Intensive Care Medicine

, Volume 32, Issue 10, pp 1569–1576

Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance

  • Alexandra Heininger
  • Elisabeth Meyer
  • Frank Schwab
  • Matthias Marschal
  • Klaus Unertl
  • Wolfgang A. Krueger
Original

Abstract

Objective

To assess the distribution of bacterial species and antimicrobial resistance in an ICU during long-term use of selective digestive decontamination (SDD) in the context of national reference data.

Design and setting

Five-year prospective observational study in a 24-bed interdisciplinary surgical ICU of a university hospital (study ICU) participating in the project “Surveillance of Antimicrobial Use and Antimicrobial Resistance in German Intensive Care Units” (SARI; reference ICUs).

Patients

Resistance data were obtained from all patients; patients intubated for at least 2 days received SDD (colistin, tobramycin, amphotericin B).

Interventions and measurements

SDD was performed in 1,913 of 7,270 patients. Antimicrobial resistance was examined in 4,597 (study ICU) and 46,346 (reference ICUs) isolates.

Results

Methicillin-resistant Staphylococcus aureus (MRSA) remained stable (2.76 and 2.58 isolates/1000 patient days) in the study ICU; this was below the German average (4.26 isolates/1000 patient days). Aminoglycoside- and betalactam-resistant Gram-negative rods did not increase during SDD use. Aminoglycoside resistance of Pseudomonas aeruginosa was 50% below the mean value of SARI (0.24 vs. 0.52 isolates/1,000 patient days). The relative frequency of enterococci and coagulase-negative staphylococci (CNS) was higher than in the SARI ICUs (23.2% vs. 17.3%, and 25.0% vs. 20.6%, respectively).

Conclusion

Routine 5-year-use of SDD was not associated with increased antimicrobial resistance in our ICU with low baseline resistance rates. Vigorous surveillance and control measures to search and destroy MRSA were considered a mandatory component of the SDD program. The relative increase in enterococci and CNS is of concern requiring further investigation.

Keywords

Selective digestive decontamination Antimicrobial resistance Methicillin resistant Staphylococcus aureus Bacterial spectrum Antibiotic selection pressure 

References

  1. 1.
    Vincent J-L, Jacobs F (2003) Infection in critically ill patients: clinical impact and management. Curr Opin Infect Dis 16:309–313PubMedGoogle Scholar
  2. 2.
    Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281–288PubMedCrossRefGoogle Scholar
  3. 3.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Bun-Buisson C, Canadian Critical Trials Group (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 159:1249–1256PubMedGoogle Scholar
  4. 4.
    Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S (1992) A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. N Engl J Med 326:594–599PubMedCrossRefGoogle Scholar
  5. 5.
    Stoutenbeek CP, van Saene HKF, Miranda DR, Miranda DR, Zandstra DF (1984) The effect of selective decontamination and infection rate in multiple trauma patients. Intensive Care Med 10:185–192PubMedCrossRefGoogle Scholar
  6. 6.
    Unertl K, Ruckdeschel G, Selbmann HK, Forst H, Lenhart FP, Peter K (1987) Prevention of colonization and respiratory infections in long-term prophylaxis. Intensive Care Med 13:106–113PubMedCrossRefGoogle Scholar
  7. 7.
    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 and consultants of the Dutch Working group on Antibiotic Policy (2000) Selective digestive decontamination in patients in intensive care. J Antimicrob Chemother 46:351–362PubMedCrossRefGoogle Scholar
  8. 8.
    Nathens AB, Marshall JC (1999) Selective decontamination of the digestive tract in surgical patients. A systemic review of the evidence. Arch Surg 134:170–176PubMedCrossRefGoogle Scholar
  9. 9.
    D'Amico R, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberati A (1998) Effectiveness of antibiotic prophylaxis in critically ill adult patients: systemic review of randomised controlled trials. BMJ 316:1275–1285PubMedGoogle Scholar
  10. 10.
    Krueger WA, Lenhart FP, Neeser G, Ruckdeschel G, Schreckhase H, Eissner HJ, Forst H, Eckart J, Peter K, Unertl KE (2002) Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical trial. Am J Respir Crit Care Med 166:1029–1037PubMedCrossRefGoogle Scholar
  11. 11.
    De Jonge E, Schultz MJ, Spanjaard L, Bossuyt PMM, Vroom MB, Dankert J, Kesecioglu J (2003) Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 362:1011–1016PubMedCrossRefGoogle Scholar
  12. 12.
    De La Cal MA, Cerda E, Gardi-Hierro P, van Saene HK, Gomez Santos D, Negro E, Lorente JA (2005) Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg 241:424–430CrossRefGoogle Scholar
  13. 13.
    De Jonge (2005) Effects of selective decontamination of digestive tract on mortality and antibiotic resistance in the intensive-care unit. Curr Opinion Crit Care 11:144–149CrossRefGoogle Scholar
  14. 14.
    Van Saene HKF, Petros AJ, Ramsay Gl, Baxby D (2003) All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth. Intensive Care Med 29:677–690PubMedGoogle Scholar
  15. 15.
    Kollef MH (2003) Selective digestive decontamination should not be routinely employed. Chest 123:464S–468SCrossRefGoogle Scholar
  16. 16.
    Kollef MH, Micek ST (2005) Strategies to prevent antimicrobial resistance in the intensive care unit. Crit Care Med 33:1845–1853PubMedCrossRefGoogle Scholar
  17. 17.
    Nasia S, Adnan S, Luey MR (2004) The role of selective digestive decontamination for reducing infection in patients undergoing liver transplantation: a systematic review and meta-analysis. Liver Transpl 10:817–827CrossRefGoogle Scholar
  18. 18.
    Verwaest C, Verhaegen J, Ferdinande P, Schetz M, Van den Berghe G, Verbist L, Lauwers P (1997) Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit Care Med 25:63–71PubMedCrossRefGoogle Scholar
  19. 19.
    Meyer E, Schwab F, Jonas D, Rueden H, Gastmeier P, Daschner FD (2004) Surveillance of antimicrobial use and antimicrobial resistance in intensive care units (SARI). I. Antimicrobial use in German intensive care units. Intensive Care Med 30:1089–1096PubMedCrossRefGoogle Scholar
  20. 20.
    Meyer E, Jonas D, Schwab F, Rueden H, Gastmeier P, Daschner FD (2003) Design of a surveillance system of antibiotic use and bacterial resistance in German intensive care units (SARI). Infection 31:208–215PubMedGoogle Scholar
  21. 21.
    National Committee for Clinical Laboratory Standards (2000) Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. Approved standard, 5th edn. NCCLS document M7-A5, Wayne, Pa., USAGoogle Scholar
  22. 22.
    Geffers C, Koch J, Sohr D, Nassauer A, Daschner F, Rueden H, Gastmeier P (2000) Aufbau einer Referenzdatenbank für die Surveillance nosokomialer Infektionen auf Intensivstationen. Erste Ergebnisse des nationalen Krankenhaus-Infektions-Surveillance-Systems (KISS). Anaesthesist 49:732–737PubMedCrossRefGoogle Scholar
  23. 23.
    Bonten MJM, Slaughter S, Ambergen AW, Haydn MK, van Voorhis J, Nathan C, Weinstein RA (1998) The role of colonisation pressure in the spread of vancomycin-resistant enterococci. An important infection control variable. Arch Intern Med 158:1127–1132PubMedCrossRefGoogle Scholar
  24. 24.
    Bonten MJM, Austin DJ, Lipsitch M (2001) Understanding the spread of antibiotic-resistant pathogens in hospitals: mathematical models as tools for infection control. Clin Infect Dis 33:1739–1746PubMedCrossRefGoogle Scholar
  25. 25.
    Kollef MK, Fraser VJ (2001) Antibiotic resistance in the intensive care unit. Ann Intern Med 134:298–314PubMedGoogle Scholar
  26. 26.
    Leone M, Albanese J, Antonini F, Nguyen-Michel A, Martin C (2003) Long-term (6-year) effect of selective digestive decontamination on antimicrobial resistance in intensive care, multiple-trauma patients. Crit Care Med 31:2090–2095PubMedCrossRefGoogle Scholar
  27. 27.
    Lingnau W, Berger J, Javorsky F, Fille M, Allerberger F, Benzer H (1998) changing bacterial ecology during a five year period of selective intestinal decontamination. J Hosp Infect 39:195–206PubMedCrossRefGoogle Scholar
  28. 28.
    Sánchez García M, Cambronero Galache JA, Lopez Diaz J, Cerda Cerda E, Rubio Balsco J, Gomez Aguinaga 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 158:908–916PubMedGoogle Scholar
  29. 29.
    Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis HM, Boyce JM, Farr BM (2003) SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 24:362–386PubMedCrossRefGoogle Scholar
  30. 30.
    Farr BM (2004) Prevention and control of methicillin-resistant Staphylococcus aureus infections. Curr Opin Infect Dis 17:317–322PubMedCrossRefGoogle Scholar
  31. 31.
    Anonymous (2005) Zum gehäuften Auftreten von glycopeptidresistenten Enterococcus faecium in südwestdeutschen Krankenhäusern. Epidemiol Bull 17:150–155Google Scholar
  32. 32.
    Hammond PJ, Potgieter PD (1995) Longterm effects of selective decontamination on antimicrobial resistance. Crit Care Med 23:637–645PubMedCrossRefGoogle Scholar
  33. 33.
    Saunders GL, Hammond JM, Potgieter PD, Plumb HA, Forder AA (1994) Microbiological surveillance during selective decontamination of the digestive tract (SDD). J Antimicrob Chemother 34:529–544PubMedGoogle Scholar
  34. 34.
    Brun-Buisson C, Legrand P, Rauss A, Richard C, Montravers F, Beses M, Meakins JL, Soussy CJ, Lemaire F (1989) Intestinal decontamination for control of nosocomial multiresistant Gram-negative bacilli. Study of an outbreak in an intensive care unit. Ann Intern Med 110:873–881PubMedGoogle Scholar
  35. 35.
    Krueger WA, Unertl KE (2002) Selective decontamination of the digestive tract. Curr Opin Crit Care 8:139–144PubMedCrossRefGoogle Scholar
  36. 36.
    Bonten MJ, Krueger WA (2006) Selective decontamination of the digestive tract: cumulating evidence, at last? Semin Respir Crit Care Med 27:18–22PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Alexandra Heininger
    • 1
  • Elisabeth Meyer
    • 2
  • Frank Schwab
    • 3
  • Matthias Marschal
    • 4
  • Klaus Unertl
    • 1
  • Wolfgang A. Krueger
    • 1
  1. 1.Department for Anesthesiology and Intensive Care MedicineTübingen University HospitalTübingenGermany
  2. 2.Institute of Environmental Medicine and Hospital EpidemiologyFreiburg University HospitalFreiburgGermany
  3. 3.Institute of Hygiene, National Reference Center for Surveillance of Nosocomial InfectionsFree University Berlin BerlinGermany
  4. 4.Department of Medical Microbiology and Hospital Infection controlTübingen University HospitalTübingenGermany

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