Reducing the Dosing Frequency of Selective Digestive Tract Decontamination to Three Times Daily Provides Effective Decontamination of Potentially Pathogenic Micro-Organisms

This study evaluated the effectiveness of selective digestive tract decontamination (SDD) application three times daily (t.i.d.) compared to the standard four times daily (q.i.d.). Retrospective equivalence study with a before-and-after design on a tertiary ICU in which the SDD frequency was reduced from q.i.d. to t.i.d. All patients with ICU admissions ≥ 72h, and with ≥ 2 surveillance cultures collected on different dates were included in this study. We compared successful decontamination of Gram-negative bacteria (GNB). Furthermore, time to decontamination, ICU-acquired GNB bacteraemia and 28-day mortality were compared between the two groups.


Introduction
Infection is a major complication among patients in the intensive care unit (ICU) resulting in additional morbidity, higher risk of mortality and increasing health care costs. [1] Selective digestive tract decontamination (SDD) is a common measure to prevent infections on the ICU. The principle behind SDD is that by reducing the numbers of potentially pathogenic microorganisms (PPM) in the gut, the risk of ICU-acquired infections can be reduced. [2] Intestinal decontamination of Gram-negative bacteria (GNB) was associated with a three-fold reduction in ICU-acquired bacteraemia with GNB. [3] The positive effect of SDD on clinical outcomes, i.e. Improved survival and less infectious complications while maintaining a low prevalence of antibiotic resistance, has been demonstrated by three cluster-randomized studies. [3][4][5] The SDD regime is applied in ventilated patients with an expected duration of arti cial ventilation >48 hours and consists of a mixture of non-absorbable antimicrobials combined with intravenous cefotaxime during the rst four days of ICU admission. SDD is applied q.i.d. and this frequency has remained unchanged since the rst SDD studies in the 1980s. There have been no studies that evaluated the optimal dosing frequency of SDD in order to achieve GNB decontamination. Reducing the dosing frequency of SDD paste application from four to three times daily (t.i.d.) would lower antimicrobial consumption and related health care costs. More importantly, by reducing the dosing frequency the nightly administration of SDD paste application could be omitted, thereby preventing sleep interruption.
Facilitating uninterrupted sleep reduces the incidence of delirium and is essential for adequate immune, metabolic, and endocrine functioning. [6,7] In an attempt to increase the quality of sleep for ICU patients, the dosing frequency of SDD application was reduced from q.i.d. to t.i.d in 2017. This t.i.d. SDD dosing regimen has been the standard of care since. This provided us with the opportunity to perform a beforeand after study comparing the e cacy q.i.d. versus the t.i.d. SDD application frequency, in terms of GNB decontamination of the digestive tract and subsequent ICU-acquired GNB-infections.

Setting, Design and Population
We retrospectively studied electronic microbiology and patient data gathered in the period from November 2011 until July 2019 on the ICU of the Amsterdam University Medical Centre, location VU medical centre (VUmc), a 28 bed ICU in a 730-bed tertiary care centre in the Netherlands. Data were derived from an automated database combining laboratory data with pseudo-anonymous patient data from the Electronic patient dossier (EPD). This database was constructed for antimicrobial stewardship and infection prevention purposes and consists of microbiological data, admission and discharge data, Medicine Administration Records, Surgical interventions and a small amount of patient data: sex, date of birth, date of death. Data visualization was performed using TIBCO® Spot re®. The non-absorbable antibiotics in the SDD regimen consist of application of paste (colistin 2%, tobramycin 2%, amphoterin B 2%) in the oral cavity and of suspension (colistin 100 mg, tobramycin 80 mg, amphotericin 500 mg) via the nasogastric tube. This regimen was applied q.i.d. until 26-05-2017, thereafter the same regimen was applied t.i.d. Patients admitted to the ICU also receive 4 days of intravenous cefotaxime q.i.d. 1 g, this practice did not change over the course of time.
All adult patients with an ICU admission of at least 72h and with at least 2 surveillance cultures drawn on two separate days were included in the analysis.

Microbiological Methods
Surveillance cultures were taken on admission to the ICU and thereafter once a week on Mondays for pharynx and anus, and on Mondays and Thursdays for sputum. All surveillance cultures were included in the analysis. Surveillance cultures within 72h of admission represented the ora at admission on the ICU and are further called baseline surveillance cultures.
Based on previous literature the following aerobic GNB were de ned as PPMs: Klebsiella, Enterobacter, Citrobacter, Proteus, Morganella, Serratia, Acinetobacter and Pseudomonas species. [8] By assessing the prevalence of GNB in the blood cultures of the patients in our cohort we found that Stenotrophomonas maltophilia was also a frequent cultured pathogen in the study period and was therefore added as an PPM. Because we also want to assess the reduction of carriage of endogenous "normal" but potentially pathogenic ora we added Escherichia Coli to the list.
In the Amsterdam UMC medical microbiology laboratories, antimicrobial susceptibility was tested using automated systems, gradient tests and/or using the disk diffusion method.
Decontamination was de ned as the reduction of Gram-negative bacterial load to a level at which surveillance cultures are negative (rectal or faeces, pharyngeal and sputum). The number of days in which decontamination should occur to be considered successful, i.e. adequate to reduce infectious complications and mortality, has not been previously de ned. In the study of de Smet et al --in which the relationship between SDD and reduction of mortality was con rmed --the frequency of GNB isolation from rectal swabs among patients receiving SDD was reduced from 56% at day 3 to 15% at day 14. [4] The SDD regimen used in the study of de Smet et al was identical to the q.i.d. regimen used in this study. Therefore we chose to de ne successful decontamination as a surveillance culture result negative for GNB within 14 days without positive follow-up surveillance culture for GNB during ICU-admission, i.e.
follow-up lasted until the moment of discharge from the ICU.
In case of new fever two blood cultures were drawn. ICU-acquired bacteremia with GNB was de ned as bacteraemia occurring at least 48 hours after ICU admission with growth of either Enterobacterales or glucose-nonfermenting Gram-negative rods, without documented bacteraemia with the same species in the rst 48 hours of ICU admission. Polymicrobial bacteraemia was de ned when one or more microorganisms were isolated from one or more blood cultures, and clinical evidence suggested they had arisen from a common source and were part of the same episode. If the source was unknown, all positive blood cultures occurring within 48 hours of each other are considered as a single bacteraemia.
28-day all-cause mortality is de ned as death for any cause within 28 days after the date of admission to the ICU.
Due to the before-after study design, we anticipated that time dependent factors such as antimicrobial resistance could introduce bias. We described the combined prevalence of susceptibility for the components of SDD (tobramycin and colistin) in surveillance cultures at baseline.

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Two groups were formed on the basis of the dosing frequency of SDD, q.i.d. versus t.i.d. Continuous variables are presented as median and interquartile range. Categorical variables are presented as percentages. For the difference in proportion of patients with successful decontamination of PPMs in both groups and for comparison of susceptibility of Gram-negative bacteria at baseline a Chi-square test was used. For the difference in time to decontamination of PPMs from surveillance cultures a Kaplan Meier curve was used. For equivalence testing the two one-sided test (TOST) procedure was used. The largest clinically acceptable effect for which equivalence can be declared was a mean difference of 10%. The equivalence limit was set to 0.1 (d E = 0.1). All data available was used, no formal sample size was calculated. Odds ratio was calculated to compare 28-day all-cause mortality between the two groups. Data analysis was performed using R Statistical Software (version 3.6.1; R Foundation for Statistical Computing, Vienna, Austria).  Table 2 shows the proportion of successful decontamination in the two groups. Successful decontamination, de ned as GNB negative surveillance cultures within 14 days without any further GNB detection in surveillance cultures thereafter, was not signi cantly different between the two groups ( Table  2). To show non-inferiority of the t.i.d. regime, equivalence test of the proportions of successful decontamination was performed ( Figure 2). With an equivalence bound of 0.1 and a 98% con dence interval, the proportions of successful decontamination of GNB are equivalent in both groups. The time to decontamination of GNB is shown in gure 3. The log-rank test, to compare time to decontamination of GNB between the two cohorts, did not show any difference between the groups (p-value of 0.55).

Results
We observed 27 episodes of ICU-acquired bacteraemia with GNB during the study period, 17/1236 before (1.4%) and 10/722 (1.4%) after adjustment of SDD application frequency, with an incidence of 0.9 episodes/1000 ICU days in both. Causative pathogens in intensive care unit-acquired bacteraemia are shown in table 3. 28-day all-cause mortality was 26.1% and 25.6% in the q.i.d. and t.i.d. groups, odds ratios for death at day 28 in the t.i.d. group compared to the q.i.d. group was 0.99 (95% con dence interval [CI], 0.80-1.21).
To control for potential changes in resistance epidemiology between the two time periods, especially with regard to the incidence of bacteria that were susceptible to the SDD antibiotics, we compared the surveillance cultures at baseline (Table 4). Between 72-71% (for the q.i.d. and t.i.d. group) of all admissions started with GNB positive surveillance cultures at baseline. Susceptibility for tobramycin or colistin in Gram-negative bacteria in baseline surveillance cultures was 97.3% and 96.8% (for the q.i.d. and t.i.d. group) with a p-value of 0.61 using the chi-square test. We conclude that the baseline epidemiology at admission on the ICU is comparable, and that our results are not biased by an epidemiological shift in susceptibility rate between the two historical cohorts.
The incidence of VAP on our ward has been shown to be 3.3/1,000 ventilation days. [9] Prevalence measurements for the national 'PREZIES' survey of hospital infections are performed every three months. [10,11] Based on these surveys, the prevalence of VAP in q.i.d. cohort (median 0.1 % of admitted patients, range 0-19%) did not signi cant increase after change to the t.i.d. regime (median 0.1 % of admitted patients, range 0-21%).

