Intensive Care Medicine

, Volume 29, Issue 5, pp 677–690 | Cite as

All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth

  • Hendrick K. F. van SaeneEmail author
  • Andy J. Petros
  • Graham Ramsay
  • Derrick Baxby



The objective was to compare evidence of the effectiveness, costs and safety of the traditional parenteral antibiotic-only approach against that gathered from 53 randomised trials involving more than 8,500 patients and six meta-analyses on selective decontamination of the digestive tract (SDD) to control infection on the intensive care unit (ICU).


Traditionalists believe that all infections are due to breaches of hygiene except those established in the first 2 days, and that all micro-organisms can cause death. In contrast, newer insights show that transmission via the hands of carers are responsible only for infections occurring after one week, and that only a limited range of 15 potential pathogens contribute to mortality.

Interventions to prevent ICU infection

The traditional approach is based on hand disinfection aiming at the prevention of transmission of all micro-organisms, to control all infections that occur after 2 days on the ICU. The second feature is the restrictive use of systemic antibiotics, only in cases of microbiologically proven infection. In contrast, SDD aims to control the three types of infection: primary, secondary endogenous and exogenous due to 15 potential pathogens. The classical SDD tetralogy comprises four components: (i) a parenteral antibiotic, cefotaxime, administered for three days to prevent primary endogenous infections typically occurring 'early'; (ii) the oropharyngeal and enteral antimicrobials, polymyxin E, tobramycin and amphotericin B administered in throat and gut throughout the treatment on the ICU to prevent secondary endogenous infections tending to develop 'late'; (iii) a high standard of hygiene to control transmission of potential pathogens; and (iv) surveillance samples of throat and rectum to monitor the efficacy of the treatment.


(i) Infectious morbidity; (ii) mortality; (iii) antimicrobial resistance; and (iv) costs.


Properly designed trials on hand disinfection have never demonstrated a reduction in either pneumonia and septicaemia, or mortality. Two randomised trials using restrictive antibiotic policies failed to show a survival benefit at 28 days. In both trials the proportion of resistant isolates obtained from the lower ways was >60% despite significantly less use of antibiotics in the test group. A formal cost effectiveness analysis of the traditional antibiotic policies has not been performed. On the other hand, two meta-analyses have shown that SDD reduces the odds ratio for lower airway infections to 0.35 (0.29–0.41) and mortality to 0.80 (0.69–0.93), with a 6% overall mortality reduction from 30% to 24%. No increase in the rate of super infections due to resistant bacteria could be demonstrated over a period of 20 years of clinical research. Four randomised trials found the cost per survivor to be substantially lower in patients receiving SDD than for those traditionally managed.


The traditionalists still rely on level 5 evidence, i.e. expert opinion, with a grade E recommendation, whilst the proponents of SDD are able to cite level 1 evidence allowing a grade A recommendation in their attempts to control infection on the ICU. The main reason for SDD not being widely used is the primacy of opinion over evidence.


Critically ill Intensive care unit Selective digestive decontamination Traditional antibiotic policies Infectious morbidity Mortality Antimicrobial resistance Costs 



We gratefully acknowledge Drs. Vladimir Damjanovic and Sophie Rosseneu for carefully reviewing the manuscript, and Mrs. Lynda Jones for meticulously typing it.


