Twenty five years of selective digestion decontamination – the questions remain unanswered
Authors:
Kratochvíl Milan; Ševčík Pavel
Authors‘ workplace:
Klinika anesteziologie, resuscitace a intenzivní medicíny FN Brno a LF MU Brno
Published in:
Anest. intenziv. Med., 19, 2008, č. 5, s. 260-268
Category:
Intesive Care Medicine - Review Article
Overview
Selective digestive decontamination in intensive care is a part of the preventive antimicrobial measures expected to make a positive contribution to the infection prevention, treatment, epidemiology and economy of ICUs. Since its origination it has been used in a limited number of centers reporting many positive results. A wider spread of the method has been thwarted by its not always conclusive and encouraging results and especially fears of promoting antimicrobial resistance which originate in the currently accepted restrictive antibiotic policy. According to this policy, antibiotic prophylaxis in general is not only ineffective but may also produce increased prevalence of multi-restistant bacteria. Our review offers pathophysiologic principles of selective digestive decontamintation, different aspects of its effect and the opinions of the present- -day promoters and opponents of the method. Even in the 25 years since it was brougt into practice in intensive care, the verdict about its place in the hospital-acquired infection prevention remains open.
Key words:
selective digestive decontamination – secondary endogenous infections – infection prevention – antibiotic resistance – ventilator-associated pneumonia
Sources
1. Stoutenbeek, Ch. P., van Saene H. K. F., 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, p. 185–192.
2. Silvestri, L., Kerr, S., Gullo, A. Prevention of infection using selective decontamination of the digestive tract. In Infection Control in the Intensive Care Unit. 2nd ed., Springer : Milan 2005, p. 297–312.
3. Ibrahim, E. H., Ward, S., Sehrman, G. et al. A comparative anasysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting. Chest, 2000, 117, p. 1434–1442.
4. Van Saene, H., K., F. Zandstra, D. F. Selective decontamination of the digestive tract: Rationale behind evidence-based use in liver transplantation. Liver Transpl., 2004, 10, p. 828–833.
5. Lackner, F., Haider, W., Orbes, S., Pichler, H., Rotter, M., Werner, H. P. Septicaemia in critical care patients treated with high doses of antibiotics. Resuscitation, 1975, 3, p. 205–209.
6. Price, D. J., Ghonheim, A. T. Dangers of antibiotic therapy in ventilated patients (abstract) Third World Congress on Intensive and Critical Care Medicine. Crit. Care Med., In Abstracts of original papers to be presented at the Third World Congress on Intensive and Critical Care Medicine, 1981, 9, 260 p.
7. Donowitz, L. G., Wenzel, R. P., Hoyt, J. W. High risk of hospital-acquired infection in the ICU patient. Crit. Care Med., 1982, 10, p. 355–357.
8. Garlock, J. H., Seley, G. P. Use of sulfanilamide in surgery of the colon and rectum. Preliminary report. Surgery, 1939, 5, p. 787–790.
9. Schimpff, S. C., Young, V. M., Green, W. H., Vermeulen, G. D., Moody, M. R., Wiernik, P. H. Origin of infection in acute nonlymphocytic leukemia. Significance of hospital acquisition of potential pathogens. Ann. Intern. Med., 1972, 77, p. 707–714.
10. Klastersky, J., Debusscher, L., Weerts, D., Daneau, D. Use of oral antibiotics in protected units environment: clinical effectiveness and role in the emergence of antibiotic- resistant strains. Pathol. Biol., 1974, 22, p. 5–12.
11. van der Waaij, D., Berghuis de Vries, J. M., Lekkerkerk van der Wees, J. E. C. Colonization resistance of the digestive tract in conventional and antibiotic-treated mice. J. Hyg. Camb., 1971, 69, p. 405–411.
12. Stoutenbeek, Ch. P., Miranda, D. R., van Saene, H. K. F. A new technique for infection prevention in the ICU. Sixth european congress of Anaesthesiology (Abstract). Anaesthesia, 1982, vol summaries: 56.
13. van Saene J. J. M., van Saene H. K. F., Stoutenbeek Ch. P., Lerk, C. F. Influence of faeces on the activity of antimicrobial agents used for decontamination of the alimentary canal. Scand. J. Infect. Dis., 1985, 17: 295-300.
14. Lambert-Zechovsky, N., Aufrant, C., Bingen, E., Blum, C., Proux, M. C., Mathieu, H. Cefotaxime in children: efficacy, tolerance and effect on the intestinal bacterial flora. J. Antimicrob. Chemotherapy, 1980, 6, p. 235–242.
15. Krueger, W. A., Unertl K. E. Selective decontamination of the digestive tract. Curr. Opin. Crit. Care, 2002, 8, p. 139–144.
16. Silvestri, L., van Saene, H. K. F., Milanese M., Gregori D., Gullo A. Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials. J. Hosp. Inf., 2007, 65, p. 187–203.
17. Nathens, A. B., Marshall, J. C. Selective decontamination of the digestive tract in surgical patients. A systematic review of evidence. Arch. Surg., 1999, 134, p. 170–176.
18. D’Amico, R., Pifferi S., Leonetti, C., Torri, V., Tinazzi, A., Liberati, A. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. Br. Med. J., 1998, 316, p. 1275–1285.
19. van Nieuwenhoven, Ch. A., Buskens, E., van Tiel, F. H., Bonten M. J. M. Relationship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients. JAMA, 2001, 286, p. 335–340.
20. Silvestri, L., van Saene, H. K. F., Milanese, M., Gregori, D. Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomized controlled trials. Intensive Care Med., 2005, 31, p. 898–910.
21. Kollef, M. H. The role of selective digestive tract decontamination on mortality and respiratory tract infections. Chest, 1994, 105, p. 1101–1108.
22. Liberati, A., D‘Amico, R., Pifferi, Torri, V., Brazzi, L. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database of Systematic Reviews 1997, Issue 3. Art. No.: CD000022. DOI: 10.1002/14651858.CD000022.pub2. http://www.cochrane.org/reviews/en/ab000022.html
23. Heyland, D. K., Cook, D. J., Jaeschke, R., Griffith, L., Lee, H. N., Guyatt, G. H. Selective decontamination of the digestive tract. An overwiew. Chest, 1994, 105, p. 1221–1229.
24. Selective Decontamination of the Digestive Tract Trialists’ Collaborative Group. Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. Br. Med. J., 307, p. 525–532.
25. Safdar, N., Said, A., Lucey, M. R. The role of selective digestive decontamination for reducing infection in patients undergoing liver transplantation: a systematic review and meta-analysis. Liver Transpl., 2004, 10, p. 817–827.
26. 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, 338, p. 1389–1390.
27. Van Till, J. W. O., van Ruler, O., Lamme, B., Weber, R. J. P., Reitsma, J. B., Boermeester, M. A. Single-drug therapy or selective decontamination of the digestive tract as antifungal prophylaxis in critically ill patients: a systematic review. Crit. Care, 2007, dostupné na: http://ccforum.com/content/ 11/6/R126.
28. Gatt, M., Reddy, S., Macfie, J. Review article: bacterial translocation in the critically ill- evidence and methods of prevention. Aliment. Pharmacol. Ther., 2007, 25, p. 741-757.
29. Stoutenbeek, Ch. P., van Saene, H. K. F., Little, R. A., Whitehead, A., for the working Group on Selective Decontamination of the Digestive Tract– The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial. Int. Care Med., 2007, 33, p. 261–270.
30. Safdar, N., Crnich, C. J., Maki, D. G. The pathogenesis of ventilator-associated pneumonia: Its relevance to developing effective strategies for prevention. Resp. Care, 2005, 50, p. 725–741.
31. Bonten, M. J., Gaillard, C. A., Tiel van, F. H., Smeets, H. G., Geest van der, S., Stobberingh, E. E. The stomach is not a source for colonization of the upper respiratory tract and pneumonia in ICU patients. Chest, 1994, 105, p. 878–884.
32. Garrouste-Orgeas, M., Chevret, S., Arlet, G., Marie, O., Rouveau, M., Popoff, N., Schlemmer, B. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am. J. Resp. Crit. Care. Med., 1997, 156, p. 1647–1655.
33. Stoutenbeek, Ch. P., van Saene H. K. F., Miranda D. R., Zandstra D. F., Langrehr, D. The effect of oropharyngeal decontamination using topical nonabsorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients. J. Trauma, 1987, 27, p. 357–364.
34. Bergmans, D. C. J. J., Bonten, M. J. M., Gaillard, C. A., Paling, J. C., van der Geest, S. et al. Prevention of ventilator-associated pneumonia by oral decontamination. A prospective, randomized, double- blind, placebo-controlled study. Am. J. Respir. Crit. Care Med., 2001, 164, p. 382–388.
35. Silvestri, L., van Saene, H. K. F., Milanese, M., Fontana, F., Gregori, D. et al Prevention of MRSA pneumonia by oral vacomycin decontamination: a randomised trial. Eur. Respir. J., 2004, 23, p. 921–926.
36. Koeman, M., van der Ven, J. A. M., Hak, E., Joore, H. C. A., Kaasjager, K. et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am. J. Resp. Crit. Care Med., 2006, 173, p. 1348–1355.
37. DeRiso, A. J. et al. Chlorhexidine gluconate 0,12 % oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest, 1996, 109, p. 1556–1561.
38. Segers, P., Speekenbrink, R. G. H., Ubbink, D. T., van Ogtrop, M. L., de Mol, B. A. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate. A randomized controlled trial. JAMA, 2006, 296, p. 2460–2466.
39. Fourrier, F., Dubois, D., Pronnier, P., Herbecq, P., Leroy, O., Desmettre, T., Pottier-Cau, E., Boutigny, H., Di Pompéo, C., Durocher, A., Roussel-Delvallez, M., PIRAD Study Group: Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit. Care Med., 2005, 33, p. 1728–1735.
40. Chlebicki, M. P., Safdar, N. Topical chlorhexidine for prevention of ventilator associated pneumonia: A meta-analysis. Crit. Care Med., 2007, 35, p. 595–602.
41. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am. J. Respir. Crit. Care Med., 2005, 171, p. 388–416.
42. Dodek, P., Keenan, S., Cook, D., Heyland, D., Jacka, M., Hand, L., Muscedere, M., Foster, D., Mehta, N., Hall, R., Brun-Buisson, Ch., for the Canadian Critical Care Trials Group and the Canadian Critical Care Society: Evidence-based clinical practice guideline for the prevention of ventilator--associated pneumonia. Ann. Intern. Med., 2004, 141, p. 305–313.
43. Dellinger, R. P., Levy M. M., Carlet, J. M., Bion, J. et al. Surviving Sepsis Campaign: International guidelines for the management of severe sepsis and septic shock: 2008. Crit. Care Med., 2008, 36, p. 296–327.
44. Sun, X., Wagner, D., Knaus, W. Does selective decontamination of the digestive tract reduce mortality for severely ill patients? Crit. Care. Med., 1996, 24, p. 753–755.
45. Hadfield, R. J., Parr, M. J. A., Manara, A. R. Late deaths in multiple trauma patients receiving intensive care. Resuscitation, 2001, 49, p. 279–281.
46. Krueger, W. A., Lenhart, F.-P., Neeser, G., Ruckdeschel, G., Schreckhase, H. et al. Influence of combined intravenous and topical antibiotic prohylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients. Am. J. Respir. Crit. Care Med., 2002, 166, p. 1029–1037.
47. Chytra, I. Vliv selektivní dekontaminace zažívacího traktu na infekční plicní komplikace u nemocných s kraniocerebrálním poraněním. Autoreferát dizertace k získání vědecké hodnosti kandidáta lékařských věd. Univerzita Karlova, Lékařská fakulta, Plzeň 1997, 39 s.
48. Zobel, G., Kuttnig, M., Grubbauer, H.-M. et al. Reduction of colonization and infection rate during pediatric intensive care by selective decontamination of the digestive tract. Crit. Care Med., 1991, 19, p. 1242–1246.
49. Ruza, F., Alvarado, F., Herruzo, R. et al. Prevention of nosocomial infection in a pediatric intensive care unit (PICU) through the use of selective digestive decontamination. Eur. J. Epidemiol., 1998, 14, p. 719–727.
50. Barret, J. P., Jeschke, M. G., Herndon, D. N. Selective decontamination of the digestive tract in severely burned pediatric patients. Burns, 2001, 27, p. 439–445.
51. Dervenis, Ch., Smailis, D., Hatzitheoklitos, E. Bacterial translocation and its prevention in acute pancreatitis. J. Hepatobiliary Pancreat. Surg., 2003, 10, p. 415–418.
52. Luiten, E. J., Hop, W. C., Lange, J. F., Bruining, H. A. Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Intensive Care Med., 1998, 24, p. 438–445.
53. Sawa, H., Ueda, T., Takeyama, Y., Yasuda, T., Shinzeki, M. et al. Treatment outcome of selective digestive decontamination and enteral nutrition in patients with severe acute pancreatitis. J. Hepatobiliary Pancreat Surg., 2007, 14, p. 503–508.
54. Ozmen, S., Dursun, M., Yilmaz, S. Spontaneous bacterial peritonitis: Pathogenesis, diagnosis, and management. Acta Gastroenterol. Belg., 2006, 69, p. 276–282.
55. Rasaratnam, B., Connely, N., Chin-Dusting, J. Nitric oxide and the hyperdynamic circulation in cirrhosis: is there a role for selective intestinal decontamination? Clinical Science, 2004, 107, p. 425–434.
56. Soares-Weiser, K., Brezis, M., Tur-Kaspa, R., Leibovici, L. Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding. Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding. Cochrane Database of Systematic Reviews, 2002, 2. No. CD002907. DOI: 10.1002/14651858. CD002907, dostupné na:
http://www.cochrane.org/reviews/ en/ab002907.html
57. Bauer, M., Paxian, M., Kortgen, A. Akutes Leberversagen. Anaesthesist, 2004, 53, p. 511–530.
58. Maring, J. K., Zwaveling, J. H., Klompmaker, I. J., van der Meer, J., Slooff, M. J. Selective bowel decontamination in elective liver transplantation: no improvement in endotoxaemia, initial graft function and post-operative morbidity. Transpl. Int., 2002, 15, p. 329–334.
59. Baron, P., Traber, R. N., Traber, D. L., Nguyen, T., Hollyoak, M. et al. Gut failure and translocation following burn and sepsis. J. Surg. Research, 1994, 57, p. 197–204.
60. White, D. J., Sanders, B., Horton, J. W. Selective decontamination of the digestive tract (SDD) attenuates postburn myocardial contractile depression associated with post-burn sepsis. Crit. Care Med., 2004, 32, 12, Supplement, p. A4.
61. Horton, J., Tan, J., White, D. J., Maass, D. L., Thomas, J. A. Selective decontamination of the digestive tract attenuated the myocardial inflammation and dysfunction that occur with burn injury. Am. J. Physiol. Heart Circ. Physiol., 2004, 278, p. H2241–H2251.
62. Horton, J. W., Maass, D. L., White, J., Minei, J. P. Reducing susceptibility to bacteremia after experimental burn injury: a role for selective decontamination of the digestive tract. J. Appl. Physiol., 2007, 102, p. 2207–2216.
63. Shirani, K. Z., Pruitt, B. A., Mason, A. D. The influence of inhalation injury and pneumonia on burn mortality. Ann. Surg., 1987, 205, p. 82–87.
64. de la Cal, M. A., Cerdá, E., García-Hierro, P., van Saene, H. K. F. et al. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract. A randomized, placebo controlled, double-blind trial. Ann. Surg., 2005, 241, p. 424–430.
65. Cerdá, E., Abella, A., de la Cal, M., Lorente, J. A., García-Hierro, P. et al. Enteral vancomycin controls methicillin-resistant staphylococcus aureus endemicity in an intensive care burn unit. A 9-year prospective study. Ann. Surg., 2007, 245, p. 397–407.
