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Double-blind study of selective decontamination of the digestive tract in intensive care
J M Hammond1, P D Potgieter, G L Saunders
1Department of Medicine, University of Cape Town, South Africa.
Abstract:
Selective decontamination of the digestive tract (SDD), by means of non-absorbable antibiotics, to prevent infection in intensive-care units (ICUs) remains controversial; there is evidence that the regimen reduces the incidence of secondary infection, but no convincing reduction in morbidity or mortality has been shown and the costs and effect on microbial resistance patterns need further study. In a double-blind, placebo-controlled trial, we have tried to find out whether SDD should be used routinely in all ICU patients at high risk of secondary infection. All patients admitted to the ICU who were thought likely to stay in the unit for at least 5 days and to need intubation for longer than 48 h were enrolled and randomly allocated to groups receiving placebo or SDD (amphotericin, colistin, and tobramycin applied to the oropharynx and enterally); all patients received intravenous cefotaxime for 72 h. Of 322 patients randomised, 83 were withdrawn (80 ICU stay or duration of intubation too short, 3 protocol violations). 239 medical, trauma, and surgical patients completed the trial period (114 SDD, 125 placebo). There were no differences between SDD and placebo groups in incidence of infection (30 [26%] vs 43 [34%] patients; p = 0.22), duration of ICU stay (mean 16.2 [14.3] vs 16.8 [12.3] days), hospital stay (29.9 [SD 25.0] vs 31.9 [22.2] days), or mortality (21 [18%] vs 21 [17%]). SDD substantially increased the costs of intensive care. Mechanisms other than bacterial colonisation of the gut may bring about substantial numbers of secondary infections in ICUs. Routine use of SDD in multidisciplinary ICUs cannot be recommended.
Insights
Selective decontamination of the digestive tract (SDD) using antibiotics did not reduce infections, ICU stay, or mortality in high-risk intensive care unit (ICU) patients. SDD also increased costs, so routine use is not recommended.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Clinical Pharmacology
Background:
- Selective decontamination of the digestive tract (SDD) is a controversial method to prevent infections in intensive care units (ICUs).
- While SDD may reduce secondary infection incidence, its impact on morbidity, mortality, costs, and antimicrobial resistance requires further investigation.
- Evidence supporting routine SDD use in all high-risk ICU patients is inconclusive.
Purpose of the Study:
- To evaluate the efficacy and safety of routine selective decontamination of the digestive tract (SDD) in intensive care unit (ICU) patients at high risk of secondary infection.
- To determine if SDD impacts infection rates, length of ICU or hospital stay, and patient mortality.
- To assess the cost-effectiveness and potential impact on microbial resistance patterns of SDD.
Main Methods:
- A double-blind, placebo-controlled trial involving 322 high-risk ICU patients requiring prolonged intubation.
- Patients were randomized to receive either SDD (oral and enteral amphotericin, colistin, tobramycin) or a placebo, with all patients receiving intravenous cefotaxime for 72 hours.
- Outcomes including infection incidence, ICU and hospital stay duration, and mortality were compared between the SDD and placebo groups.
Main Results:
- No significant difference was observed in the incidence of infection between the SDD group (26%) and the placebo group (34%; p = 0.22).
- There were no statistically significant differences in the duration of ICU stay, hospital stay, or overall mortality between the two groups.
- Selective decontamination of the digestive tract (SDD) was associated with substantially increased intensive care costs.
Conclusions:
- Routine use of selective decontamination of the digestive tract (SDD) in multidisciplinary intensive care units (ICUs) cannot be recommended.
- The study suggests that mechanisms beyond gut bacterial colonization contribute to secondary infections in ICUs.
- Further research may be needed to explore alternative strategies for preventing secondary infections in critically ill patients.
