Skip to main content
PMC home page
The BMJ logoLink to The BMJ
. 1993 Aug 28;307(6903):525–532. doi: 10.1136/bmj.307.6903.525

Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. Selective Decontamination of the Digestive Tract Trialists' Collaborative Group.

PMCID: PMC1678619  PMID: 8400971

Abstract

OBJECTIVE--To determine the clinical benefits of selective decontamination of the digestive tract in patients treated in intensive care units. DESIGN--Meta-analysis of 22 randomised trials that compared different combinations of oral non-absorbable antibiotics, with or without a systemic component, with no treatment in controls. SUBJECTS--4142 patients seen in general and specialised intensive care units around the world. 2047 received some form of antibiotic treatment, the remainder no prophylaxis. DATA ANALYSIS--Each trial was reviewed through direct contact with study investigators. Data collected were: the randomisation procedure, number of patients, number excluded from the analysis, and numbers of respiratory tract infections and deaths. Data were combined according to an intention to treat analysis with the Mantel-Haenszel-Peto method. MAIN OUTCOME MEASURES--Respiratory tract infections and total mortality. RESULTS--Selective decontamination of the digestive tract significantly reduced respiratory tract infections (odds ratio 0.37; 95% confidence interval 0.31 to 0.43). The value of the common odds ratio for total mortality (0.90; 0.79 to 1.04) suggested at best a moderate treatment effect, reaching statistical significance only when the subgroup of trials of topical and systemic treatment combined was considered separately (odds ratio 0.80; 0.67 to 0.97). No firm conclusions could be drawn owing to large variations in patient mix and severity within and between trials. CONCLUSIONS--The findings strongly indicate that selective decontamination significantly reduces infection related morbidity in patients receiving intensive care. They also highlight why definite conclusions about the effect of prophylaxis on mortality cannot be drawn despite the large number of trials available. Based on the most favourable results obtained by pooling data from trials in which combined topical and systemic treatment was used it may be estimated that 6 (range 5-9) and 23 (13-139) patients would need to be treated to prevent one respiratory tract infection and one death respectively.

Full text

PDF
528

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  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. Begg C. B. A measure to aid in the interpretation of published clinical trials. Stat Med. 1985 Jan-Mar;4(1):1–9. doi: 10.1002/sim.4780040103. [DOI] [PubMed] [Google Scholar]
  3. Boissel J. P., Blanchard J., Panak E., Peyrieux J. C., Sacks H. Considerations for the meta-analysis of randomized clinical trials. Summary of a panel discussion. Control Clin Trials. 1989 Sep;10(3):254–281. doi: 10.1016/0197-2456(89)90067-6. [DOI] [PubMed] [Google Scholar]
  4. 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]
  5. 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]
  6. 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]
  7. DerSimonian R., Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986 Sep;7(3):177–188. doi: 10.1016/0197-2456(86)90046-2. [DOI] [PubMed] [Google Scholar]
  8. 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]
  9. 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]
  10. 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]
  11. Hünefeld G. Klinische Studie zur selektiven Darmdekolonisation bei 204 langzeitbeatmeten abdominal- und unfallchirurgischen Intensivpatienten. Anaesthesiol Reanim. 1989;14(3):131–153. [PubMed] [Google Scholar]
  12. 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]
  13. Laupacis A., Sackett D. L., Roberts R. S. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med. 1988 Jun 30;318(26):1728–1733. doi: 10.1056/NEJM198806303182605. [DOI] [PubMed] [Google Scholar]
  14. McGlynn E. A., Kosecoff J., Brook R. H. Format and conduct of consensus development conferences. Multi-nation comparison. Int J Technol Assess Health Care. 1990;6(3):450–469. doi: 10.1017/s0266462300001045. [DOI] [PubMed] [Google Scholar]
  15. 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]
  16. 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]
  17. 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]
  18. 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]
  19. Stewart L. A., Parmar M. K. Meta-analysis of the literature or of individual patient data: is there a difference? Lancet. 1993 Feb 13;341(8842):418–422. doi: 10.1016/0140-6736(93)93004-k. [DOI] [PubMed] [Google Scholar]
  20. 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]
  21. 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]
  22. 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]
  23. 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]
  24. 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]
  25. 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]
  26. 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]
  27. van Saene H. K., Stoutenbeek C. C., Stoller J. K. Selective decontamination of the digestive tract in the intensive care unit: current status and future prospects. Crit Care Med. 1992 May;20(5):691–703. doi: 10.1097/00003246-199205000-00024. [DOI] [PubMed] [Google Scholar]
  28. van Saene H. K., Unertl K. E., Alcock S. R., Stoutenbeek C. P., Hart C. A. Emergence of antibiotic resistance during selective digestive decontamination? J Hosp Infect. 1993 Jun;24(2):158–161. doi: 10.1016/0195-6701(93)90079-f. [DOI] [PubMed] [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES