Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study

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• 作者：Dr Anne Marie GA de Smet MD^a ; ^d ; ^{amga.desmet@gmail.com"" rel=""nofollow} ; Prof Jan AJW Kluytmans MD^e ; ^f ; Hetty EM Blok MSc^b ; Ellen M Mascini MD^g ; Robin FJ Benus MD^h ; Alexandra T Bernards MDⁱ ; Ed J Kuijper MDⁱ ; Maurine A Leverstein-van Hall MD^b ; Arjan R Jansz MD^j ; Bartelt M de Jongh MD^k ; Gerard J van Asselt MD^l ; Ine HME Frenay MD^m ; Steven FT Thijsen MDⁿ ; Simon NM Conijn^o ; Jan A Kaan MD^p ; Jan P Arends MD^h ; Patrick DJ Sturm MD^q ; Martin CJ Bootsma PhD^b ; Prof Marc JM Bonten MD^b ; ^c
• 刊名：The Lancet Infectious Diseases
• 出版年：2011
• 出版时间：May 2011
• 年：2011
• 卷：11
• 期：5
• 页码：372-380
• 全文大小：153 K

文摘

Summary

Background

Previously, we assessed selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) on survival and prevention of bacteraemia in patients in intensive-care units. In this analysis, we aimed to assess effectiveness of these interventions for prevention of respiratory tract colonisation and bacteraemia with highly resistant microorganisms acquired in intensive-care units.

Methods

We did an open-label, clustered group-randomised, crossover study in 13 intensive-care units in the Netherlands between May, 2004, and July, 2006. Participants admitted to intensive-care units with an expected duration of mechanical ventilation of more than 48 h or an expected stay of more than 72 h received SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx), SDD (SOD antibiotics in the oropharynx and stomach plus 4 days' intravenous cefotaxime), or standard care. The computer-randomised order of study regimens was applied by an independent clinical pharmacist who was masked to intensive-care-unit identity. We calculated crude odds ratios (95 % CI) for rates of bacteraemia or respiratory tract colonisation with highly resistant microorganisms in patients who stayed in intensive-care units for more than 3 days (ie, acquired infection). This trial is registered at http://isrctn.org, number ISRCTN35176830.

Findings

Data were available for 5927 (>99 % ) of 5939 patients, of whom 5463 (92 % ) were in intensive-care units for more than 3 days. 239 (13 % ) of 1837 patients in standard care acquired bacteraemia after 3 days, compared with 158 (9 % ) of 1758 in SOD (odds ratio 0·66, 95 % CI 0·53–0·82), and 124 (7 % ) of 1868 in SDD (0·48, 0·38–0·60). Eight patients acquired bacteraemia with highly resistant microorganisms during SDD, compared with 18 patients (with 19 episodes) during standard care (0·41, 0·18–0·94; rate reduction [RR] 59 % , absolute risk reduction [ARR] 0·6 % ) and 20 during SOD (0·37, 0·16–0·85; RR 63 % , ARR 0·7 % ). Of the patients staying in intensive-care units for more than 3 days, we obtained endotracheal aspirate cultures for 881 (49 % ) patients receiving standard care, 886 (50 % ) receiving SOD, and 828 (44 % ) receiving SDD. 128 (15 % ) patients acquired respiratory tract colonisation with highly resistant microorganisms during standard care, compared with 74 (8 % ) during SDD (0·58, 0·43–0·78; RR 38 % , ARR 5·5 % ) and 88 (10 % ) during SOD (0·65, 0·49–0·87; RR 32 % , ARR 4·6 % ). Acquired respiratory tract colonisation with Gram-negative bacteria or cefotaxime-resistant and colistin-resistant pathogens was lowest during SDD.

Interpretation

Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified.

Funding

None.