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Selective Digestive Tract Decontamination in Intensive Care Medicine: a Practical Guide to Controlling Infection Peter H.J. van der Voort • Hendrick K.F. van Saene Editors Selective Digestive Tract Decontamination in Intensive Care Medicine: a Practical Guide to Controlling Infection 13 Peter H.J. van der Voort Hendrick K.F. van Saene Internist-intensivist Department of Clinical Microbiology Department of Intensive Care and Infection Control Onze Lieve Vrouwe Gasthuis Royal Liverpool Children’s NHS Amsterdam, Trust of Alder Hey The Netherlands Liverpool, [email protected] United Kingdom [email protected] Cover illustration: it summarizes infection prevention in the intensive care. Adapted by H.K.F. van Saene and reprinted with permission from: C.P. Stoutenbeek (1987) Infection prevention in intensive care. Infection prevention in multiple trauma patients by selective decontamination of the digestive tract (SDD). PhD thesis, Groningen Library of Congress Control Number: 2007931632 ISBN 978-88-470-0652-2 Springer Milan Berlin Heidelberg New York e-ISBN 978-88-470-0653-9 Springer is a part of Springer Science+Business Media springer.com © Springer-Verlag Italia 2008 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the Italian Copyright Law in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the Italian Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: the publisher cannot guarantee the accuracy of any information about dosa- ge and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Simona Colombo, Milan, Italy Typesetting: Graphostudio, Milan, Italy Printing: Press Grafica Srl, Gravellona Toce (VB) Printed in Italy Springer-Verlag Italia S.r.l., Via Decembrio 28, I-20137 Milan Preface Infection control in intensive care units is a continuing challenge. Since 1984, intensivists trying to prevent infection have had the option of applying a well-bal- anced and thoroughly studied approach called selective decontamination of the digestive tract (SDD). Over 20 years of clinical SDD research, 56 randomised con- trolled trials and 10 meta-analyses have been published. The effect on mortality is debated; the effect on infection control is not. SDD is not a costly manoeuvre. Resistance does not appear to be a clinical problem. Moreover, a growing body of evidence shows that SDD might be the method that could be used to control the worldwide emergence of resistant micro-organisms. However, SDD will not have these potential effects if healthcare professionals do not apply the philosophy prop- erly and consistently. In addition, basic intensive care still needs to be adequate and the results of the cultures should be quickly and readily available. Doctors should be eager to get the results and to adjust their treatment accordingly. The effects of SDD can be completely lost in a multicentre study if these basic conditions are not all equally in place. Many ICU physicians have questions about the practical implementation and application of SDD. In addition, it has been shown that the results obtained by indi- vidual ICUs vary in the degree of success in decontamination and the outcomes they reflect. A proper understanding of the principles and meticulous implementation in clinical practice will benefit patients and reduce both staff workloads and cost. These facts encouraged us to complete this volume on the principles and practice of SDD so as to provide a practical guide that can be used in daily decision-making on infec- tion control. All the authors have been working with SDD in critically ill patients for many years. Their purpose in writing their chapters has been to share their knowl- edge with readers. Both healthcare workers who are about to start working with SDD in clinical practice and those who have already been working with SDD for some time but want to improve their practice can learn from these authors. September 2007 Peter van der Voort Hendrick K.F. van Saene Contents Contributors . IX List of Abbreviations . XI 1 The History of Selective Decontamination of the Digestive Tract . 1 H.K.F. van Saene, H.J. Rommes and D.F. Zandstra 2 The Concept of SDD . 37 H.J. Rommes 3 Infections in Critically Ill Patients: Should We Change to a Decontamination Strategy? . 47 P.H.J. van der Voort and H.K.F. van Saene 4 Gut Microbiology: How to Use Surveillance Samples for the Detection of the Carrier Status of Abnormal Flora . 