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CORRESPONDENCE
Year : 2015  |  Volume : 142  |  Issue : 1  |  Page : 90-91

Selective digestive decontamination saves lives whilst preventing resistance


1 Department of Emergency, Unit of Anaesthesia & Intensive Care, Presidio Ospedaliero 34170, Gorizia, Italy
2 Intensive Care Unit, Hospital Universitario de Getafe, Getafe, Spain
3 Institute of Ageing & Chronic Disease, University of Liverpool, Liverpool, UK

Date of Web Publication4-Aug-2015

Correspondence Address:
Luciano Silvestri
Department of Emergency, Unit of Anaesthesia & Intensive Care, Presidio Ospedaliero 34170, Gorizia
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5916.162135

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How to cite this article:
Silvestri L, de la Cal MA, van Saene HK. Selective digestive decontamination saves lives whilst preventing resistance. Indian J Med Res 2015;142:90-1

How to cite this URL:
Silvestri L, de la Cal MA, van Saene HK. Selective digestive decontamination saves lives whilst preventing resistance. Indian J Med Res [serial online] 2015 [cited 2019 Jun 17];142:90-1. Available from: http://www.ijmr.org.in/text.asp?2015/142/1/90/162135

Sir,

We read the review by Keyt et al[1] on the prevention of ventilator-associated pneumonia (VAP) in the intensive care unit. Although comprehensive, we believe that the issues of selective digestive decontamination (SDD) and selective oropharyngeal contamination (SOD) were not properly covered.

The authors claimed that the techniques showed modest reductions in mortality in reviews and meta-analyses. However, a meta-analysis of randomized controlled trials (RCTs) using the full SDD protocol of enteral and parenteral antimicrobials showed a 29 per cent reduction in mortality [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.61-0.82]; 18 patients needed to be treated with SDD to prevent one death. The mortality reduction was 42 per cent in RCTs where SDD eradicated the carrier state (OR 0.58, 95% CI 0.45-0.77) [2] . These results are consistent with those of the Cochrane meta-analysis showing a 25 per cent reduction in mortality (OR 0.75 95% CI 0.65-0.87) in patients receiving SDD [3] . In a Dutch RCT including about 1000 patients, the risk of mortality was reduced by 40 per cent in the unit where SDD was administered to all patients (OR 0.6; 95% CI 0.4-0.8) [4] . In a cluster-randomized cross-over study [5] of 5939 patients, both SDD and SOD were associated with significant relative reductions in death of 13 and 11 per cent, respectively [OR 0.83 ( p0 =0.02), and 0.86 ( p0 =0.045), respectively] compared with standard care. All these reductions in mortality cannot be simply dismissed as "modest".

The authors do not recommend SDD or SOD for VAP prevention due to concern for emergence of antibiotic resistance. Their statement is based on the ecological point-prevalence survey [6] in which all patients in the unit, whether enrolled or not in the principal study [5] , were included. The main Dutch study [5] showed that the proportion of patients with aerobic Gram-negative bacilli in rectal swabs that were not susceptible to the marker antibiotics was lower with SDD than with standard care or SOD. Additionally, a post-hoc analysis of the same Dutch RCT demonstrated that bacteraemia due to highly resistant microorganisms (HRMO) was significantly reduced by SDD compared with SOD (OR 0.37; 95% CI 0.16-0.85) and standard care (OR 0.41; 95% CI 0.18-0.94). Lower respiratory tract colonization due to HRMO was less with SDD (OR 0.58, 95% CI 0.43-0.78) and SOD (OR 0.65, 95% CI 0.49-0.87) compared with standard care [7] . In a recent meta-analysis on the development of resistance and the use of SDD no relationship between the use of SDD and resistance was reported [8] . In contrast, the use of SDD was associated with a significant reduction in colistin-resistant aerobic Gram-negative bacilli (OR 0.58, 95% CI 0.46 - 0.72) [9] .

In conclusion, SDD and SOD may protect against the development of resistance, and when present the incidence is very low [10] . Regular surveillance cultures of throat and rectal swabs, as one of the four components of SDD/SOD, can detect resistance at early stage.

 
   References Top

1.
Keyt H, Faverio P, Restrepo MI. Prevention of ventilator-associated pneumonia in the intensive care unit: A review of clinically relevant recent advancements. Indian J Med Res 2014; 139 : 814-21.  Back to cited text no. 1
    
2.
Silvestri L, van Saene HKF, Weir I, Gullo A. Survival benefit of the full selective digestive decontamination regimen. J Crit Care 2009; 24 : 474.e7-14.  Back to cited text no. 2
    
3.
Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 2009; 4 : CD000022.  Back to cited text no. 3
    
4.
de Jonge E, Schultz MJ, Spanjaard L, Bossuyt PM, Vroom MB, Dankert J, 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 : 1011-6.  Back to cited text no. 4
    
5.
de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009; 360 : 20-31.  Back to cited text no. 5
    
6.
Oodstijk EAN, de Smet AMGA, Blok HEM, Thieme Grohen ES, van Asselt GJ, Benus RFJ, et al. Ecological effects of selective decontamination on resistant Gram-negative bacterial colonization. Am J Respir Crit Care Med 2010; 181 : 452-7.  Back to cited text no. 6
    
7.
de Smet AMGA, Kluytmans JAJW, Blok HEM, Mascini EM, Benus RF, Bernards AT, et al. Selective digestive decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study. Lancet Infect Dis 2011; 11 : 372-80.  Back to cited text no. 7
    
8.
Daneman N, Sarwar S, Fowler RA, Cuthbertson BH for the SUDDICU Canadian Study Group. Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13 : 328-41.  Back to cited text no. 8
    
9.
Silvestri L, Taylor N, van Saene HKF, Bakker J. Colistin, SDD and resistance: nihil novi sub sole. Intensive Care Med 2014; 40 : 1065.  Back to cited text no. 9
    
10.
Oostdijk EAN, Kesecioglu J, Schultz MJ, Visser CE, de Jonge E, van Essen EHR, et al. Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in ICUs. A randomized clinical trial. JAMA 2014; 312 : 1429-37.  Back to cited text no. 10
    




 

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