Critically evaluate the use of selective decontamination of the digestive tract (SDD) in the ICU.
SDD is a prophylactic strategy to prevent or minimise the incidence of nosocomial infection from endogenous organisms and to prevent or minimise cross-infection by the application of non-absorbable oral and enteric antibiotics and parenteral antibiotics.
Classically SDD has four components:
OR any reasonable and adequate introduction.
Nosocomial infections cause significant morbidity and mortality in the ICU. These infections arise from a limited number of potentially pathogenic micro-organisms (PPM) carried by healthy individuals (eg Staph aureus, E coli and C albicans) and opportunistic, aerobic Gram-negative bacilli (eg Klebsiella, Pseudomonas Acinetobacter) that colonise individuals when critically ill.
The goal of SDD is to prevent or eradicate, if already present, at the start of ICU admission, the carriage of PPMs from the oropharynx and GI tract, leaving the indigenous flora, which protect against overgrowth with resistant bacteria, largely undisturbed.
Over 60 RCTs with >15,000 patients (mostly in Europe) show benefits in terms of:
Patient groups studied include general ICU, burns, gastrointestinal surgery and transplant patients.
Await the results of the international multi-centre RCT SuDDICU.
Summary statement and Personal approach:
Any reasonable statement of candidate’s own approach, for example
The beneficial effects are expected to manifest in the following ways:
Critique of the evidence
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van Saene, H. K. F., et al. "Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill." Current drug targets 9.5 (2008): 419-421.
Camus, Christophe, et al. "Short-Term Decline in All-Cause Acquired Infections With the Routine Use of a Decontamination Regimen Combining Topical Polymyxin, Tobramycin, and Amphotericin B With Mupirocin and Chlorhexidine in the ICU: A Single-Center Experience*." Critical care medicine 42.5 (2014): 1121-1130.
Daneman, Nick, et al. "Effect of selective decontamination on antimicrobial resistance in intensive care units: a systematic review and meta-analysis." The Lancet infectious diseases 13.4 (2013): 328-341.
Price, Richard, Graeme MacLennan, and John Glen. "Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis." BMJ: British Medical Journal 348 (2014).
Petros, Andy J., et al. "2B or Not 2B for Selective Decontamination of the Digestive Tract in the Surviving Sepsis Campaign Guidelines." Critical care medicine 41.11 (2013): e385-e386.
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Hurley, James C. "The perfidious effect of topical placebo: A calibration of Staphylococcus aureus Ventilator Associated Pneumonia incidence within Selective Digestive Decontamination (SDD) studies versus the broader evidence base." Antimicrobial agents and chemotherapy (2013): AAC-00424.
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Derde, L. P. G., and M. J. M. Bonten. "Controlling antibiotic resistance in intensive care units." Netherlands Journal of Critical Care, VOLUME 19 - NO 1 - FEBRUARY 2015
De Smet, A. M. G. A., et al. "Decontamination of the digestive tract and oropharynx in ICU patients." New England Journal of Medicine 360.1 (2009): 20.
Cuthbertson, B. H., et al. "A study of the perceived risks, benefits and barriers to the use of SDD in adult critical care units (The SuDDICU study)." Trials 11.1 (2010): 117.