Selective decontamination of the digestive tract

Cook County Hospital and Rush Medical College Chicago, Illinois 

In intensive care units (ICUs), pneumonia is the most frequent nosocomial infection (1-3) and occurs most often as ventilator-associated pneumonia (VAP) in patients on mechanical ventilation. The overall incidence of VAP in different studies varies between 10% and 85%, depending on the patient population and the criteria used to establish the diagnosis. Ventilator-associated pneumonia has been associated with an attributable mortality rate ranging from 13% to 47% (4-7), although this is not a consistent finding (8-10). 

According to the time of diagnosis, VAP can be subdivided into early-onset (diagnosed within the first 4 days of ventilation) and late-onset disease (diagnosed after more than 4 days of ventilation) (11). Early-onset VAP is usually caused by community-acquired bacteria colonizing the upper respiratory tract before hospital admission (e.g.. Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus), these are presumably aspirated 

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Among the many strategies developed to prevent VAP, selective decontamination of the digestive tract (SDD) is the most extensively studied. However, the data on the benefits of SDD are inconclusive, and SDD has never become a routine infection control strategy in the United States (13-16). Moreover, in The Netherlands, where SDD was first applied in intensive care patients in 1983, only 13% of all ICUs used SDD in 1996, mostly in selected groups of ventilated patients (17). 

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De Vries-Hospers HG, Welling GW, Swabb EA, Van der Waaij D Selective decontamination of the digestive tract with aztreonam A study of 10 healthy volunteers. J Infect Dis 1984 150 636-642. 

After intravenous colistimethate (5 mg/kg/day) the CSF concentration was 25% of the serum concentration in a patient with meningitis (6). For life-threatening meningitis due to such organisms, polymyxins can also be given intrathecaUy as adjunctive therapy (7). Polymyxins are also used in regimens of selective decontamination of the digestive tract (8). 

Rommes JH, Zandstra DF, van Saene HK. Selectieve darm-decontaminatie voorkomt sterfte bij intensive-carepatien-ten. [Selective decontamination of the digestive tract reduces mortality in intensive care patients.) Ned Tijdschr Geneeskd 1999 143(12) 602-6. 

Combinations of local and systemic antibiotics for selective decontamination of the digestive tract (SDD) have been advocated to reduce or prevent HAP and other nosocomial infections (108-114). The SDD often uses combinations of nonabsorbable antibiotics, such as aminoglycoside, polymyxin B, and amphotericin B in a paste, which is applied to the oropharynx, and a liquid, which is given orally, with and without systemic cefotaxime, trimethoprim, or... 

Selective Decontamination of the Digestive Tract Trialists Collaborative Group. Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. BMJ 1993 307 525-532. 

The European Society of Intensive Care Medicine, The Societe Reanimation de Langue Francaise. The first European Consensus Conference in intensive care medicine selective decontamination of the digestive tract in intensive care unit patients. Infect Control Hosp Epidemiol 1992 13 609-611. 

Cockerill FR, MuUer SM, Anhalt IP, Marsh HM, Farnell MB, Mucha P, et al. Prevention of infection in critically iU patients by selective decontamination of the digestive tract. Ann Intern Med 1992 117 545-553. 

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. N Engl J Med 1992 326 594-599. 

Duncan RA, Steger KA, Craven DE. Selective decontamination of the digestive tract risks outweigh benefits for intensive care unit patients. Semin Respir Infect 1993 8 308-324. 

Selective decontamination of the digestive tract is based on the concept of colonization resistance. Studies in mice revealed that the autochthonous intestinal flora protects against colonization with exogenous flora... 

Selective decontamination of the digestive tract was associated with a significantly lower mortality rate in 4 (45,59,61,62) of 20 studies. In another analysis, SDD seemed to be beneficial in terms of mortality rate for surgical patients only when successful decontamination could be achieved (63). How-... 

Bonten MJM, Weinstein RA. Selective decontamination of the digestive tract a measure whose time has passed Curr Opin Infect Dis 1996 9 270-275. 

Stoutenbeek CP, van Saene HKF, Miranda DR, Zandstra DF. The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intens Care Med 1984 10 185-192. 

Verhoef J, Verhage EAE, Visser MR. 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 17 1047-1054. 

Hammond JMJ, Potgieter PD. Neurologic disease requiring long-term ventilation. The role of selective decontamination of the digestive tract in preventing nosocomial infection. Chest 1993 104 547-551. 

Rocha LA, Martin MJ, Pita S, et al. Prevention of nosocomial infection in critically ill patients by selective decontamination of the digestive tract a randomized, double blind, placebo-controlled study. Intens Care Med 1992 18 398-404. 

Jacobs S, Foweraker JE, Roberts SE. Effectiveness of selective decontamination of the digestive tract in an ICU with a policy encouraging a low gastric pH. Clin Intens Care 1992 3 52-58. 

Winter R, Humphreys H, Pick A, MacGowan AP, Willatts SM, Speller DCE. A controlled trial of selective decontamination of the digestive tract in intensive care and its effect on nosocomial infection. J Antimicrob Chemother 1992 30 73-87. 

McClelland P, Murray AE, Williams PS, et al. Reducing sepsis in severe combined acute renal and respiratory failure by selective decontamination of the digestive tract. Crit Care Med 1990 18 935-939. 

Ledingham IMA, Eastaway AT, McKay IC, Alcock SR, McDonalds JC, Ramsay G. Triple regimens of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care. Lancet 1988 1 785-790. 

Mackie DP, van Hertum WAJ, Schumburg T, Kuijper EC, Knape P. Prevention of infection in burns preliminary experience with selective decontamination of the digestive tract in patients with extensive injuries. J Trauma 1992 32 570-575. 

E Ulrich C, Harinck-de Weerd JE, Bakker NC, Jacz K, Doornbos L, de Ridder VA. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections a prospective randomized study. Intens Care Med 1989 15 424-43E... 

Eox MA, Peterson S, Eabri BM, van Saene HKE, Williets T. Selective decontamination of the digestive tract in cardiac surgical patients. Crit Care Med 1991 19 1486-1490. 

Quinio B, Albanese J, Bues-Charbit M, Viviand X, Martin C. Selective decontamination of the digestive tract in multiple trauma patients. Chest 1996 109 765-772. 

Korinek AM, Laisne MJ, Nicolas MH, Raskine L, Deroin V, Sanson-Lepors MJ. Selective decontamination of the digestive tract in neurosurgical intensive care unit patients a double-blind, randomized, placebo-controlled study. Crit Care Med 1993 21 1466-1473. 

Vandenbroucke-Grauls CMJE, Vandenbroucke JP. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 1991 338 859-862. 

Sun X, Wagner DP, Knaus WA. Does selective decontamination of the digestive tract reduce mortality for severely ill patients Crit Care Med 1996 24 753-755. 

Bion JE, Badger I, Crosby HA, et al. Selective decontamination of the digestive tract reduces gram-negative pulmonary colonization but not systemic endotoxe-mia in patients undergoing elective liver transplantation. Crit Care Med 1994 22 40-49. 

Kaufhold A, Behrendt W, Krauss T, van Saene HKE. Selective decontamination of the digestive tract and methicillin-resistant Staphylococcus aureus (letter). Lancet 1992 339 1411-1412. 

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