title: Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in ICUs: a randomized clinical trial.
abstract: Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.
  
  
  
  To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.
  
  
  
  Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively.
  
  
  
  Intensive care units were randomized to administer either SDD or SOD.
  
  
  
  Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.
  
  
  
  In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6% (95% CI, 4.6%-6.7%) during SDD and 11.8% (95% CI, 10.3%-13.2%) during SOD (P < .001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77).
  
  
  
  Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria.
  
  
  
  trialregister.nlIdentifier: NTR1780.
authors.affiliation: Department of Medical Microbiology, University Medical Center Utrecht, Utrecht2Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht.
authors.forename: Evelien A N
authors.initials: EAN
authors.lastname: Oostdijk
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht.
authors.forename: Jozef
authors.initials: J
authors.lastname: Kesecioglu
authors.affiliation: Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam.
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
authors.affiliation: Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam.
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Visser
authors.affiliation: Department of Intensive Care Medicine, Leiden University Medical Center, Leiden.
authors.forename: Evert
authors.initials: E
authors.lastname: de Jonge
authors.affiliation: Department of Intensive Care Medicine, Leiden University Medical Center, Leiden.
authors.forename: Einar H R
authors.initials: EHR
authors.lastname: van Essen
authors.affiliation: Department of Medical Microbiology, Leiden University Medical Center, Leiden.
authors.forename: Alexandra T
authors.initials: AT
authors.lastname: Bernards
authors.affiliation: Department of Intensive Care, HagaZiekenhuis, The Hague.
authors.forename: Ilse
authors.initials: I
authors.lastname: Purmer
authors.affiliation: Department of Medical Microbiology, HagaZiekenhuis, The Hague.
authors.forename: Roland
authors.initials: R
authors.lastname: Brimicombe
authors.affiliation: Department of Intensive Care, Maastricht University Medical Centre+, Maastricht.
authors.forename: Dennis
authors.initials: D
authors.lastname: Bergmans
authors.affiliation: Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht.
authors.forename: Frank
authors.initials: F
authors.lastname: van Tiel
authors.affiliation: Department of Intensive Care, Rijnstate Hospital, Arnhem.
authors.forename: Frank H
authors.initials: FH
authors.lastname: Bosch
authors.affiliation: Laboratory for Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem.
authors.forename: Ellen
authors.initials: E
authors.lastname: Mascini
authors.affiliation: Laboratory for Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem.
authors.forename: Arjanne
authors.initials: A
authors.lastname: van Griethuysen
authors.affiliation: Department of Intensive Care Medicine, Catharina Hospital, Eindhoven.
authors.forename: Alexander
authors.initials: A
authors.lastname: Bindels
authors.affiliation: Laboratory for Medical Microbiology, Laboratories for Pathology and Medical Microbiology, Catharina Hospital, Eindhoven.
authors.forename: Arjan
authors.initials: A
authors.lastname: Jansz
authors.affiliation: Department of Intensive Care, Deventer Hospital, Deventer.
authors.forename: Fred A L
authors.initials: FAL
authors.lastname: van Steveninck
authors.affiliation: Department of Medical Microbiology, Deventer Hospital, Deventer.
authors.forename: Wil C
authors.initials: WC
authors.lastname: van der Zwet
authors.affiliation: Department of Intensive Care, Diakonessenhuis Utrecht, Utrecht.
authors.forename: Jan Willem
authors.initials: JW
authors.lastname: Fijen
authors.affiliation: Department of Medical Microbiology, Diakonessenhuis Utrecht, Utrecht.
authors.forename: Steven
authors.initials: S
authors.lastname: Thijsen
authors.affiliation: Department of Intensive Care, BovenIJ Hospital, Amsterdam.
authors.forename: Remko
authors.initials: R
authors.lastname: de Jong
authors.affiliation: Department of Medical Microbiology, Zaans Medical Center, Zaandam.
authors.forename: Joke
authors.initials: J
authors.lastname: Oudbier
authors.affiliation: Department of Intensive Care, Groene Hart Hospital, Gouda.
authors.forename: Adrienne
authors.initials: A
authors.lastname: Raben
authors.affiliation: Department of Medical Microbiology, Groene Hart Hospital, Gouda.
authors.forename: Eric
authors.initials: E
authors.lastname: van der Vorm
authors.affiliation: Department of Intensive Care, HagaZiekenhuis, The Hague.
authors.forename: Mirelle
authors.initials: M
authors.lastname: Koeman
authors.affiliation: Department of Medical Microbiology, Rijnland Hospital, Leiderdorp.
authors.forename: Philip
authors.initials: P
authors.lastname: Rothbarth
authors.affiliation: Department of Intensive Care, Flevo Hospital, Almere.
authors.forename: Annemieke
authors.initials: A
authors.lastname: Rijkeboer
authors.affiliation: Department of Medical Microbiology, Flevo Hospital, Almere.
authors.forename: Paul
authors.initials: P
authors.lastname: Gruteke
authors.affiliation: Department of Intensive Care, Sint Lucas Andreas Hospital, Amsterdam.
authors.forename: Helga
authors.initials: H
authors.lastname: Hart-Sweet
authors.affiliation: Department of Medical Microbiology, Sint Lucas Andreas Hospital, Amsterdam.
authors.forename: Paul
authors.initials: P
authors.lastname: Peerbooms
authors.affiliation: Department of Intensive Care, Antonius Hospital, Sneek.
authors.forename: Lex J
authors.initials: LJ
authors.lastname: Winsser
authors.affiliation: Izore, Centre for Infectious Diseases Friesland, Leeuwarden.
authors.forename: Anne-Marie W
authors.initials: AW
authors.lastname: van Elsacker-Niele
authors.affiliation: Nij Smellinghe Hospital, Drachten.
authors.forename: Kees
authors.initials: K
authors.lastname: Demmendaal
authors.affiliation: Izore, Centre for Infectious Diseases Friesland, Leeuwarden.
authors.forename: Afke
authors.initials: A
authors.lastname: Brandenburg
authors.affiliation: Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen.
authors.forename: Anne Marie G A
authors.initials: AMGA
authors.lastname: de Smet
authors.affiliation: Department of Medical Microbiology, University Medical Center Utrecht, Utrecht32Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Marc J M
authors.initials: MJM
authors.lastname: Bonten
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia; D003428:Cross Infection / Q000517:prevention & control; D018592:Cross-Over Studies; D024881:Drug Resistance, Bacterial; D005260:Female; D041981:Gastrointestinal Tract / Q000382:microbiology*; D016905:Gram-Negative Bacterial Infections / Q000517:prevention & control*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009960:Oropharynx / Q000382:microbiology*; D012007:Rectum / Q000382:microbiology; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents