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Intensive Care Medicine

, Volume 10, Issue 4, pp 185–192 | Cite as

The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients

  • C. P. Stoutenbeek
  • H. K. F. van Saene
  • D. R. Miranda
  • D. F. Zandstra
Original Articles

Abstract

122 multiple trauma patients staying in the ICU for 5 or more days and needing mechanical ventilation were investigated to determine the effect of selective decontamination of the digestive tract on prevention of infection. The (retrospectively studied) control group of 59 patients received no antibiotic prophylaxis. The infection rate during ICU-stay was 81%. Most infections were caused by potentially pathogenic microorganisms (PPM) from the oral cavity or the intestines (i.e. endogenous infections). The oropharynx and the intestines were rapidly colonised with ICU-associated gram-negative bacilli. After 2 weeks more than 80% of patients were found colonised. This secondary colonisation of the digestive tract is a very important stage in the pathogenesis of infections. Sixty-three patients were selectively decontaminated with nonabsorbable antibiotics, administered through the gastric tube even if peristalsis was absent. Emphasis was laid on the selective decontamination of the oral cavity, using topical application of an antibiotic paste. With this technique the oral cavity was free of PPM within 3 days in most patients. No secondary colonisation was found. Rectal colonisation decreased significantly after 5 days. Secondary colonisation occurred in 9 patients with PPM sensitive to the antibiotics used. The prophylactic regimen included systemic cefotaxim, directed against early endogenous infection. The suppression and after some time the absence of the endogenous source of PPM resulted in a significant reduction of colonisation and infection. The total infection rate decreased to 16%.

Key words

Selective decontamination of the digestive tract (SDD) Multiple trauma Infection Colonisation Endogenous Prevention 