66. Eggimann, P., Chioléro, R. L. et al. Is there really a survival benefit of SDD in burns? Ann. Surg., 2006, 244, p. 325–326.
67. Levy, S. B. Multidrug resistence – a sign of the times. New Eng. J. Med., 1998, 338, p. 1376–1378.
68. Trouillet, J. L., Chastre, J., Vuagnat, A. et al. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am. J. Respir. Crit. Care Med., 1998, 157, p. 531–539.
69. Kollef, M. H., Ward. S. The influence of mini-BAL cultures on patient outcomes: implications fot the antibiotic management of ventilator-associated penumonia. Chest, 1998, 113, p. 412–420.
70. Salgado, C. D., O’Grady, N., Farr, B. M. Prevention and control of antimicrobial-resistant infections in intensive care patients. Crit. Care Med., 2005, 33, p. 2373–2382.
71. van Saene, H. K. F. In Infection control in ICU. 2nd ed., Springer : Milano 2007, s. 593–604.
72. 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, 326, p,. 594–599.
73. Sánchez, M., Cambronero, J. A., López, J., Cerdá E., Rubio, J. et al. Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients. A randomized, double-blind, placebo-controlled, multicenter trial. Am. J. Resp. Crit. Care Med., 1998, 158, p. 908–916.
74. Al Naiemi, N., Heddema, E. R., Bart, A., de Jonge E., Vandenbroucke-Grauls, Ch. M. et al. Emergence of multidrug resistant Gram-negative bacteria during selective decontamination of the digestive tract on an intensive care unit. J. Antimicr. Chemotherapy, 2006, 58, p. 853–856.
75. Heininger, A., Meyer, E., Schwab, F., Marschal, M., Unertl, K., Krueger, W. A. Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance. Intensive Care Med., 2006, 32, p. 1569–1576.
76. de Jonge, E., Schulz, M. J., Spanjaard, L., Bossuyt, P. M. M., Vroom, M. B. et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet, 2003, 362, p. 1011–1016.
77. Brun-Buisson, C., Legrand, P., Rauss, A., Richard, C., Montravers, F. et al. Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli: Study of an outbreak in an intensive care unit. Ann. Int. Med., 1989, 110, p. 873–881.
78. van der Voort, P. H. SDD: What are the risks of prevention? Přednáška, ISICEM, Brussels, 19. 3. 2008.
79. Bartlett, J. G. Selective decontamination of the digestive tract and its effect on antimicrobial resistance. Crit. Care Med., 1995, 23, p. 613–615.
80. van der Voort, P. H., van Roon, E. A., Kampinga, G. A., Boersma, E. C., Gerritsen, R. T. et al. A before-after study of multi-resistance and cost of selective decontamination of the digestive tract. Infection, 2004, 32, p. 271–277.
81. Bregeon, F., Ciais, V., Carret, V., Gregoire, R., Saux, P. et al. Is ventilator-associated pneumonia an independent risk factor for death? Anesthesiology, 2001, 94, p. 554–560.
82. Feron, B., Adair, C. G., Gorman, S. P., McClurg, B. Interaction of sucralfate with antibiotics used for selective decontamination of the gastrointestinal tract. Am. J. Hosp. Pharm., 1993, 50, p. 2550–2553.
83. Kollef, M. H. Selective digestive decontamination should not be routinely employed. Chest, 2003, 123, p. 464S–468S.
84. Bonten, M. J. M. Selective digestive tract deconatmination- will it prevent infection with multidrug-resistant gram-negative pathogens but still be applicable in institutions where methicillin-resistant Staphylococcus aureus and vacomycin-resistant enterococci are endemic? Clin. Infect Dis., 2006, 43, p. S70–74.
85. Ševčík, P. Selective decontamination of the digestive tract: Problems to be discussed. Scripta Medica, 1994, 67, p. 11–14.
86. Bonten, M. J. M. SDD – the final answer? Přednáška, ISICEM, Brussels, 19. 3. 2008.
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