Selective Decontamination of the Digestive Tract: Cumulating Evidence, at Last?

ABSTRACT

Selective decontamination of the digestive tract (SDD), an infection-control strategy designed to prevent nosocomial pneumonia in mechanically ventilated patients, has been implemented in numerous studies for more than 2 decades, but its role remains controversial. Sentinel studies in the 1960s and 1970s identified a link between colonization of the upper respiratory tract and subsequent increased risk of developing nosocomial pneumonia in critically ill patients. Studies in the 1980s found that prophylaxis with topical and systemic antibiotics to decontamination of the upper respiratory tract and gastrointestinal tract (particularly depleting gram-negative aerobic bacteria) was associated with lower rates of infections. However, impact on survival was not substantiated. However, several recent studies (including randomized trials and meta-analyses) suggest that SDD may improve survival in selected cohorts of critically ill patients in intensive care units (ICUs). Because liberal use of SDD (or any antimicrobial prophylactic strategy) may lead to escalating antimicrobial resistance, the risk of resistance varies according to local pathogens and resistance patterns. This review describes the development of the SDD concept, discusses recently published trials, and develops points for discussion and research. Additional studies are required to further define appropriate indications and limitations of this preventative strategy.

Selective decontamination of the digestive tract - colonization - nosocomial pneumonia - infection control - ventilator-associated pneumonia

