Table 2.
Post hoc analyses and secondary studies on SDD and SOD
| References | Design | Main results | Comments | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| de Smet et al. [6] | 2 centres among 13 Dutch ICUs (NEJM 2009) | Post-ICU rate of nosocomial infection (/1000 days at-risk) | No impact of SDD/SOD on post-ICU infection rates | |||||||||
| SC: 8.3 | ||||||||||||
| SOD: 11.2 | RR 1.44 (0.87–2.39) | |||||||||||
| SDD: 12.9 | RR 1.49 (0.90–2.47) | |||||||||||
| Oostdijk et al. [7] | 13 Dutch ICUs (NEJM 2009) Samples from 6 point-prevalence surveys before, during and after SDD/SOD | Respiratory samples (n = 2304): | Pre-intervention | Intervention | Post-intervention | SDD/SOD decreased resistance in respiratory and rectal samples, followed by a rebound effect after stopping it | ||||||
| Ceftazidime-resistant | 10 % (7.6–13.3 %) | 4 % (2.6–4.6 %) | 10 % (7.4–13.0 %) | |||||||||
| Tobramycin-resistant | 10 % (6.9–12.5 %) | 6 % (4.5–6.9 %) | 12 % (8.8–14.6 %) | |||||||||
| Ciprofloxacin-resistant | 14 % (10.4–17.0 %) | 5 % (3.5–5.7 %) | 12 % (9.0–14.9 %) | |||||||||
| Rectal samples (n = 2963) | Pre-intervention | Intervention | Post-intervention | |||||||||
| Ceftazidime-resistant | 6 % (4.7–7.5 %) | 5 % (3.9–6.7 %) | 15 % (12.4–17.0 %) | |||||||||
| Tobramycin-resistant | 9 % (7.7–11.2 %) | 7 % (5.5–8.7 %) | 13 % (10.4–14.7 %) | |||||||||
| Ciprofloxacin-resistant | 12 % (9.7–13.5 %) | 7 % (5.1–8.2 %) | 13 % (10.8–15.2 %) | |||||||||
| Benus et al. [8] | 1 of 13 Dutch ICUs (NEJM 2009) Fluorescent in situ hybridization analysis of the intestinal microbiota | Total number of bacteria cultured from the faeces | SDD/SOD reduced the bacterial count of the faeces | |||||||||
| SC: (21 out of 121 patients): 3.7 × 109 (2.2–6.2) | ||||||||||||
| SOD: (19 out of 111 patients): 1.6 × 109 (0.8–3.4) | ||||||||||||
| SDD: (19 put of 86 patients): 1.9 × 109 (0.9–4.3) | ||||||||||||
| Enterococcus faecalis | Enterococcus faecium | F. prausnitzii | SDD/SOD significanty increased enterococci | |||||||||
| SC: | 2.6 × 106 | 6.3 × 106 | 5.5 × 107 | |||||||||
| SOD | 7.6 × 106 | P < 0.05 | 9.8 × 106 | NS | 4.0 × 107 | NS | ||||||
| SDD | 69 × 106 | P < 0.05 | 54 × 106 | P < 0.05 | 0.1 × 107 | P < 0.05 | ||||||
| Oostdijk et al. [9] | 13 Dutch ICUs (NEJM 2009) and 1 ICU (UMC Utrecht: 08/2008–08/2010) | Cumulative rate of bacteremia according to respiratory colonization status: | SDD decreased bacteremia only in patients successfully decolonized | |||||||||
| SC: 4.5/1000 patient-days | ||||||||||||
| SOD: 3.0/1000 patient-days | ||||||||||||
| SDD: 3.0/1000 patient-days in patients remaining colonized by enterobacteriae | ||||||||||||
| SDD: 1.0/1000 patient-days in patients successfully decolonized | ||||||||||||