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References

  1. 1.
    Altemeier WA, Culbertson WR, Hummel RP (1968) Surgical considerations of endogenous infections sources, types and methods of control. Surg Clin North Am 48:227PubMedGoogle Scholar
  2. 2.
    Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD (1980) Epidemiology of trauma deaths. Am J Surg 140:144CrossRefPubMedGoogle Scholar
  3. 3.
    Bradley JA, Ledingham McAI, Hamilton DNH (1981) Assessment of host resistance of critically ill surgical patients by the response to recall skin antigens. Int Care Med 7:105Google Scholar
  4. 4.
    Cross AS, Roup B (1981) Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med 70:681CrossRefPubMedGoogle Scholar
  5. 5.
    Daschner FD (1978) Antibiotikaprophylaxe in der Intensivmedizin. Helv Chir Acta 45:475PubMedGoogle Scholar
  6. 6.
    Daschner FD, Frey P, Wolff G, Baumann PC, Suter P (1982) Nosocomial infections in Intensive Care wards: a multicenter study. Int Care Med 8:5Google Scholar
  7. 7.
    Du Moulin GC, Paterson DG, Hedley-Whyte J, Lisbon A (1982) Aspiration of gastric bacteria in antacid-treated patients: a frequent cause of postoperative colonisation of the air-way. Lancet 1:242PubMedGoogle Scholar
  8. 8.
    Espersen F, Gabrielsen J (1981) Pneumonia due to Staphylococcus aureus during mechanical ventilation. J Infect Dis 144(1):19PubMedGoogle Scholar
  9. 9.
    Freeman J, McGowan JE (1978) Risk factors for nosocomial infection. J Infect Dis 138:811PubMedGoogle Scholar
  10. 10.
    Gaya G (1976) Infection control in intensive care. Br J Anaesth 48:9PubMedGoogle Scholar
  11. 11.
    Goris RJA, Draaisma J (1982) Cause of death after blunt trauma. J Trauma 22:141PubMedGoogle Scholar
  12. 12.
    Hillman KM, Riordan T, O'Farrell SM, Soad Tabaqchali (1982) Colonization of the gastric contents in critically ill patients. Crit Care Med 10:444PubMedGoogle Scholar
  13. 13.
    Johanson WG, Pierce AK, Sanford JP (1969) Pharyngeal bacterial flora of hospitalized patients: emergency of gramnegative bacilli. N Engl J Med 281:1137PubMedGoogle Scholar
  14. 14.
    Johanson WG, Higuchi JH, Chadhuri TR, Woods DE (1980) Bacterial adherence to epithelial cells in bacillary colonization of the respiratory tract. Am Rev Respir Dis 121:55PubMedGoogle Scholar
  15. 15.
    Johanson WG, Pierce AK, Sanford JP, Thomas GD (1972) Nosocomial respiratory infections with gram-negative bacilli. Ann Intern Med 77:101Google Scholar
  16. 16.
    La Force M (1981) Hospital acquired gram-negative rod pneumonias: an overview. Am J Med 70:664Google Scholar
  17. 17.
    La Force FM, Hopkins J, Trow R, Wang WU (1976) Human oral defenses against gram-negative rods. Am Rev Respir Dis 114:929Google Scholar
  18. 18.
    Le Frock JL, Ellis ChA, Weinstein L (1979) The impact of hospitalization on the aerobic fecal microflora. Am J Med Sci 277:269Google Scholar
  19. 19.
    Miranda DR, van Saene HKF, Stoutenbeek CP, Zandstra DF (1983) Environment and costs in a surgical ICU. The implication of selective decontamination of the digestive tract (SDD). Acta Anaesthiol Belg 34:223Google Scholar
  20. 20.
    Nichols RL (1981) Use of prophylactic antibiotics in surgical practice. Am J Med 70:686CrossRefPubMedGoogle Scholar
  21. 21.
    Northey D, Adess ML, Hartsuck JM, Rhoades ER (1974) Microbial surveillance in a surgical intensive care unit. Surg Gynecol Obstet 139:321PubMedGoogle Scholar
  22. 22.
    Preston GA, Larson EL, Stamm WE (1981) The effect of private isolation rooms on patients care practices, colonization and infection in an intensive care unit. Am J Med 70:641CrossRefPubMedGoogle Scholar
  23. 23.
    Romano Ph, Margenet A, Soussy C, Metlzheim B (1979) Bilan bactériologique due service de réanimation chirugicale et traumatologique de l'hôpital Henri Mondor. Ann Anesthiol France 20:655Google Scholar
  24. 24.
    Rosebury Th (1962) Microorganisms indigenous to man McGraw-Hill, New YorkGoogle Scholar
  25. 25.
    Rose HD, Babcock JB (1975) Colonization of intensive care unit patients with gram-negative bacilli. Am J Epidemiol 101:495PubMedGoogle Scholar
  26. 26.
    Rosendorf LL, Daicoff G, Baer H (1974) Source of gram-negative infection after open-heart surgery. Thorac Cardiovasc Surg 67:195Google Scholar
  27. 27.
    Saene van HKF, Stoutenbeek ChP, Miranda DR, Zandstra DF (1983) A novel approach to infection control in the intensive care unit. Acta Anaesthiol Belg 34:193Google Scholar
  28. 28.
    Schimpff SC, Young VM, Green WH (1972) Origin of infection in acute nonlymphocytic leukemia: significance of hospital acquisition of potential pathogens. Ann Intern Med 77:707PubMedGoogle Scholar
  29. 29.
    Schimpff SC (1980) Infection prevention during profound granulocytopenia. Ann Intern Med 93:358PubMedGoogle Scholar
  30. 30.
    Schimpff SC, Miller RM, Polakavetz RN, Hornic RB (1974) Infection in the severely traumatized patient. Ann Surg 179:352PubMedGoogle Scholar
  31. 31.
    Schwartz SN, Dowling JN, Benkovic C, De Quittner-Buchanan M, Postko T, Yee RB (1978) Source of gram-negative bacilli colonizing the trachea of intubated patients. J Infect Dis 138:227PubMedGoogle Scholar
  32. 32.
    Sleyfer DTh, Mulder NH, de Vries-Hospers HG, Fidler V, Nieweg O, van der Waay D, van Saene HKF (1980) Infection prevention in granulocytopenic patients by selective decontamination of the digestive tract. Eur J Cancer 16:859Google Scholar
  33. 33.
    Sprunt K, Redman W (1968) Evidence suggesting importance of role of interbacterial inhibition in maintaining balance of normal flora. Ann Intern Med 68:579PubMedGoogle Scholar
  34. 34.
    Stevens RM, Teres D, Skillman JJ, Feingold Ds (1974) Pneumonia in an intensive care unit. A 30-month experience. Arch Intern Med 134:106CrossRefPubMedGoogle Scholar
  35. 35.
    Stoddart JC (1983) Hospital-acquired infections. In: Tinker J, Rapin M (eds) Care of the critically ill patient. Springer Verlag, Berlin, p 873Google Scholar
  36. 36.
    Thorp JM, Richards WC, Telfer ABM (1979) A survey of infection in an intensive care unit. Anaesthesia 34:643PubMedGoogle Scholar
  37. 37.
    Uffelen van R, van Saene HKF, Fidler V, Löwenberg A (1983) Oropharyngeal flora: source of colonization of the respiratory tract in patients on artificial ventilation. Intensive Care Med (submitted)Google Scholar
  38. 38.
    Waay van der D J (1979) Colonization resistance of the digestive tract as a major lead in the selection of antibiotics for therapy. In: Waay D van der, Verhoef J (eds) New criteria for antimicrobial prophylaxis. Proceedings of a symposium, Utrecht Excerpta MedicaAmsterdam, p 271Google Scholar
  39. 39.
    Waay van der D, Berghuis-de Vries JM, Lekkerkerk-van der Wees JEC (1969) Colonisation resistance of the digestive tract in conventional and antibiotic treated mice. J Hyg (Camb) 405:71Google Scholar
  40. 40.
    Williams RC, Gibbons RJ (1972) Inhibition of bacterial adherence by secretoory immunoglobulin A: a mechanism of antigen disposal. Science 77:697Google Scholar
  41. 41.
    Yoshioka H, Fujita K, Maruyama S, Oka R (1982) Changes in aerobic pharyngeal flora related to antibiotic use and the emergence of gram-negative bacilli. Clin Pediatr 21(8):460Google Scholar

Copyright information

© Springer-Verlag 1984

Authors and Affiliations

  • C. P. Stoutenbeek
    • 1
  • H. K. F. van Saene
    • 2
  • D. R. Miranda
    • 1
  • D. F. Zandstra
    • 1
  1. 1.Institute for Anesthesiology and Intensive CareUniversity of GroningenGroningenThe Netherlands
  2. 2.Department of Clinical BacteriologyUniversity of GroningenGroningenThe Netherlands

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