Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients

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Abstract

The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown.

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Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial.

Evert de Jonge, Marcus Schultz, Lodewijk Spanjaard … (2003)

Selective decontamination of the digestive tract (SDD) is an infection-prevention regimen used in critically ill patients. We assessed the effects of SDD on intensive-care-unit (ICU) and hospital mortality, and on the acquisition of resistant bacteria in adult patients admitted to intensive care. We did a prospective, controlled, randomised, unblinded clinical trial. 934 patients admitted to a surgical and medical ICU were randomly assigned oral and enteral polymyxin E, tobramycin, and amphotericin B combined with an initial 4-day course of intravenous cefotaxime (SDD group n=466), or standard treatment (controls n=468). Primary endpoints were ICU and hospital mortality and the acquisition of resistant bacteria. In the SDD group 69 (15%) patients died in the ICU compared with 107 (23%) in the control group (p=0.002). Hospital mortality was lower in the SDD groups than in the control group (113 [24%] vs 146 [31%], p=0.02). During their stay in intensive care, colonisation with gram-negative bacteria resistant to ceftazidime, ciprofloxacin, imipenem, polymyxin E, or tobramycin occurred in 61 (16%) of 378 SDD patients and in 104 (26%) of 395 patients in the control group (p=0.001). Colonisation with vancomycin-resistant enterococcus occurred in five (1%) SDD patients and in four (1%) controls (p=1.0). No patient in either group was colonised with meticillin-resistant Staphylococcus aureus. In a setting with low prevalence of vancomycin-resistant enterococcus and meticillin-resistant S aureus, SDD can decrease ICU and hospital mortality and colonisation with resistant gram-negative aerobic bacteria.

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Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial

Lennie P G Derde, Ben Cooper, Herman Goossens … (2014)

Summary Background Intensive care units (ICUs) are high-risk areas for transmission of antimicrobial-resistant bacteria, but no controlled study has tested the effect of rapid screening and isolation of carriers on transmission in settings with best-standard precautions. We assessed interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in European ICUs. Methods We did this study in three phases at 13 ICUs. After a 6 month baseline period (phase 1), we did an interrupted time series study of universal chlorhexidine body-washing combined with hand hygiene improvement for 6 months (phase 2), followed by a 12–15 month cluster randomised trial (phase 3). ICUs were randomly assigned by computer generated randomisation schedule to either conventional screening (chromogenic screening for meticillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]) or rapid screening (PCR testing for MRSA and VRE and chromogenic screening for highly resistant Enterobacteriaceae [HRE]); with contact precautions for identified carriers. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, for which we calculated step changes and changes in trends after the introduction of each intervention. We assessed acquisition by microbiological surveillance and analysed it with a multilevel Poisson segmented regression model. We compared screening groups with a likelihood ratio test that combined step changes and changes to trend. This study is registered with ClinicalTrials.gov, number NCT00976638. Findings Seven ICUs were assigned to rapid screening and six to conventional screening. Mean hand hygiene compliance improved from 52% in phase 1 to 69% in phase 2, and 77% in phase 3. Median proportions of patients receiving chlorhexidine body-washing increased from 0% to 100% at the start of phase 2. For trends in acquisition of antimicrobial-resistant bacteria, weekly incidence rate ratio (IRR) was 0·976 (0·954–0·999) for phase 2 and 1·015 (0·998–1·032) for phase 3. For step changes, weekly IRR was 0·955 (0·676–1·348) for phase 2 and 0·634 (0·349–1·153) for phase 3. The decrease in trend in phase 2 was largely caused by changes in acquisition of MRSA (weekly IRR 0·925, 95% CI 0·890–0·962). Acquisition was lower in the conventional screening group than in the rapid screening group, but did not differ significantly (p=0·06). Interpretation Improved hand hygiene plus unit-wide chlorhexidine body-washing reduced acquisition of antimicrobial-resistant bacteria, particularly MRSA. In the context of a sustained high level of compliance to hand hygiene and chlorhexidine bathings, screening and isolation of carriers do not reduce acquisition rates of multidrug-resistant bacteria, whether or not screening is done with rapid testing or conventional testing. Funding European Commission.

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Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis

Richard Price, Graeme S. MacLennan, John Glen (2014)

Objectives To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis. Design Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence. Inclusion criteria Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo. Results Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain. Conclusion Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.

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Author and article information

Journal

Title: JAMA

Abbreviated Title: JAMA

Publisher: American Medical Association (AMA)

ISSN (Print): 0098-7484

Publication date Created: November 27 2018

Publication date (Print): November 27 2018

Volume: 320

Issue: 20

Page: 2087

Affiliations

[1 ]Intensive Care Center and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands

[2 ]Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands

[3 ]Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England

[4 ]Infectious Diseases–Internal Medicine, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain

[5 ]Department of Microbiology, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain

[6 ]Department of Intensive Care, Hospital de Sant Pau-Universitat Autònoma de Barcelona, Barcelona, Spain

[7 ]Adult Critical Care, University Hospital of Wales, Cardiff, Wales

[8 ]Intensive Care, Ghent University Hospital, Ghent, Belgium

[9 ]Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium

[10 ]Department of Intensive Care Medicine, Clinique Saint Pierre, Ottignies-Louvain-la-Neuve, Belgium

[11 ]Microbiology Department, Clinique Saint Pierre, Ottignies-Louvain-la-Neuve, Belgium

[12 ]IntensiveCare Medicine, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium

[13 ]Laboratory of Medical Microbiology, Vaccine, & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium

[14 ]Department of Intensive Care Medicine, CHU Liège, Liege, Belgium

[15 ]Clinical Microbiology, CHU Liège, Liege, Belgium

[16 ]Anesthesiology and Critical Care, AZ Sint Jan Bruges, Bruges, Belgium

[17 ]Microbiology Laboratory, Saint-Lucas Hospital Ghent, Ghent, Belgium

[18 ]Serviço de Medicina Intensiva, Centro Hospitalar de Trás-os-Montes os Montes e Alto Douro, Vila Real, Portugal

[19 ]Medical Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain

[20 ]Microbiology Department, Hospital Clinic of Barcelona, Barcelona, Spain

[21 ]Laboratory for Respiratory Microbiology, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia

[22 ]Intensive Care Unit, University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia

[23 ]Intensive Care Unit, Hospital Universitario La Fe, Valencia, Spain

[24 ]Intensive Care (UCIP), Hospital Santo Antonio–Centro Hospitalar do Porto (CHP), Porto, Portugal

[25 ]Microbiology Laboratory, Hospital Santo Antonio–Centro Hospitalar do Porto (CHP), Porto, Portugal

[26 ]Department of Microbiology, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy

[27 ]Intensive Care Unit, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy

[28 ]Department of Anesthesia and Intensive Care, Ospedale Infermi RIMINI–AUSL della Romagna, Rimini, Italy

[29 ]Medical Intensive Care and Infection Control Unit, CHU Henri Mondor & University Paris Est Créteil, Paris, France

Article

DOI: 10.1001/jama.2018.13765

PMC ID: 6583563

PubMed ID: 30347072

SO-VID: 7671669b-e48a-4737-8d46-a4c580929ff1

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Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients : A Randomized Clinical Trial

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Most cited references 5

Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial.

Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial

Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis

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