REFERENCES

• 1 Johanson W G, Pierce A K, Sanford J P. Changing pharyngeal bacterial flora of hospitalized patients.  N Engl J Med. 1969;  281 1137-1140
• 2 Johanson Jr W G, Pierce A K, Sanford J P, Thomas G D. Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract.  Ann Intern Med. 1972;  77 701-706
• 3 Greenfield S, Teres D, Bushnell L S, Hedley-Whyte J, Feingold D S. Prevention of gram-negative bacillary pneumonia using aerosol polymyxin as prophylaxis, I: Effect on the colonization pattern of the upper respiratory tract of seriously ill patients.  J Clin Invest. 1973;  52 2935-2940
• 4 Klick J M, du Moulin G C, Hedley-Whyte J, Teres D, Bushnell L S, Feingold D S. Prevention of gram-negative bacillary pneumonia using polymyxin aerosol as prophylaxis, II: Effect on the incidence of pneumonia in seriously ill patients.  J Clin Invest. 1975;  55 514-519
• 5 Feeley T W, du Moulin G C, Hedley-Whyte J, Bushnell L S, Gilbert J P, Feingold D S. Aerosol polymyxin and pneumonia in seriously ill patients.  N Engl J Med. 1975;  293 471-475
• 6 Stoutenbeek C P, van Saene H KF, Miranda D R, Zandstra D F. The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients.  Intensive Care Med. 1984;  10 185-192
• 7 van der Waaij D. Colonization resistance of the digestive tract: clinical consequences and implications.  J Antimicrob Chemother. 1982;  10 263-270
• 8 Stoutenbeek C P, van Saene H KF, Miranda D R, Zandstra D F, Langrehr D. The effect of oropharyngeal decontamination using topical nonabsorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients.  J Trauma. 1987;  27 357-364
• 9 van Nieuwenhoven C A, Buskens E, van Tiel F H, Bonten M J. Relationship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients.  JAMA. 2001;  286 335-340
• 10 Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S. A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics.  N Engl J Med. 1992;  326 594-599
• 11 Hammond J MJ, Potgieter P D, Saunders G L, Forder A A. Double-blind study of selective decontamination of the digestive tract in intensive care.  Lancet. 1992;  340 5-9
• 12 Wiener J, Itokazu G, Nathan C, Kabins S A, Weinstein R A. A randomized, double-blind, placebo-controlled trial of selective decontamination in a medical-surgical intensive care unit.  Clin Infect Dis. 1995;  20 861-867
• 13 Ferrer M, Torres A, Gonzalez J et al.. Utility of selective digestive decontamination in mechanically ventilated patients.  Ann Intern Med. 1994;  120 389-395
• 14 Bergmans D C, Bonten M J, Gaillard C A et al.. Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study.  Am J Respir Crit Care Med. 2001;  164 382-388
• 15 Pugin J, Auckenthaler R, Lew D P, Suter P M. Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia: a randomized, placebo-controlled, double-blind clinical trial.  JAMA. 1991;  265 2704-2710
• 16 Rodriguez-Roldan J M, Altuna-Cuesta A, Lopez A et al.. Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial pharyngeal nonabsorbable paste.  Crit Care Med. 1990;  18 1239-1242
• 17 Pneumatikos I, Koulouras V, Nathanail C, Goe D, Nakos G. Selective decontamination of subglottic area in mechanically ventilated patients with multiple trauma.  Intensive Care Med. 2002;  28 432-437
• 18 DeRiso A JII, Ladowski J S, Dillon T A, Justice J W, Peterson A C. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery.  Chest. 1996;  109 1556-1561
• 19 Fourrier F, Dubois D, Pronnier P et al.. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study.  Crit Care Med. 2005;  33 1728-1735
• 20 Sirvent J M, Torres A, El-Ebiary M, Castro P, de Batlle J, Bonet A. Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma.  Am J Respir Crit Care Med. 1997;  155 1729-1734
• 21 Heyland D K, Cook D J, Griffith L, Keenan S P, Brun-Buisson C. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient.  Am J Respir Crit Care Med. 1999;  159 1249-1256
• 22 Cook D J, Walter S D, Cook R J et al.. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients.  Ann Intern Med. 1998;  129 433-440
• 23 Ewig S, Torres A, El-Ebiary M et al.. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury: incidence, risk factors, and association with ventilator-associated pneumonia.  Am J Respir Crit Care Med. 1999;  159 188-198
• 24 Carrico C J, Meakins J L, Marshall J C, Fry D, Maier R V. Multiple-organ-failure syndrome.  Arch Surg. 1986;  121 196-200
• 25 Marshall J C, Christou N V, Horn R, Meakins J L. The microbiology of multiple organ failure: the proximal gastrointestinal tract as an occult reservoir of pathogens.  Arch Surg. 1988;  123 309-315
• 26 Krueger W A, Krueger-Rameck S, Koch S, Carey V, Pier G B, Huebner J. Assessment of the role of antibiotics and enterococcal virulence factors in a mouse model of extraintestinal translocation.  Crit Care Med. 2004;  32 467-471
• 27 Brun-Buisson C, Legrand P, Rauss A et al.. Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli: study of an outbreak in an intensive care unit.  Ann Intern Med. 1989;  110 873-881
• 28 Bouter H, Schippers E F, Luelmo S A et al.. No effect of preoperative selective gut decontamination on endotoxemia and cytokine activation during cardiopulmonary bypass: a randomized, placebo-controlled study.  Crit Care Med. 2002;  30 38-43
• 29 Agusti C, Pujol M, Argerich M J et al.. Short-term effect of the application of selective decontamination of the digestive tract on different body site reservoir ICU patients colonized by multiresistant Acinetobacter baumannii .  J Antimicrob Chemother. 2002;  49 205-208
• 30 van Saene J J, van Saene H K, Stoutenbeek C P, Lerk C F. Influence of faeces on the activity of antimicrobial agents used for decontamination of the alimentary canal.  Scand J Infect Dis. 1985;  17 295-300
• 31 D'Amico R, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberati A. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systemic review of randomised controlled trials.  BMJ. 1998;  316 1275-1285
• 32 Nathens A B, Marshall J C. Selective decontamination of the digestive tract in surgical patients. a systemic review of the evidence.  Arch Surg. 1999;  134 170-176
• 33 van Saene H, Petros A J, Ramsay G, Baxby D. All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth.  Intensive Care Med. 2003;  29 677-690
• 34 Bonten M JM, Brun-Buisson C, Weinstein R A. Selective decontamination of the digestive tract: to stimulate or stifle?.  Intensive Care Med. 2003;  29 672-676
• 35 Krueger W A, Lenhart F P, Neeser G et al.. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical trial.  Am J Respir Crit Care Med. 2002;  166 1029-1037
• 36 de Jonge E, Schultz M, Spanjaard L et al.. Effects of selective decontamination of the digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomized controlled trial.  Lancet. 2003;  362 1011-1016
• 37 de la Cal M A, Cerda E, Garcia-Hierro P et al.. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial.  Ann Surg. 2005;  241 424-430
• 38 Krueger W A, Ruckdeschel G, Unertl K. Influence of intravenously administered ciprofloxacin on aerobic intestinal microflora and fecal drug levels when administered simultaneously with sucralfate.  Antimicrob Agents Chemother. 1997;  41 1725-1730
• 39 Krueger W A, Ruckdeschel G, Unertl K. Elimination of fecal Enterobacteriaceae by intravenous ciprofloxacin is not inhibited by concomitant sucralfate: a microbiological and pharmacokinetic study in patients.  Infection. 1999;  27 335-340
• 40 Verwaest C, Verhaegen J, Ferdinande P et al.. Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit.  Crit Care Med. 1997;  25 63-71
• 41 Misset B, Kitzis M D, Conscience G, Goldstein F W, Fourrier A, Carlet J. Mechanisms of failure to decontaminate the gut with polymixin E, gentamycin and amphotericin B in patients in intensive care.  Eur J Clin Microbiol Infect Dis. 1994;  13 165-170
• 42 Lingnau W, Berger J, Javorsky F, Fille M, Allerberger F, Benzer H. Changing bacterial ecology during a five year period of selective intestinal decontamination.  J Hosp Infect. 1998;  39 195-206