title: 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.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified.
  
  
  BACKGROUND
  None.
authors.affiliation: Division of Perioperative and Emergency Care, University Medical Centre Utrecht, Utrecht, The Netherlands. amga.desmet@gmail.com
authors.forename: Anne Marie G A
authors.initials: AM
authors.lastname: de Smet
authors.forename: Jan A J W
authors.initials: JA
authors.lastname: Kluytmans
authors.forename: Hetty E M
authors.initials: HE
authors.lastname: Blok
authors.forename: Ellen M
authors.initials: EM
authors.lastname: Mascini
authors.forename: Robin F J
authors.initials: RF
authors.lastname: Benus
authors.forename: Alexandra T
authors.initials: AT
authors.lastname: Bernards
authors.forename: Ed J
authors.initials: EJ
authors.lastname: Kuijper
authors.forename: Maurine A
authors.initials: MA
authors.lastname: Leverstein-van Hall
authors.forename: Arjan R
authors.initials: AR
authors.lastname: Jansz
authors.forename: Bartelt M
authors.initials: BM
authors.lastname: de Jongh
authors.forename: Gerard J
authors.initials: GJ
authors.lastname: van Asselt
authors.forename: Ine H M E
authors.initials: IH
authors.lastname: Frenay
authors.forename: Steven F T
authors.initials: SF
authors.lastname: Thijsen
authors.forename: Simon N M
authors.initials: SN
authors.lastname: Conijn
authors.forename: Jan A
authors.initials: JA
authors.lastname: Kaan
authors.forename: Jan P
authors.initials: JP
authors.lastname: Arends
authors.forename: Patrick D J
authors.initials: PD
authors.lastname: Sturm
authors.forename: Martin C J
authors.initials: MC
authors.lastname: Bootsma
authors.forename: Marc J M
authors.initials: MJ
authors.lastname: Bonten
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D000935:Antifungal Agents / Q000494:pharmacology*; D001419:Bacteria / Q000187:drug effects; D018592:Cross-Over Studies; D003666:Decontamination / Q000379:methods*; D024881:Drug Resistance, Bacterial; D025141:Drug Resistance, Fungal; D041981:Gastrointestinal Tract / Q000382:microbiology*; D006801:Humans; D007362:Intensive Care Units; D009960:Oropharynx / Q000382:microbiology*
chemical_list: D000900:Anti-Bacterial Agents; D000935:Antifungal Agents