| de Smet et al. [10] | 13 Dutch ICUs (NEJM 2009) Rate of bacteremia and respiratory tract acquisition of microorganisms in patients staying >3 days | Any bacteremia (except Coagulase-negative | Bacteremia with highly-resistant Staphylococci) microorganisms | SDD > SOD decreased bacteremia | ||||||||
| SC: 239/1837 (13 %) | 19/1837 (0.10 %) | |||||||||||
| SOD: 158/1758 (9 %) | OR: 0.66 (0.53–0.82) NNT: 25 | 20/1758 (1.03 %) | NS | |||||||||
| SDD: 124/1868 (7 %) | OR: 0.48 (0.38–0.60) NNT: 16 | 8/1868 (0.04 %) | OR:0.41 (0.18–0.94) NNT:170 | |||||||||
| Respiratory tract acquisition of any microorganisms | Of highly-resistant microorganisms | SDD > SOD decreased respiratory colonization | ||||||||||
| SC: 867/881 (98 %) | 128/881 (15 %) | |||||||||||
| SOD: 862/886 (97 %) | NS | 88/886 (10 %) | OR: 0.65 (0.49–0.87) NNT: 22 | |||||||||
| SDD: 800/828 (97 %) | OR: 0.46 (0.24–0.88) | 74/828 (9 %) | OR: 0.58 (0.43–0.78) NNT: 18 | |||||||||
| Respiratory tract acquisition of Enterococcus spp | Of Candida spp | SDD > SOD increased respiratory colonization by enterococci Candida spp and Psedomonas aeruginosa | ||||||||||
| SC: 37/881 (4 %) | 393/881 (45 %) | |||||||||||
| SOD: 32/886 (3 %) | NS | 476/886 (53 %) | OR: 1.44 (1.20–1.74) | |||||||||
| SDD: 93/828 (11 %) | OR: 2.89 (1.95–4.29) | 465/828 (56 %) | OR: 1.59 (1.31–1.93) | |||||||||
| Respiratory tract acquisition of tobramycin-resistant non-fermenting Gram-negative pathogens (such as P. aeruginosa) | ||||||||||||
| SC: 18/881 (2 %) | ||||||||||||
| SOD: 20/886 (2 %) | NS | |||||||||||
| SDD: 49/828 (6 %) | OR: 3.02 (1.74–5.20) | |||||||||||
| Oostdijk et al. [11] | 13 Dutch ICUs (NEJM 2009) Patients receiving SDD with rectal sampling and 1 single centre cohort; UMC Utrecht 01/2008–08/2009 | Proportion of successful decontamination under SDD | SDD less successfully decolonized the digestive tract from resistant microorganisms | |||||||||
| Patients with digestive enterobacteriaceae at ICU admission | 399/507 (79 %) | |||||||||||
| Patients with cephalosporin-susceptible microorganisms | 343/430 (80 %) | |||||||||||
| Patients with cephalosporin-resistant microorganisms | 56/77 (73 %) | P < 005 | ||||||||||
| Patients with aminoglycoside-susceptible microorganisms | 368/457 (81 %) | |||||||||||
| Patients with aminoglycoside-resistant microorganisms | 31/50 (62 %) | P < 0.05 | ||||||||||
| Patients with any resistant microorganism at ICU entry | 23/109 (21 %) | |||||||||||
| Patients with any resistant microorganism at ICU discharge | 24/109 (22 %) | NS | ||||||||||
| Melsen et al. [12] | 13 Dutch ICUs (NEJM 2009) post hoc analysis of surgical (n = 2762) versus non-surgical (n = 3165) patients | 28-day mortality in surgical patients | 28-day mortality in non-surgical patients | SDD decreased mortality in non-surgical patients | ||||||||