  1. 1.
    Larson EL, Association for Professionals in Infection Control and Epidemiology 1992–1993, 1994 APIC Guidelines Committee (1995) APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23:251–269CrossRefGoogle Scholar
  2. 2.
    Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stéphan F, Similowski T, Mercat A, Diehl JL, Sollet JP, Tenaillon A (2000) Invasive and non-invasive strategies for management of suspected ventilator-associated pneumonia. Ann Intern Med 132:621–630CrossRefGoogle Scholar
  3. 3.
    Stoutenbeek CP, van Saene HKF, Miranda DR, Zandstra DF (1984) The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Med 10:185–192CrossRefGoogle Scholar
  4. 4.
    Spencer RC (1996) Definitions of nosocomial infections. In: Emmerson AM, Ayliffe GAJ (eds) Surveillance of nosocomial infections. Baillieres Clin Infect Dis 3:237–252Google Scholar
  5. 5.
    Brun-Buisson C, Doyon F, Carlet J (1996) Bacteremia and severe sepsis in adults: a multi centre prospective survey on ICUs and wards of 24 hospitals. Am J Respir Crit Care Med 154:617–624CrossRefGoogle Scholar
  6. 6.
    Rayner BL, Willcox PA (1988) Community-acquired bacteraemia; a prospective survey of 239 cases. QJM 259:907–919Google Scholar
  7. 7.
    Silvestri L, Monti Bragadin C, Milanese M, Gregori D, Consales C, Gullo A, van Saene HKF (1999) Are most ICU-infections really nosocomial? A prospective observational cohort study in mechanically ventilated patients. J Hosp Infect 42:125–133CrossRefGoogle Scholar
  8. 8.
    De la Cal MA, Cerda E, Garcia-Hierro P, Lorente L, Sanchez-Conchiero M, Diaz C, van Saene HKF (2001) Pneumonia in patients with severe burns. A classification according to the concept of the carrier state. Chest 119:1160–1165CrossRefGoogle Scholar
  9. 9.
    Petros AJ, O'Connell M, Roberts C, Wade P, van Saene HKF (2001) Systemic antibiotics fail to clear multi drug-resistant Klebsiella from a pediatric ICU. Chest 119:862–866CrossRefGoogle Scholar
  10. 10.
    Silvestri L, Sarginson RE, Hughes J, Milanese M, Gregori D, van Saene HKF (2002) Most nosocomial pneumonias are not due to nosocomial bacteria in ventilated patients. Evaluation of the accuracy of the 48 h time cut-off using carriage as the gold standard. Anaesth Intensive Care 30:275–282CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Morar P, Singh V, Maruka Z, Jones A, Baines PB, Selby A, Sarginson R, Hughes J, van Saene R (2002) Differing pathways of lower airway colonization and infection according to mode of ventilation (endotracheal vs. tracheostomy). Arch Otolaryngol Head Neck Surg 128:1061–1066CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Van Saene HKF, Damjanovic V, Alcock SR (2001) Basics in microbiology for the patient requiring intensive care. Curr Anaesth Crit Care 12:6–17CrossRefGoogle Scholar
  13. 13.
    Kerver AJH, Rommes JH, Mevissen-Verhage EAE, Hulstaert PF, Vos A, Verhoef J, Wittebol P (1988) Prevention of colonization and infection in critically ill patients: a prospective randomized study. Crit Care Med 16:1087–1093CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Sanchez-Garcia M, Cambronero-Galache JA, Lopez Diaz J, Cerda Cerda E, Rubio Blasco J, Gomez Aquinaga MA, Nunez Reiz A, Rogero Marin S, Onoro Canaveral JJ, Sacristan del Castillo JA (1998) Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients. Am J Respir Crit Care Med 158:908–916CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Garrouste-Orgeas M, Marie O, Rouveau M, Villiers S, Arlet G, Schlemmer B (1996) Secondary carriage with multi-resistant Acinetobacter baumannii and Klebsiella pneumoniae in an adult ICU population: relationship with nosocomial infection and mortality. J Hosp Infect 34:279–289CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Teare L, Handwashing Liaison Group (1999) Handwashing. A modest measure—with big effects. BMJ 318:686CrossRefGoogle Scholar
  17. 17.
    Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, Peters S, Rutledge F, Griffith L, McLelland A, Wood G, Kirby A, Tweeddale M, Pagliarello J, Johnston R (1998) A comparison of sucralfate and ranitidine for the prevention of upper gastro-intestinal bleeding in patients requiring mechanical ventilation. N Engl J Med 338:791–797CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Weinstein RA (1989) Selective intestinal decontamination—an infection control measure whose time has come? Ann Intern Med 110:853–855CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Baxby D, van Saene HKF, Stoutenbeek CP, Zandstra DF (1996) Selective decontamination of the digestive tract: 13 years on, what it is and what it is not. Intensive Care Med 22:699–706CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Johanson WG, Pierce AK, Sandford JP (1969) Changing pharyngeal bacterial flora of hospitalized patients. Emergence of Gram-negative bacilli. N Engl J Med 281:1137–1140CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Marshall JC, Christou NV, Meakins JL (1988) Small-bowel overgrowth and systemic immunosuppression in experimental peritonitis. Surgery 104:404–411PubMedPubMedCentralGoogle Scholar
  22. 22.
    Yao YM, Lu LR, Yu Y, Liang HP, Chen JS, Shi ZG, Zhou BT, Zeng ZY (1997) Influence of selective decontamination of the digestive tract on cell-mediated immune function and bacteria/endotoxin translocation in thermally injured rats. J Trauma 42:1073–1079CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Van Uffelen R, van Saene HKF, Fidler V, Lowenberg A (1984) Oropharyngeal flora as a source of bacteria colonizing the lower airways in patients on artificial ventilation. Intensive Care Med 10:233–237CrossRefGoogle Scholar
  24. 24.
    Luiten EJT, Hop WCJ, Endtz HP, Bruining HA (1998) Prognostic importance of gram-negative intestinal colonization preceding pancreatic infection in severe acute pancreatitis. Intensive Care Med 24:438–445CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Stoutenbeek CP, van Saene HKF, Miranda DR, Zandstra DF, Langrehr D (1987) The effect of oropharyngeal decontamination using topical non-absorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients. J Trauma 27:357–364CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Stoutenbeek CP (1989) The role of systemic antibiotic prophylaxis in infection prevention in intensive care by SDD. Infection 17:418–421CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Langer M, Carreto E, Haeusler EA (2001) Infection control in ICU: back (forward) to surveillance samples? Intensive Care Med 27:1561–1563CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Semmelweis IP (1861) Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers. Pest, HartlebenGoogle Scholar
  29. 29.
    Jarvis WR (1994) Handwashing—the Semmelweis lesson forgotten? Lancet 344:1311–1312CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Daschner FD, Frey P, Wolff G, Baumann PC, Suter P (1982) Nosocomial infections in intensive care wards: a multicenter prospective study. Intensive Care Med 8:5–9CrossRefGoogle Scholar
  31. 31.
    Larson E (1999) Skin hygiene and infection prevention: more of the same of different approaches? Clin Infect Dis 29:1287–1294CrossRefGoogle Scholar
  32. 32.
    Sackett DL, Strauss SE, Richardson WS, Rosenberg WM, Haynes RB (2000) Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone, EdinburghGoogle Scholar
  33. 33.
    Salzman TC, Clark JJ, Klemm L (1967) Hand contamination of personnel as a mechanism of cross-infection in nosocomial infections with antibiotic-resistant Escherichia coli and Klebsiella aerobacter. Antimicrob Agents Chemother 97–100Google Scholar
  34. 34.
    Nystrom B (1983) Optimal design/personnel for control of intensive care unit infection. Infect Control 4:388–390CrossRefGoogle Scholar
  35. 35.
    Crossley K, Landesmann B, Zaske D (1979) An outbreak of infections caused by strains of Staphylococcus aureus resistant to methicillin and aminoglycosides. II. Epidemiology studies. J Infect Dis 139:280–287CrossRefGoogle Scholar
  36. 36.
    Khan MU (1982) Interruption of shigellosis by handwashing. Trans R Soc Trop Med Hyg 76:164–168CrossRefGoogle Scholar
  37. 37.
    Tarr PHL (1995) Escherichia coli O157: H7. Clinical, diagnostic, and epidemiological aspects of human infection. Clin Infect Dis 20:1–10CrossRefGoogle Scholar
  38. 38.
    Widmer AF (2000) Replace handwashing with use of waterless alcohol hand rub? Clin Infect Dis 31:136–143CrossRefGoogle Scholar
  39. 39.
    Ruiz M, Torres A, Ewig S, Marcos MA, Alcon A, Lledo R, Asenjo MA, Maldonaldo A (2000) Non-invasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome. Am J Respir Crit Care Med 162:119–125CrossRefGoogle Scholar
  40. 40.