Discussion
Despite its common use, the optimal SDD dosing regime has not previously been evaluated in a clinical setting. The present study demonstrated that a t.i.d. application regime application regimen provides equally effective selective digestive tract decontamination compared to the standard q.i.d. regime. SDD effectiveness was demonstrated within a large patient population (n = 1958) receiving either t.i.d. (n = 722) or q.i.d. (n = 1236) administration. Several outcome measures support our conclusion. First, the proportion of successful decontamination was equal in both groups. Second, the time to decontamination of GNB did not, at any time point, differ signi cantly. Finally, we found no signi cant differences in clinically relevant outcomes (i.e. ICU-acquired bacteraemia and 28-day all-cause mortality) between the two cohorts.
Although the goal of SDD is digestive tract decontamination and subsequent reduction of ICU-acquired infection, the four cluster-randomized controlled trials that have previously investigated the e cacy of SDD did not report the time to-or success of decontamination. [3][4][5]12] The primary outcome of our study can therefore not directly be compared to these trials. However, the close association between gut (de-)colonization and ICU-acquired infection is well established. [13][14][15][16][17][18] Frencken et al showed that both rectal and respiratory tract colonization were associated with bacteraemia (cause-speci c hazard ratios, 7.37 [95% CI, 3.25-16.68] and 2.56 [95% CI, 1.09-6.03], respectively). [14] Oostdijk et al found that respiratory tract decolonization and intestinal tract decolonization was associated with a 33% and 45% reduction in the occurrence of intensive care unit acquired Gram-negative bacteraemia, respectively. Moreover, Oostdijk et al reported a reduction of proportion of colonization in patients treated with SDD throughout intensive care unit stay from approximately 30% at day 1 to 15-20% at day 20. [13] The fact that decontamination rates found in our study are comparable to the results found in the large prospective study of the Smet et al (i.e. 85% of patients cultured after 14 days are decolonized from GNB), in which clinical effectiveness of SDD application was proven, is a clear indication that t.i.d. administration of SDD is clinically effective and safe. [4,13] Furthermore, the secondary clinical outcomes de ned in our study (ICU-acquired bacteraemia and 28-day all-cause mortality), in which t.i.d. proved to be non-inferior to q.i.d, supports this conclusion.
Strengths of our study are the size of our study population and the detailed information about intestinal colonization during SDD. This study provides, for the rst time, detailed insight into the underlying dynamics of culture-results during SDD. We demonstrated equal microbiological and clinical effectiveness of less frequent dosing. This is re ected in a stable incidence of ICU-acquired GNB bacteraemia and 28-day all-cause mortality. Our study also has limitations. We used a monocentric retrospective approach, using a historical control group. We had no detailed clinical information on ventilator associated pneumonias in individual patients. On a population level, however, we noted no signi cant change in prevalence of VAP since the introduction of the t.i.d. application regime. [11] Besides, Bergmans et al showed previously that decolonization of the respiratory tract results in a relative risk reduction of 67% in the incidence of VAP. This makes a difference in VAP incidence despite the equivalent decontamination rates in our cohorts unlikely. [19] The retrospective design precludes correction for hidden variables in the original data that might have confounded the results. Yet, potential confounders in the original uncontrolled data are likely to be present in both groups (t.i.d. versus q.i.d.). Speci cally, we ruled out an epidemiological shift in susceptibility for the SDD antibiotics, which could otherwise have biased the results.
Our ndings support a t.i.d. SDD application frequency in the ICU. This new regime was designed as an sleep-promoting intervention on the ICU. Many sleep-disturbing factors are present on the ICU, but clinical interventions are one of the most important disruptive factors and should therefore be avoided. [20] Furthermore any unnecessary antibiotic use should be avoided to reduce the harm that can result from antibiotic-associated adverse events. [21] During the t.i.d. SDD application period of three years tobramycin and colistin resistance did not change, which is in line with previous studies assessing antibiotic resistance during the use of SDD. [22][23][24]

Conclusion
Based on time to-and success of decontamination of Gram-negative bacteria, incidence of ICU-acquired GNB bacteraemia (0.9/1000 ICU days) and 28-day all-cause mortality there is no difference between a t.i.d. and a q.i.d. SDD application regime. These study ndings justify implementation of a t.i.d. SDD application regimen in ICUs where a standard (q.i.d.) regimen is in place.

Declarations
Funding: No nancial support was used for this study.