| SC: 209/973 (21.6 %) | 335/1016 (33.2 %) | |||||||||||
| SOD: 194/866 (22.6 %) | OR: 0.97 (0.77–1.22) | 308/1038 (30.0 %) | OR: 0.77 (0.63–0·94) | |||||||||
| SDD: 191/923 (20.8 %) | OR: 0.86 (0.69–1.09) | 349/1111 (31.7 %) | OR: 0.85 (0.70–1·03) | |||||||||
| Bacteremia in surgical patients | Bacteremia in non-surgical patients | SDD/SOD decreased bacteremia in all patients | ||||||||||
| SC: 86/973 (8.8 %) | 84/1016 (8.3 %) | |||||||||||
| SOD: 50/866 (5.8 %) | P < 0.05 | 60/1038 (5.8 %) | P < 0.05 | |||||||||
| SDD: 39/923 (4.2 %) | P < 0.05 | 41/1111 (3.7 %) | P < 0.05 | |||||||||
| Oostdijk et al. [13] | 9 of 13 Dutch ICUs (NEJM 2009) with colistin susceptibility testing | Colistin susceptibility testing (n = 1022 patients) | Medium-term (24 months) acquisition of colistin-resistance | |||||||||
| Acquisition of rectal colistin-resistant microorganisms | 2.4 (2.5–4.2)/1000 patient-days | |||||||||||
| Evolution from colistin-susceptible to colistin-resistant | 1.7 % (1.0–2.7) | |||||||||||
| Wittekamp et al. [14] | 5 of 13 Dutch ICUs participating in 2 large studies: I: SC, SOD-I, SDD-I (NEJM 2009) 1007 respiratory and 1093 rectal samples obtained from 1189 patients II: SOD-II, SDD-II (JAMA 2014) 1755 respiratory and 1808 rectal samples obtained from 1865 patients | SC | SDD-I | SOD-I | SDD-II | SOD-II | Long-term SDD/SOD (over 7 years) decreased tobramycin resistance in rectal and respiratory samples | |||||
| Tobramycin resistance in rectal samples: | 12.1 % | 6.6 %1,2 | 14 % | 4.2 %3,4 | 8 %5,6 | |||||||
| 1 SDD-I vs SC: RR 0.54 (0.34–0.87) | ||||||||||||
| 2 SDD-I vs SOD-I: RR 0.46 (0.29–0.72) | ||||||||||||
| 3 SDD-II vs SDD-I: RR 0.64 (0.40–1.04) | ||||||||||||
| 4 SDD-II vs SC: RR 0.35 (0.23–0.53) | ||||||||||||
| 5 SOD-II vs SOD-I: RR 0.56 (0.39–0.78) | ||||||||||||
| 6 SOD-II vs SC: RR 0.66 (0.47–0.95) | ||||||||||||
| Tobramycin resistance in respiratory samples | 10.9 % | 6.7 %1 | 9.7 % | 5.3 %2,3 | 4.5 %3,4 | |||||||
| 1 SDD-I vs SC: RR 0.61 (0.38–1.00) | ||||||||||||
| 2 SDD-II vs SC: RR 0.48 (0.32–0.73) | ||||||||||||
| 3 SOD-II vs SOD-I: RR 0.48 (0.30–0.76) | ||||||||||||
| 4 SOD-II vs SC: RR 0.42 (0.27–0.64) | ||||||||||||
| Colistin resistance in rectal samples | 2.7 % | 2.8 % | 1.2 % | 1.7 % | 1.1 %1 | Long-term SDD/SOD (over 7 years) did not increase resistance to colistin | ||||||
| 1 SOD-II vs SC: RR 0.41 (0.17–0.98) | ||||||||||||
| Colistin resistance in respiratory samples | 0.9 % | 2.1 % | 1.7 % | 1.1 % | 0.6 % | |||||||
SDD selective decontamination of the digestive tract, SOD selective oropharyngeal decontamination, SC standard care, NS not significant, APACHE II acute physiology and chronic health evaluation II score, ICU intensive care unit, OR odds ratio, RR relative risk, vs versus, 95 % CI 95 % confidence interval