmers T. C., Smith H., Jr Randomized versus historical controls for clinical trials. Am J Med. 1982 Feb;72(2):233–240. doi: 10.1016/0002-9343(82)90815-4. [DOI] [PubMed] [Google Scholar]
  42. Salmerón J. M., Titó L., Rimola A., Mas A., Navasa M. A., Llach J., Ginès A., Ginès P., Arroyo V., Rodés J. Selective intestinal decontamination in the prevention of bacterial infection in patients with acute liver failure. J Hepatol. 1992 Mar;14(2-3):280–285. doi: 10.1016/0168-8278(92)90171-k. [DOI] [PubMed] [Google Scholar]
  43. Selective digestive decontamination in intensive care unit patients. Intensive Care Med. 1992;18(3):182–188. doi: 10.1007/BF01709246. [DOI] [PubMed] [Google Scholar]
  44. Stoutenbeek C. P., van Saene H. K., Miranda D. R., Zandstra D. F. The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Med. 1984;10(4):185–192. doi: 10.1007/BF00259435. [DOI] [PubMed] [Google Scholar]
  45. Sydow M., Burchardi H., Crozier T. A., Rüchel R., Busse C., Seyde W. C. Einfluss der selektiven Dekontamination auf nosokomiale Infektionen, Erregerspektrum und Antibiotikaresistenz bei langzeitbeatmeten Intensivpatienten. Anasth Intensivther Notfallmed. 1990 Dec;25(6):416–423. [PubMed] [Google Scholar]
  46. Tetteroo G. W., Wagenvoort J. H., Castelein A., Tilanus H. W., Ince C., Bruining H. A. Selective decontamination to reduce gram-negative colonisation and infections after oesophageal resection. Lancet. 1990 Mar 24;335(8691):704–707. doi: 10.1016/0140-6736(90)90813-k. [DOI] [PubMed] [Google Scholar]
  47. Ulrich C., Harinck-de Weerd J. E., Bakker N. C., Jacz K., Doornbos L., de Ridder V. A. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study. Intensive Care Med. 1989;15(7):424–431. doi: 10.1007/BF00255597. [DOI] [PubMed] [Google Scholar]
  48. Unertl K., Ruckdeschel G., Selbmann H. K., Jensen U., Forst H., Lenhart F. P., Peter K. Prevention of colonization and respiratory infections in long-term ventilated patients by local antimicrobial prophylaxis. Intensive Care Med. 1987;13(2):106–113. doi: 10.1007/BF00254795. [DOI] [PubMed] [Google Scholar]
  49. Vandenbroucke-Grauls C. M., Vandenbroucke J. P. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet. 1991 Oct 5;338(8771):859–862. doi: 10.1016/0140-6736(91)91510-2. [DOI] [PubMed] [Google Scholar]
  50. Verhoef J., Verhage E. A., Visser M. R. A decade of experience with selective decontamination of the digestive tract as prophylaxis for infections in patients in the intensive care unit: what have we learned? Clin Infect Dis. 1993 Dec;17(6):1047–1054. doi: 10.1093/clinids/17.6.1047. [DOI] [PubMed] [Google Scholar]
  51. Webb C. H. Antibiotic resistance associated with selective decontamination of the digestive tract. J Hosp Infect. 1992 Sep;22(1):1–5. doi: 10.1016/0195-6701(92)90125-6. [DOI] [PubMed] [Google Scholar]
  52. Weinstein R. A. Epidemiology and control of nosocomial infections in adult intensive care units. Am J Med. 1991 Sep 16;91(3B):179S–184S. doi: 10.1016/0002-9343(91)90366-6. [DOI] [PubMed] [Google Scholar]
  53. Weinstein R. A. Selective intestinal decontamination--an infection control measure whose time has come? Ann Intern Med. 1989 Jun 1;110(11):853–855. doi: 10.7326/0003-4819-110-11-853. [DOI] [PubMed] [Google Scholar]
  54. Winter R., Humphreys H., Pick A., MacGowan A. P., Willatts S. M., Speller D. C. A controlled trial of selective decontamination of the digestive tract in intensive care and its effect on nosocomial infection. J Antimicrob Chemother. 1992 Jul;30(1):73–87. doi: 10.1093/jac/30.1.73. [DOI] [PubMed] [Google Scholar]
  55. Yusuf S., Peto R., Lewis J., Collins R., Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985 Mar-Apr;27(5):335–371. doi: 10.1016/s0033-0620(85)80003-7. [DOI] [PubMed] [Google Scholar]
  56. Zobel G., Kuttnig M., Grubbauer H. M., Semmelrock H. J., Thiel W. Reduction of colonization and infection rate during pediatric intensive care by selective decontamination of the digestive tract. Crit Care Med. 1991 Oct;19(10):1242–1246. doi: 10.1097/00003246-199110000-00005. [DOI] [PubMed] [Google Scholar]
  57. du Moulin G. C., Paterson D. G., Hedley-Whyte J., Lisbon A. Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of postoperative colonisation of the airway. Lancet. 1982 Jan 30;1(8266):242–245. doi: 10.1016/s0140-6736(82)90974-6. [DOI] [PubMed] [Google Scholar]

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