TY - JOUR
T1 - Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs A Randomized Clinical Trial
AU - Oostdijk, Evelien A. N.
AU - Kesecioglu, Jozef
AU - Schultz, Marcus J.
AU - Visser, Caroline E.
AU - de Jonge, Evert
AU - van Essen, Einar H. R.
AU - Bernards, Alexandra T.
AU - Purmer, Ilse
AU - Brimicombe, Roland
AU - Bergmans, Dennis
AU - van Tiel, Frank
AU - Bosch, Frank H.
AU - Mascini, Ellen
AU - van Griethuysen, Arjanne
AU - Bindels, Alexander
AU - Jansz, Arjan
AU - van Steveninck, Fred A. L.
AU - van der Zwet, Wil C.
AU - Fijen, Jan Willem
AU - Thijsen, Steven
AU - de Jong, Remko
AU - Oudbier, Joke
AU - Raben, Adrienne
AU - van der Vorm, Eric
AU - Koeman, Mirelle
AU - Rothbarth, Philip
AU - Rijkeboer, Annemieke
AU - Gruteke, Paul
AU - Hart-Sweet, Helga
AU - Peerbooms, Paul
AU - Winsser, Lex J.
AU - van Elsacker-Niele, Anne-Marie W.
AU - Demmendaal, Kees
AU - Brandenburg, Afke
AU - de Smet, Anne Marie G. A.
AU - Bonten, Marc J. M.
PY - 2014
Y1 - 2014
N2 - IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance. OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively. INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD. MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6%(95% CI, 4.6%-6.7%) during SDD and 11.8%(95% CI, 10.3%-13.2%) during SOD (P <.001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77). CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria
AB - IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance. OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively. INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD. MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6%(95% CI, 4.6%-6.7%) during SDD and 11.8%(95% CI, 10.3%-13.2%) during SOD (P <.001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77). CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria
U2 - https://doi.org/10.1001/jama.2014.7247
DO - https://doi.org/10.1001/jama.2014.7247
M3 - Article
C2 - 25271544
SN - 0098-7484
VL - 312
SP - 1429
EP - 1437
JO - JAMA
JF - JAMA
IS - 14
ER -