    Alvarez-Lerma F, ICU-acquired Pneumonia Study Group (1996) Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med 22:387–394CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    D'Amico R, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberati A (1998) Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomized controlled trials. BMJ 316:1275–1285CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Nathens AB, Marshall JC (1999) Selective decontamination of the digestive tract in surgical patients. A systematic review of the evidence. Arch Surg 134:170–176CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    De Jonge E, Schultz MJ, Spanjaard L, Bossuyt PPM, Vroom MB, Dankert J, Kesecioglu J (2002) Effects of selective decontamination of the digestive tract on mortality and antibiotic resistance. Intensive Care Med 28 (suppl1): S12Google Scholar
  44. 44.
    Silvestri L, Mannucci F, van Saene HKF (2000) Selective decontamination of the digestive tract: a life saver. J Hosp Infect 45:185–190CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 159:1249–1256CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Renaud B, Brun-Buisson C (2001) Outcomes of primary and catheter-related bacteremia. Am J Respir Crit Care Med 163:1584–1590CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Webb CH (2000) Selective decontamination of the digestive tract, SDD: a commentary. J Hosp Infect 46:106–109CrossRefGoogle Scholar
  48. 48.
    Silvestri L, Mannucci F, van Saene HKF (2001) Selective decontamination of the digestive tract. J Hosp Infect 48:320–327CrossRefGoogle Scholar
  49. 49.
    Van Saene HKF, Fox MA, Stoutenbeek CP (1995) Treating selective decontamination of the digestive tract versus cost-effectiveness analysis. Chest 108:288CrossRefGoogle Scholar
  50. 50.
    Rocha LA, Martin MJ, Pita S, Paz J, Seco C, Margusino L, Villaneuva R, Duran MT (1992) Prevention of nosocomial infections in critically ill children by selective decontamination of the digestive tract. A randomized double blind placebo-controlled study. Intensive Care Med 18:398–404CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Korinek AM, Laisne MJ, Nicolas MH, Raskine L, Deroin V, Sanson-Lepors MJ (1993) Selective decontamination of the digestive tract in neuro-surgical intensive care unit patients. A double-blind, randomized, placebo-controlled study. Crit Care Med 21:1468–1473CrossRefGoogle Scholar
  52. 52.
    Stoutenbeek CP, van Saene HKF, Zandstra DF (1996) Prevention of multiple organ system failure by selective decontamination of the digestive tract in multiple trauma patients. In: Faist E, Baue AE, Schildberg FW (eds) The immune consequences of trauma, shock and sepsis—mechanisms and therapeutic approaches. Pabst, Lengerich, pp 1055–1066Google Scholar
  53. 53.
    Cunha BA (2000) Antibiotic resistance. Med Clin North Am 84:1407–1429CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Van Saene HKF, Percival A (1991) Bowel micro-organisms—a target for selective antimicrobial control. J Hosp Infect 19 [Suppl C]:19–41Google Scholar
  55. 55.
    Flynn DM, Weinstein RA, Nathan C, Gaston MA, Kabins SA (1987) Patient's endogenous flora as the source of 'nosocomial' Enterobacter in cardiac surgery. J Infect Dis 156:363–368CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Modi N, Damjanovic V, Cooke RWI (1987) Outbreak of cephalosporin-resistant Enterobacter cloacae infection in a neonatal intensive care unit. Arch Dis Child 62:148–151CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Toltzis PH, Yamashita T, Vilt L, Green M, Morrissey A, Spinner-Block S, Blumer J (1998) Antibiotic restriction does not alter endemic colonization with resistant Gram-negative rods in a pediatric intensive care unit. Crit Care Med 26:1893–1899CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Van Saene HKF, Stoutenbeek CP, Geitz JN, van Saene JJM, Hart CA (1988) Effect of amoxycillin on 'colonisation resistance' in human volunteers. Microb Ecol Health Dis 1:169–177CrossRefGoogle Scholar
  59. 59.
    Donskey CJ, Chowdry TK, Hecker MT, Hoyen CK, Hanrahan JA, Hujer AM, Hutton-Thomas RA, Whalen CC, Bonomo RA, Rice LB (2000) Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients. N Engl J Med 343:1925–1932CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    De Man P, Verhoeven BAN, Verbrugh HA, Vos MC, van den Anker JN (2000) An antibiotic policy to prevent emergence of resistant bacilli. Lancet 355:973–978CrossRefGoogle Scholar
  61. 61.