59 H.K.F. van Saene 5 Compounding Medication for Digestive Decontamination: Pharmaceutical Aspects . 73 R. Schootstra and J.P. Yska 6 Nursing and Practical Aspects in the Application and Implementation of SDD . 89 J. Oenema and J. Mysliwiec 7 The Effects of Hand-Washing, Restrictive Antibiotic Use and SDD on Morbidity . 99 M.J. Schultz and P.E. Spronk 8 The Effects of SDD on Mortality . 111 E. de Jonge VIII Contents 09 Antimicrobial Resistance During 20 Years of Clinical SDD Research . 121 D.F. Zandstra, H.K.F. van Saene and P.H.J. van der Voort 10 The Costs of SDD . 133 P.H.J. van der Voort 11 SDD for the Prevention and Control of Outbreaks . 141 J.I. van der Spoel and R.T. Gerritsen 12 Preoperative Prophylaxis with SDD in Surgical Patients . 155 H.M. Oudemans-van Straaten 13 The Role of SDD in Liver Transplantation: a Meta-Analysis . 165 P.H.J. van der Voort and H.K.F. van Saene 14 Do Burn Patients Benefit from Digestive Tract Decontamination? . 173 J.E.H.M. Vet and D.P. Mackie 15 How to Design an Antibiotic Strategy that Respects the Indigenous Flora . 183 J.L. Bams Two Clinical Cases . 193 P.H.J. van der Voort Subject Index . 197 Contributors Hans L. Bams, MD Anaesthesiologist-intensivist, Skills Centre, University Hospital Groningen, Groningen, The Netherlands Rik T. Gerritsen, MD Internist-intensivist, Department of Intensive Care, Medical Centre Leeuwarden Leeuwarden, The Netherlands Evert de Jonge, MD, PhD Internist-intensivist, Department of Intensive Care, Academic Medical Centre Amsterdam, The Netherlands Dave M. Mackie, MD, PhD Anaesthesiologist-intensivist, Department of Anaesthetics, Intensive Care and Burns Unit, Red Cross Hospital Beverwijk, The Netherlands Jeanine Mysliwietz, RN Intensive care nurse, Department of Intensive Care, Medical Centre Leeuwarden Leeuwarden, The Netherlands Jetske Oenema, RN Intensive care nurse, Department of Intensive Care, Medical Centre Leeuwarden Leeuwarden, The Netherlands Heleen M. Oudemans-van Straaten, MD, PhD Internist-intensivist, Department of Intensive Care, Onze Lieve Vrouwe Gasthuis Amsterdam, The Netherlands Hans J. Rommes, MD, PhD Internist-intensivist, Department of Intensive Care, Gelre Ziekenhuizen, Lukas Location Apeldoorn, The Netherlands X Contributors Hendrick K.F. van Saene, MD, PhD Department of Clinical Microbiology and Infection Control, Royal Liverpool Children’s NHS Trust of Alder Hey Liverpool, United Kingdom Rients Schootstra, PharmD Hospital pharmacist, Pharma Assist Hoogeveen, The Netherlands Markus J. Schultz, MD, PhD Internist-intensivist, Department of Intensive Care, Academic Medical Centre Amsterdam, The Netherlands Hans I. van der Spoel, MD Intensivist, Department of Intensive Care, Onze Lieve Vrouwe Gasthuis Amsterdam, The Netherlands Peter E. Spronk, MD, PhD Internist-intensivist, Department of Intensive Care, Gelre Ziekenhuizen, Lucas Location Apeldoorn, The Netherlands Jacqueline E.H.M. Vet, MD Anaesthesiologist-intensivist, Department of Anaesthesia, Intensive Care and Burns Unit, Red Cross Hospital Beverwijk, The Netherlands Peter H.J. van der Voort, MD, PhD, MSc Internist-intensivist, Department of Intensive Care, Onze Lieve Vrouwe Gasthuis Amsterdam, The Netherlands Jan P. Yska, PharmD Hospital Pharmacist, Department of Hospital Pharmacy, Medical Centre Leeuwarden Leeuwarden, The Netherlands Durk F. Zandstra, MD, PhD Anaesthesiologist-Intensivist, Department of Intensive Care, Onze Lieve Vrouwe Gasthuis Amsterdam, The Netherlands List of Abbreviations AGNB Aerobic Gram-Negative Bacteria APACHE Acute Physiology and Chronic Health Evaluation AR Antimicrobial Resistance BSI Blood Stream Infection C Control CAP Community-Acquired Pneumonia CFU Colony Forming Units COPD Chronic Obstructive Pulmonary Disease EBM Evidence-Based Medicine GALT Gut-Associated Lymphoid Tissue GCLP Good Control Laboratory Practice GMP Good Manufacturing Practice HAP Hospital-Acquired Pneumonia ICU Intensive Care Unit IgA Immunoglobulin A IPI Intrinsic Pathogenicity Index MIC Minimal Inhibitory Concentration MRAb Multi-Resistant Acinetobacter baumannii MRSA Methicillin- or Multi-Resistant Staphylococcus aureus NA Not Available OA Ofloxacin - Amphotericin B P Placebo PGA Polymyxin - Gentamycin - Amphotericin B PGN Polymyxin - Gentamycin - Neomycin PPM Potentially Pathogenic Microorganism PTA Polymyxin E – Tobramycin – Amphotericin B RCT Randomised Controlled Trial SAPS Simplified Acute Physiology Score

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