Prevention of hospital-acquired infections by selective digestive decontamination

Selective decontamination of the digestive tract (SDD) has been advocated to prevent ventilator-associated pneumonia (VAP) and possibly other nosocomial infections. However, its incorporation into standard health care practices has been limited.

Comprehensive literature search using www.pubmed.gov and derivative cross-references.

The abundance of basic science and clinical literature largely supports the concept that the incidence of VAP declines after the introduction of SDD, although there are some controversial aspects. Several meta-analyses and recent controlled clinical trials have supported the benefit of SDD. A few years ago, the Institute for Healthcare Improvement introduced the "ventilator bundle," a set of simple evidence-based measures designed to reduce the incidence of pneumonia. These measures have been implemented rapidly throughout the country. Of the four initial measures (elevation of the head of the bed, daily "sedation vacations" with assessment of readiness for endotracheal extubation, prophylaxis against stress-related gastric mucosal hemorrhage, and deep venous thrombosis prophylaxis), only the first two affect the development of VAP either directly or indirectly.

The evidence supporting SDD as a prevention measure for VAP is at least as good as that supporting the ventilator bundle, if not better. At many centers, a topical oral antiseptic (e.g., chlorhexidine) has been incorporated as a fifth element of the ventilator bundle.