    Gonzales RD, Schreckenberger PC, Graham MB, Kelkar S, Den Besten K, Quinn JP (2001) Infections due to vancomycin resistant Enterococcus faecium resistant to linezolid. Lancet 357:1179CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Cunha BA (2001) Effective antibiotic-resistance control strategies. Lancet 357:1307–1308CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Kollef MH, Sherman G, Ward S, Fraser VJ (1999) Inadequate antimicrobial treatment of infections. A risk factor for hospital mortality among critically ill patients. Chest 115:462–474CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH (2000) The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 118:146–155CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Stoutenbeek CP, van Saene HKF, Zandstra DF (1987) The effect of oral non-absorbable antibiotics on the emergence of resistant bacteria in patients in an intensive care unit. J Antimicrob Chemother 19:513–520CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Tetteroo GWM, Wagenvoort JHT, Bruining HA (1994) Bacteriology of selective decontamination: efficacy and rebound colonization. J Antimicrob Chemother 34:139–148CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Hammond JMJ, Potgieter PD (1995) Long-term effects of selective decontamination on antimicrobial resistance. Crit Care Med 23:637–645CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Sarginson RE, Shankar KR, Viviani M (2001) Type of infections in the critically ill. Curr Anaesth Crit Care 12:18–24CrossRefGoogle Scholar
  69. 69.
    Baines PB, Meyer J, de la Cal MA (2001) Antimicrobial resistance in the intensive care unit: the use of oral non-absorbable antimicrobials may prolong the antibiotic era. Curr Anaesth Crit Care 12:41–47CrossRefGoogle Scholar
  70. 70.
    Damjanovic V, Connolly CM, van Saene HKF, Cooke RWI, Corkill JE, van Belkum A, van Velzen D (1993) Selective decontamination with nystatin for control of a Candida outbreak in a neonatal intensive care unit. J Hosp Infect 24:245–259CrossRefGoogle Scholar
  71. 71.
    D'Agata EMC, Thayer V, Schaffner W (2001) An outbreak of Acinetobacter baumannii: the importance of cross-transmission. Infect Control Hosp Epidemiol 21:588–591CrossRefGoogle Scholar
  72. 72.
    Brun-Buisson C, Legrand P, Rauss A, Richard C, Montravers F, Besbes M, Meakins JL, Soussy CJ, Lemaire F (1989) Intestinal decontamination for control of nosocomial multi-resistant Gram-negative bacilli. Ann Intern Med 110:873–881CrossRefGoogle Scholar
  73. 73.
    Taylor ME, Oppenheim BA (1991) Selective decontamination of gastrointestinal tract as an infection control measure. J Hosp Infect 71:271–278CrossRefGoogle Scholar
  74. 74.
    Silvestri L, Milanese M, Oblach L, Fontana F, Gregori D, Guerro R, van Saene HKF (2002) Enteral vancomycin to control methicillin-resistant Staphylococcus aureus outbreak in mechanically ventilated patients. Am J Infect Control 30:391–399CrossRefGoogle Scholar
  75. 75.
    Stoutenbeek CP, van Saene HKF (1990) Infection prevention in intensive care by selective decontamination of the digestive tract. J Crit Care 5:137–156CrossRefGoogle Scholar
  76. 76.
    Vollaard EJ, Clasener HAL (1994) Colonization resistance. Antimicrob Agents Chemother 38:409–414CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP (1995) The natural history of the systemic inflammatory response syndrome (SIRS). JAMA 273:117–123CrossRefGoogle Scholar
  78. 78.
    Daschner F, Langmaack H, Wiedemann B (1983) Antibiotic resistance in intensive care unit areas. Infect Control 4:382–387CrossRefGoogle Scholar
  79. 79.
    Pugin J, Auckenthaler R, Lew DP, Suter PM (1991) Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia. JAMA 265:2704–2710CrossRefGoogle Scholar
  80. 80.
    Quinio B, Albanese J, Bues-Charbit M, Viviand X, Martin C (1996) Selective decontamination of the digestive tract in multiple trauma patients. Chest 109:765–772CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Go ES, Urban C, Burns J, Kreiswirth B, Eisner W, Mariano N, Mosinka-Snipas K, Rahal JJ (1994) Clinical molecular epidemiology of Acinetobacter infections sensitive only to polymyxin B and sulbactam. Lancet 344:1329–1332CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Fink MP, Snydman DR, Niederman MS, Leeper KV, Johnson RH, Heard SO, Wunderinck RG, Caldwell JW, Schentag JJ, Siami GA, Zameck RL, Haverstock DC, Reinhart HH, Echols RM, Severe Pneumonia Study Group (1994) Treatment of severe pneumonia in hospitalized patients: results of a multi-center, randomized, double-blind trial comparing intravenous ciprofloxacin with imipenem-cilastatin. Antimicrob Agents Chemother 38:547–557CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Nixon JR, Nielsen MS (2000) Selective decontamination of the digestive tract—current national practice. Br J Anaesth 84:682P–683PCrossRefGoogle Scholar
  84. 84.
    Bogaards MJ (2001) An inventarisation of the products. Selective digestive decontamination in the Netherlands. Pharm Weekbl 136:706–712Google Scholar
  85. 85.
    Vincent JL (1999) Prevention of nosocomial bacterial pneumonia. Thorax 54:544–549CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Kollef MH (2000) The clinical use of selective digestive decontamination. Crit Care 4:327–332CrossRefPubMedPubMedCentralGoogle Scholar
  87. 87.
    Farr BM (2000) Reasons for non-compliance with infection control guidelines. Infect Control Hosp Epidemiol 21:411–416CrossRefPubMedPubMedCentralGoogle Scholar
  88. 88.
    Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC (1992) A comparison of results of meta-analyses of randomized control trials and recommendation of clinical experts. JAMA 268:240–248CrossRefPubMedPubMedCentralGoogle Scholar
  89. 89.
    Ebner W, Kropec-Hubner A, Daschner FD (2000) Bacterial resistance and overgrowth due to selective decontamination of the digestive tract. Eur J Clin Microbiol Infect Dis 19:243–247CrossRefPubMedPubMedCentralGoogle Scholar
  90. 90.
    Bonten MJM, Kullberg BJ, van Dalen R, Girbes ARJ, Hoepelman IM, Hustinx W, van der Meer JWM, Speelman P, Stobberingh EE, Verbrugh HA, Verhoef J, Zwaveling JH, consultants of the Dutch Working Group on Antibiotic Policy (2000) Selective digestive decontamination in patients in intensive care. J Antimicrob Chemother 46:351–362CrossRefPubMedPubMedCentralGoogle Scholar
  91. 91.
    Bonten MJM, van Tiel FH, van der Geest S, Stobberingh EE, Gaillard CA (1993) Enterococcus faecalis pneumonia complicating topical antimicrobial prophylaxis. N Engl J Med 328:209–210CrossRefPubMedPubMedCentralGoogle Scholar
  92. 92.
    Kollef MH (1996) Long-term effects of selective decontamination on antimicrobial resistance. Crit Care Med 24:177–178CrossRefPubMedPubMedCentralGoogle Scholar
  93. 93.
    Potgieter PD, Linton DM, Oliver S, Forder AA (1987) Nosocomial infections in a respiratory intensive care unit. Crit Care Med 15:495–498CrossRefPubMedPubMedCentralGoogle Scholar
  94. 94.
    Hammond JMJ, Potgieter PD, Saunders GL, Forder AA (1992) Double blind study of selective decontamination of the digestive tract in intensive care. Lancet 340:5–9CrossRefPubMedPubMedCentralGoogle Scholar
  95. 95.
    European Society of Intensive Care Medicine, Société Réanimation de Langue Française (1992) The First European Consensus Conference in Intensive Care Medicine: selective decontamination of the digestive tract in intensive care patients. Infect Control Hosp Epidemiol 13:609–611CrossRefGoogle Scholar
  96. 96.
    Wazana A (2000) Physicians and the pharmaceutical industry. Is a gift ever just a gift? JAMA 283:373–380CrossRefPubMedPubMedCentralGoogle Scholar
  97. 97.
    Garattini S, Liberati A (2000) The risk of bias from omitted research. Evidence must be independently sought and free of economic interests. BMJ 321:845–846CrossRefPubMedPubMedCentralGoogle Scholar
  98. 98.
    Torres A, Carlet J, European Task Force on Ventilator-Associated Pneumonia (2001) Ventilator-associated pneumonia. Eur Respir J 17:1034–1045CrossRefPubMedPubMedCentralGoogle Scholar
  99. 99.
    Royal College of Pathologists (2002) Continuing professional development. J Hosp Infect 50:161CrossRefGoogle Scholar
  100. 100.
    University of California at San Francisco, Stanford University Evidence-based Practice Center (2001) Making health care safer: a critical analysis of patient safety practice. Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • Hendrick K. F. van Saene
    • 1
    • 2
    Email author
  • Andy J. Petros
    • 3
  • Graham Ramsay
    • 4
  • Derrick Baxby
    • 1
  1. 1.Department of Medical MicrobiologyUniversity of LiverpoolLiverpoolUK
  2. 2.Department of Clinical Microbiology and Infection ControlRoyal Liverpool Children's HospitalLiverpoolUK
  3. 3.Paediatric Intensive Care UnitGreat Ormond Street Hospital for Children NHS TrustLondonUK
  4. 4.Department of Intensive CareUniversity HospitalMaastrichtThe Netherlands

Personalised recommendations