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Infection control in critically ill patients: effects of selective decontamination of the digestive tract
C J Rogers1, H K van Saene, P M Suter
1Department of Pharmacy, Royal Liverpool University Hospital, United Kingdom.
Abstract:
The use of selective decontamination of the digestive tract (SDD) to control infection in the intensive care unit (ICU) is reviewed. There are three basic patterns of infection in the ICU: primary endogenous, secondary endogenous, and exogenous. In exogenous infection, no microbial carriage precedes colonization and infection. In endogenous infection, infection is preceded by oropharyngeal or GI carriage. A primary endogenous infection is caused by an organism carried by the patient on admission to the ICU, whereas a secondary endogenous infection is caused by organisms acquired in the ICU. The traditional approach to infection control in the ICU has included frequent hand washing, limiting the use of agents for prophylaxis of stress-ulcer bleeding, and limiting the use of injectable antimicrobials to the treatment of infection in order to prevent resistance. The recognition that hand washing only partially reduces endogenous infection led to the use of nonabsorbable antimicrobials to abolish oropharyngeal and gastrointestinal carriage of potentially pathogenic microorganisms. In addition, the use of an injectable antimicrobial during the first four days in the ICU to control primary endogenous infection was considered not to lead to resistance as long as it was combined with nonabsorbable antimicrobials. Of 41 fully reported clinical trials of SDD, 33 showed a significant reduction of infectious morbidity among patients who received SDD. Of the 32 trials in which carriage of potential pathogens was a measured endpoint, 31 showed a reduction in carriage. Of the 24 studies in which resistance was an endpoint, 22 showed no increase in resistance associated with SDD. Only 10 of 35 trials that examined death showed a significant decrease in mortality. SDD, used in conjunction with traditional infection-control measures, diminishes microbial carriage and infectious morbidity in the ICU without increasing antimicrobial resistance.
Insights
Selective decontamination of the digestive tract (SDD) reduces infections in intensive care units (ICUs) by decreasing microbial carriage and infectious morbidity without increasing antimicrobial resistance.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Microbiology
Background:
- Intensive care units (ICUs) face complex infection patterns: primary endogenous, secondary endogenous, and exogenous.
- Traditional infection control in ICUs includes hand washing and judicious antimicrobial use.
- Hand washing alone has limited efficacy against endogenous infections, prompting exploration of alternative strategies.
Purpose of the Study:
- To review the efficacy of selective decontamination of the digestive tract (SDD) in controlling ICU infections.
- To assess the impact of SDD on microbial carriage, infectious morbidity, antimicrobial resistance, and mortality.
- To evaluate SDD in conjunction with established infection control practices.
Main Methods:
- Review of 41 fully reported clinical trials on selective decontamination of the digestive tract (SDD).
- Analysis of trials measuring infectious morbidity, microbial carriage, antimicrobial resistance, and mortality as endpoints.
- Synthesis of data on SDD's effectiveness when combined with traditional infection control measures.
Main Results:
- Selective decontamination of the digestive tract (SDD) significantly reduced infectious morbidity in 33 out of 41 trials.
- SDD demonstrated a reduction in the carriage of potential pathogens in 31 out of 32 trials.
- No increase in antimicrobial resistance was observed in 22 out of 24 studies evaluating resistance as an endpoint.
Conclusions:
- Selective decontamination of the digestive tract (SDD) effectively diminishes microbial carriage and infectious morbidity in the ICU setting.
- SDD, when integrated with traditional infection control methods, does not appear to increase antimicrobial resistance.
- While SDD shows promise in reducing infections and morbidity, its impact on mortality requires further investigation.