Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in ICUs: a randomized clinical trial

Oostdijk, E.A.N.; Kesecioglu, J.; Schultz, M.J.; Visser, C.E.; Jonge, E. de; Essen, E.H.R. van; ... ; Bonten, M.J.M. (2014)

Article / Letter to editor

IMPORTANCE\nSelective 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.\nOBJECTIVE\nTo compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.\nDESIGN, SETTING, AND PARTICIPANTS\nPragmatic, 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.\nINTERVENTIONS\nIntensive care units were randomized to administer either SDD or SOD.\nMAIN OUTCOMES AND MEASURES\nUnit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.\nRESULTS\nIn 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).\nCONCLUSIONS AND RELEVANCE\nUnit-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.\nTRIAL REGISTRATION\ntrialregister.nlIdentifier: NTR1780.

• All authors: Oostdijk, E.A.N.; Kesecioglu, J.; Schultz, M.J.; Visser, C.E.; Jonge, E. de; Essen, E.H.R. van; Bernards, A.T.; Purmer, I.; Brimicombe, R.; Bergmans, D.; Tiel, F. van; Bosch, F.H.; Mascini, E.; Griethuysen, A. van; Bindels, A.; Jansz, A.; Steveninck, F.L. van; Zwet, W.C. van der; Fijen, J.W.; Thijsen, S.; Jong, R. de; Oudbier, J.; Raben, A.; Vorm, E. van der; Koeman, M.; Rothbarth, P.; Rijkeboer, A.; Gruteke, P.; Hart-Sweet, H.; Peerbooms, P.; Winsser, L.J.; Elsacker-Niele, A.M.W. van; Demmendaal, K.; Brandenburg, A.; Smet, A.M.G.A. de; Bonten, M.J.M.
• Date: 2014-10-08
• Journal: Journal of the American Medical Association
• Volume: 312
• Issue: 14
• Pages: 1429 - 37
• DOI: doi:10.1001/jama.2014.7247