Selective digestive decontamination, a seemingly effective regimen with individual benefit or a flawed concept with...

Area of Science:

• Critical Care Medicine
• Infectious Disease Epidemiology
• Clinical Pharmacology

Background:

• Selective digestive decontamination (SDD) regimens, combining topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP), are recognized for preventing intensive care unit (ICU)-acquired infections.
• The effectiveness of SDD has primarily been demonstrated within randomized concurrent control trials (RCCTs), leading to questions about its broader population-level impact.
• The concept of SDD implying a population benefit requires further investigation beyond controlled trial settings.

Purpose of the Study:

• To reify the concept of selective digestive decontamination (SDD) in humans by analyzing a broad accumulated evidence base.
• To evaluate the population-level effects of SDD, including studies utilizing non-concurrent controls (NCC).
• To determine if SDD use in the ICU context is associated with overall population harm.

Main Methods:

• A comprehensive analysis of the accumulated evidence base for SDD was performed.
• Studies involving topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP) with non-concurrent controls (NCC) were included.
• The study treated the accumulated evidence as a natural experiment to assess population-level outcomes.

Main Results:

• The analysis of the broad evidence base, including NCC studies, allowed for the reification of the SDD concept in humans.
• The investigation indicated potential overall population harm associated with SDD use.
• Higher event rates were observed in the ICU context with the utilization of SDD regimens.

Conclusions:

• While SDD regimens show efficacy in preventing ICU-acquired infections within specific trial designs (RCCTs), their broader population impact requires careful consideration.
• The reification of the SDD concept through a natural experiment using accumulated evidence suggests a potential for population-level harm.
• The findings indicate that SDD use in the ICU may be associated with increased event rates, challenging the assumption of universal population benefit.