We are interested in the debate on the efficacy and safety of selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) raised by Schultz and Haas in their review [1].
The authors concluded that 'SDD and SOD are equally effective with respect to the prevention of mortality' [1]. This statement is based on the results of a Dutch randomized controlled trial [2], which was the first to demonstrate a survival benefit of SOD. However, the mortality reduction was higher, albeit not significantly, in the SDD group than in the SOD group. Additionally, a recent meta-analysis, including nine SOD randomized controlled trials and 4,733 patients, failed to show any significant mortality reduction (odds ratio (OR) = 0.93; 95% confidence interval (CI) = 0.81 to 1.07) [3]. In contrast, there is robust evidence indicating that SDD including parenteral and enteral antimicrobials significantly reduces mortality [4].
The authors wrote that 'whether SDD or SOD are favorable with regard to development of antibiotic resistance is yet unknown' [1]. The Dutch randomized controlled trial, however, showed that patients with aerobic Gram-negative bacilli in rectal swabs resistant to the marker antibiotics numbered less with SDD than with SOD [2]. Additionally, bacteremia due to highly resistant pathogens was significantly reduced by SDD compared with SOD (OR = 0.37, 95% CI = 0.16 to 0.85), and lower respiratory tract colonization due to highly resistant pathogens was lower with SDD (OR = 0.58, 95% CI = 0.43 to 0.78) than with SOD (OR = 0.65, 95% CI = 0.49 to 0.87) compared with standard care [5].
We believe that SDD is superior to SOD in terms of both mortality reduction and emergence of resistance.
Abbreviations
- CI:
-
confidence interval
- OR:
-
odds ratio
- SDD:
-
selective digestive decontamination
- SOD:
-
selective oropharyngeal decontamination.
References
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Silvestri L, van Saene HK, Weir I, Gullo A: Survival benefit of the full selective digestive decontamination regimen. J Crit Care 2009, 24: 474.e7-474.e14. 10.1016/j.jcrc.2008.11.005
de Smet AM, Kluytmans J, Blok H, Bonten M, Bootsma M: Effects of selective digestive and selective oropharyngeal decontamination on bacteraemia and respiratory tract colonization with highly resistant micro-organisms [abstract]. Clin Microbiol Infect 2010,16(Suppl 2):S98.
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Silvestri, L., Taylor, N., Zandstra, D.F. et al. Selective digestive decontamination is superior to selective oropharyngeal decontamination. Crit Care 15, 411 (2011). https://doi.org/10.1186/cc10068
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DOI: https://doi.org/10.1186/cc10068