Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs
Authors: Evelien A. N. Oostdijk, Jozef Kesecioglu, Marcus J. Schultz, Caroline E. Visser, Evert de Jonge, Einar H. R. van Essen, Alexandra T. Bernards, Ilse Purmer, Roland Brimicombe, Dennis Bergmans, Frank van Tiel, Frank H. Bosch, Ellen Mascini, Arjanne van Griethuysen, Alexander Bindels, Arjan Jansz, Fred (A.) L. van Steveninck, Wil C. van der Zwet, Jan Willem Fijen, Steven Thijsen, Remko de Jong, Joke Oudbier, Adrienne Raben, Eric van der Vorm, Mirelle Koeman, Philip Rothbarth, Annemieke Rijkeboer, Paul Gruteke, Helga Hart-Sweet, Paul Peerbooms, Lex J. Winsser, Anne-Marie W. van Elsacker-Niele, Kees Demmendaal, Afke Brandenburg, Anne Marie G.A. de Smet, Marc J. M. Bonten
Journal: JAMA (2014)

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 5957 and 6040 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-wideprevalenceofantibiotic-resistantgram-negativebacteria.Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTSIn 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 = .40for difference).Day 28-mortality was 25.7% and 23.8% during SOD and SDD, respectively (adjusted odds ratio, 0.85 [95% CI, 0.77-0.93];P = .001),and this difference was similar between surgical and nonsurgical patients.Intensive care unit-acquired bacteremia occurred in 5.9% and 4.5% of the patients during SOD and SDD, respectively (odds ratio, 0.74 [95% CI, 0.63-0.88];P < .001;number needed to treat, 69).CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance.Compared with SOD, SDD was associated with lower day-28 mortality, rectal carriage of antibiotic-resistant gram-negative bacteria, and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycosideresistant gram-negative bacteria.