Chest
Volume 123, Issue 5, Supplement, May 2003, Pages 464S-468S
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Selective Digestive Decontamination Should Not Be Routinely Employed*

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There is a general consensus that antimicrobial resistance in the hospital setting has emerged as an important variable influencing patient outcome and resource utilization. Hospitals worldwide are faced with increasingly rapid emergence and spread of antibiotic-resistant bacteria. Both antibiotic-resistant Gram-negative bacilli and Gram-positive bacteria are reported as important causes of hospital-acquired infections. Few antimicrobial agents are available for effective treatment. Selective digestive decontamination (SDD) is a technique aimed at selectively eliminating aerobic Gram-negative bacilli and yeast from the mouth and stomach to reduce the occurrence of hospital-acquired infections, including ventilator-associated pneumonia. Unfortunately, the application of SDD has been associated with emergence of antibiotic-resistant bacterial strains, limiting its overall utility.

Section snippets

Prevalence of Antimicrobial Resistance in the ICU

ICUs, along with other specialty areas within hospitals (eg, organ transplant wards, oncology units), frequently have high levels of antimicrobial usage among patients maintained in close proximity. This type of environment may explain the high levels of antimicrobial resistance observed within such areas of the hospital. A multicenter European survey examined a total of 9,166 Gram-negative bacterial strains from 7,308 patients in ICUs from 118 hospitals.5 The most frequently isolated organisms

Risk Factors for Antibiotic Resistance

A number of investigators have demonstrated a close association between the use of antibiotics and the emergence of antibiotic resistance both in Gram-negative and Gram-positive bacteria.7891011 The recent experience with antibiotic cycling or scheduled antibiotic class changes also demonstrates how rapidly antibiotic-resistant bacteria can emerge within the hospital setting as antibiotic use patterns change.121314 Trouillet and coworkers15 examined 135 consecutive episodes of VAP, of which 77

Implications of Increasing Bacterial Antibiotic Resistance

In general, infections with antibiotic-resistant bacteria are associated with greater hospital mortality and longer lengths of hospital stay.22 Colonization and infection with antibiotic-resistant bacteria increase the likelihood that patients will receive inadequate antimicrobial therapy (ie, antimicrobial therapy to which the identified causative microorganisms are resistant). Several investigations have demonstrated a strong association between the administration of inadequate antibiotic

Recent Meta-analyses of SDD

The main focus of SDD is to selectively eliminate aerobic Gram-negative bacilli and yeast from the aerodigestive tract using a combination of topical and parenteral antibiotics (Table 1). A large number of clinical trials have examined the use of SDD in the ICU setting. Meta-analysis represents a method used to group randomized clinical trials in order to increase the power of their observations. Two large meta-analyses have been conducted that review the use of SDD. The first is a European

SDD and Antibiotic Resistance

In one of the largest trials of SDD, Gastinne and coworkers46 found that pneumonia due to staphylococci was more common among SDD-treated patients. The emergence of pneumonia due to Gram-positive bacteria in association with the use of SDD has also been reported by other investigators.47 Hammond and Potgieter48 found a statistically significant increase in the occurrence rate of infections caused by Acinetobacter species in the year after beginning a trial of SDD in their ICUs compared to the

Conclusion

Antibiotic resistance has become a major concern for both community-acquired and nosocomial infections. The development and use of SDD has occurred during the recent explosion in infections due to antibiotic-resistant microorganisms. Unfortunately, the overall impact of SDD on the development of antibiotic resistance cannot be fully determined based on the existing medical literature. However, the use of SDD as well as other antibiotics should be carefully monitored as a potential stimulus for

References (55)

  • SB Levy

    Multidrug resistance: a sign of the times

    N Engl J Med

    (1998)
  • H Hanberger et al.

    Antibiotic susceptibility among aerobic Gram-negative bacilli in intensive care units in 5 European countries

    JAMA

    (1999)
  • GS Itokazu et al.

    Antimicrobial resistance rates among gram-negative bacilli recovered from patients in intensive care units: evaluation of a national postmarketing surveillance program

    Clin Infect Dis

    (1996)
  • JY Fagon et al.

    Nosocomial pneumonia in patients receiving continuous mechanical ventilation: prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture technique

    Am Rev Respir Dis

    (1989)
  • J Ortiz et al.

    Infections caused byEscherichia coliresistant to norfloxacin in hospitalized cirrhotic patients

    Hepatology

    (1999)
  • SL Kaplan et al.

    Three-year multicenter surveillance of systemic pneumococcal infections in children

    Pediatrics

    (1998)
  • MB Edmond et al.

    Vancomycin-resistantEnterococcus faeciumbacteremia: risk factors for infection

    Clin Infect Dis

    (1995)
  • JJ Rahal et al.

    Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella

    JAMA

    (1998)
  • KS Meyer et al.

    Nosocomial outbreak of Klebsiella infection resistant to late-generation cephalosporins

    Ann Intern Med

    (1993)
  • C Urban et al.

    Effect of sulbactam on infections caused by imipenem-resistantAcinetobacter calcoaceticus biotype antratus.

    J Infect Dis

    (1993)
  • JL Trouillet et al.

    Ventilator-associated pneumonia caused by potentially drug-resistant bacteria

    Am J Respir Crit Care Med

    (1998)
  • MH Kollef

    Ventilator-associated pneumonia: a multivariate analysis

    JAMA

    (1993)
  • DJ Cook et al.

    Risk factors for ICU-acquired pneumonia

    JAMA

    (1998)
  • MJ Richards et al.

    Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System

    Crit Care Med

    (1999)
  • DA Goldmann et al.

    Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals: a challenge to hospital leadership

    JAMA

    (1996)
  • MH Kollef et al.

    The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia

    Chest

    (1998)
  • F Alvarez-Lerma

    Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit: ICU-Acquired Pneumonia Study Group

    Intensive Care Med

    (1996)
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