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CORRESPONDENCE
Year : 2015  |  Volume : 142  |  Issue : 1  |  Page : 91-92

Authors' response


1 South Texas Veterans Health Care System; University of Texas Health Science Center at San Antonio, San Antonio, TX, Italy
2 Health Science Department, University of Milan-Bicocca, Respiratory Unit, San Gerardo Hospital, Monza, Italy

Date of Web Publication4-Aug-2015

Correspondence Address:
H Keyt
South Texas Veterans Health Care System; University of Texas Health Science Center at San Antonio, San Antonio, TX
Italy
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Source of Support: None, Conflict of Interest: None


PMID: 26261174

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How to cite this article:
Keyt H, Faverio P, Restrepo M I. Authors' response. Indian J Med Res 2015;142:91-2

How to cite this URL:
Keyt H, Faverio P, Restrepo M I. Authors' response. Indian J Med Res [serial online] 2015 [cited 2019 Sep 21];142:91-2. Available from: http://www.ijmr.org.in/text.asp?2015/142/1/91/162142

We read with great interest the letter by Silvestri and collaborators [1] in response to our review article on VAP [2] . As the authors emphasize, the use of selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) is strongly supported by the literature. However, we feel it is necessary to be cautious in fully recommending this intervention for two reasons: (i) meta-analyses and systematic reviews lack the precision to delineate potential negative or harmful consequences of an intervention, and (ii) we question the generalizability of the data to a global community with diverse population characteristics. For these reasons, our article suggests that SDD has a "modest" effect.

We believe that the most recently published meta-analysis of multiple intervention strategies for prevention of hospital-acquired pneumonia supports our position [3] . This meta-analysis again confirms that only SDD among all the interventions used in the prevention of hospital acquired pneumonia, significantly decreases the rate of mortality compared with controls [n=10,227; risk ratio (RR) 0.84; 95% confidence interval (95% CI) 0.76-0.92; p0 <0.001]. However, careful review of the 30 randomized controlled trials included in the mortality assessment in this study, reveals that 24 studies did not reach a significant result supporting the survival benefit. The six studies that showed a significant decrease in mortality were performed in countries or hospitals with a prevalence rate of multi-drug resistant organisms(MDRO) inferior or absent to many hospitals systems around the world, although baseline rates of MDRO are not regularly reported in the studies included in the mortality outcome of the mentioned meta-analysis. Therefore, the literature has not yet definitively answered the questions: (i) will SDD reduce mortality in places with high or moderate baseline prevalence of MDROs?, and (ii) will SDD protect accurately for the development of MDRO emergence in ICUs with moderate or high baseline prevalent vancomycin-resistant enterococcus (VRE) or methicillin resistant Staphylococcus aureus (MRSA)?

Additionally, we believe that the question of whether SDD may cause harm has also not been definitively answered. Multiple studies, including one by the authors of the letter, report an increase in MRSA associated with SDD [4],[5],[6],[7],[8],[9],[10] . This finding is particularly notable in the context of the recent study by Magill, et a[11] . which reports that in 184 ICUs in the US, Clostridium difficile and MRSA are the two most important pathogens causing healthcare associated infections. The antimicrobials utilized in the SDD do not cover MRSA or VRE, but may cause antimicrobial pressure due to the use of second or third generation cephalosporins. Finally, a real concern for the medical community in India is how the New Delhi metallo-β-lactamase 1 (NDM-1) in Pseudomonas aeruginosa will behave when exposed to SDD therapy?

Clearly, the magnitude of applying an intervention that has been shown to increase the rate of MDROs or that has not been tested in high prevalent MDRO ICUs is a matter of concern. Therefore, we conclude that the decision to apply an intervention such as SDD to patients in an ICU, goes beyond the baseline reading and understanding of the current results published in the medical literature. In this particular case, a strict knowledge of the ecology with standardized surveillance programmes is critical before generalized application of the results of this intervention to the global community.

 
   References Top

1.
Silvestri L, de la Cal MA, van Saene HKF. Selective digestive decontamination saves lives whilst preventing resistance. Indian J Med Res 2015; 142 : 90-2.  Back to cited text no. 1
    
2.
Keyt H, Faverio P, Restrepo MI. Prevention of ventilator-associated pneumonia in the intensive care unit: A review of the clinically relevant recent advancements. Indian J Med Res 2014; 139 : 814-21.  Back to cited text no. 2
    
3.
Roquilly A, Marret E, Abraham E, Asehnoune K. Pneumonia prevention to decrease mortality in intensive care unit: A systematic review and meta-analysis. Clin Infect Dis 2015; 60 : 64-75.  Back to cited text no. 3
    
4.
De la Cal MA, Cerda E, Garcia-Hierro P, van Saene HK, Gomez-Santos D, Nego E, 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 : 424-30.  Back to cited text no. 4
    
5.
Ferrer M, Torres A, Gonzalez J, Puiq de la Bellacasa J, el-Ebiary M, Roca M, et al. Utility of selective digestive decontamination in mechanically ventilated patients. Ann Intern Med 1994; 120 : 389-95.  Back to cited text no. 5
    
6.
Flaherty J, Nathan C, Kabins SA, Weinstein RA. Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit. J Infect Dis 1990; 162 : 1393-7.  Back to cited text no. 6
    
7.
Fox MA, Peterson S, Fabri BM, van Saene HK. Selective decontamination of the digestive tract in cardiac surgical patients. Crit Care Med 1991; 19 : 1486-90.  Back to cited text no. 7
    
8.
Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S: French Study Group on Selective Decontamination of the Digestive Tract. A controlled trial in intensive care units of selective decontamination of the digestive tract with non absorbable antibiotics. N Engl J Med 1992; 326 : 594-9.  Back to cited text no. 8
    
9.
Godard J, Guillaume C. Reverdy ME, Bachmann P, Bui-Xuan B, Negeotte A, et al. Intestinal decontamination in a polyvalent ICU: a double-blind study. Intensive Care Med 1990; 16 : 307-11.  Back to cited text no. 9
    
10.
Hammond JM, Potgieter PD, Saunders GL, Forder AA. Double-blind study of selective decontamination of the digestive tract in intensive care. Lancet 1992; 340 : 5-9.  Back to cited text no. 10
    
11.
Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014; 370 : 1198-208.  Back to cited text no. 11
    




 

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