Infectious Diseases, 2015; Early Online: 1–4
BRIEF REPORT
Ventilator-associated pneumonia rates after introducing selective digestive tract decontamination
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
RONNY M. SCHNABEL, JOHANNES B.J. SCHOLTE, KIM E.H.M. VAN DER VELDEN, PAUL M.H.J. ROEKAERTS & DENNIS C.J.J. BERGMANS From the Department of Intensive Care Medicine, Maastricht University Medical Centre⫹, The Netherlands
Abstract The incidence of ventilator-associated pneumonia (VAP) before and after the introduction of selective oral decontamination (SOD) only and selective digestive tract decontamination (SDD) in a general intensive care population was examined. SOD as standard of care was introduced in December 2010 and SDD, including SOD, in January 2012 for all patients with an expected length of intensive care unit (ICU) stay of at least 48 h. The diagnosis of VAP was based on clinical criteria and quantitative cultures of bronchoalveolar lavage fluid. A total of 4945 mechanically ventilated patients accounting for 37 554 ventilator days in the period from 2005 to 2013 were analyzed. The incidence of VAP per 1000 ventilator days declined significantly from 4.38 ⫾ 1.64 before to 1.64 ⫾ 0.43 after introduction of SOD/SDD (p ⫽ 0.007). Implementation of SOD/SDD as standard of care in ICUs may thus be effective in preventing VAP.
Keywords: Bronchoalveolar lavage, critical care, decontamination, preventive measures, antibacterial agents
Introduction Ventilator-associated pneumonia (VAP) is defined as a new-onset pneumonia that occurs in patients receiving mechanical ventilation for more than 48 h. It is a nosocomial infection in critically ill patients with an incidence that varies from 4 to 42% depending on the applied diagnostic criteria [1]. VAP is associated with an attributable mortality risk of 13% [2]. Selective oral decontamination (SOD) and selective digestive tract decontamination (SDD) are prophylactic strategies for VAP. In SOD, topical antibiotics (polymyxin E, tobramycin, amphotericin B) are applied to the oropharynx. SDD consists of oropharyngeal and gastric application of the same non-absorbable antibiotics along with a 4-day course of intravenous cefotaxime. Both strategies focus on prevention of pathogenic bacterial overgrowth in critically ill patients, secondary colonization, and infection with gram-negative bacteria, Staphylococcus aureus, and yeasts. The aim is to maintain the anaerobic intestinal flora through selective use of antibiotics without anti-anaerobic activity. The course of systemic antibiotic therapy in SDD is intended to treat incubating
infections at the time of ICU admission with commensal respiratory tract flora [3–5]. There has been growing evidence that SOD/SDD can prevent ICUacquired infections [6,7]. This study examined the VAP incidence at a tertiary ICU before and after the introduction of SOD/SDD as standard of care.
Materials and methods The study was conducted at the Maastricht University Medical Centre⫹, a tertiary care, university hospital in the Netherlands with 2 general 9-bed ICUs with approximately 700 admissions annually. Bronchoalveolar lavage (BAL) was the standard diagnostic modality in all patients who were suspected of having VAP, when presenting with three or more of the following clinical criteria: rectal temperature ⬎ 38.0°C or ⬍ 35.5°C; leukocytosis of ⬎ 10 000/μl, and/or left shift (the ratio of immature to mature neutrophils) or leukopenia ⬍ 3000/μl; more than 10 leukocytes per high power field in Gram stain of endotracheal aspirate; a positive culture of endotracheal aspirate; a new, persistent or progressive infiltrate on chest
Correspondence: R. Schnabel, Maastricht University Medical Centre⫹, Department of Intensive Care Medicine, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands. Tel: ⫹ 31 43 387 6543. Fax: ⫹ 31 43 387 4330. E-mail: [email protected] (Received 9 December 2014 ; accepted 9 March 2015) ISSN 2374-4235 print/ISSN 2374-4243 online © 2015 Informa Healthcare DOI: 10.3109/23744235.2015.1031172
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R. M. Schnabel et al.
Table I. Intensive care unit (ICU) characteristics including incidence of ventilator-associated pneumonia (VAP). Before introduction of SOD/SDD
Characteristic Year General ICU admissions Mechanically ventilated patients Ventilator days Ø length of ventilation (days) BALs performed VAP VAP/1000 ventilator days
2005 642 475 4747 10 73 18 3.79
2006 630 464 4780 10 61 19 3.97
2007 574 416 4601 11 75 29 6.3
2008 743 579 4222 7 68 26 6.16
After introduction of SOD/SDD 2010 a 714 592 4217 7 50 9 2.13
2009 706 561 4608 8 72 18 3.91
2011 778 603 3492 6 40 4 1.15
2012b 786 607 3331 5 35 6 1.8
2013 866 648 3556 5 48 7 1.97
radiograph [8]. A fiberoptic bronchoscope (Pentax FB-15H/FB-15X, Pentax Medicals, Tokyo, Japan) was introduced and ‘wedged’ into the affected segmental or subsegmental bronchus. Sterile saline (0.9% sodium chloride at room temperature) was instilled in four aliquots of 50 ml, immediately aspirated, and recovered. Further analysis was highly standardized as described by de Brauwer et al. [9]. BAL fluid analysis was considered to support the diagnosis of VAP when ⱖ 2% BAL fluid cells contained intracellular organisms, and/or bacterial microorganisms grew at a concentration of ⱖ 104 colony forming units (cfu)/ml. Commensal flora was considered nonpathogenic and subsequently the BAL fluid sample was classified as negative [10]. SOD consists of topical application of 0.5 g of a paste containing amphotericin B (2%), polymyxin E (2%), and tobramycin (2%) in the oropharynx. SDD consists of SOD plus 4 days of intravenous cefotaxime (1000 mg, every 6 h) and application of amphotericin B, polymyxin, and tobramycin (10 ml, with doses of 500 mg, 100 mg, and 80 mg, respectively)
in the stomach every 6 h. Topical antibiotics were used until discharge from the ICU. SOD was introduced as standard of care in December 2010 and SDD (including SOD) in January 2012. This study was an evaluation of standard care and according to hospital regulations approved by the institutional medical ethics committee. The incidences of VAP were expressed per 1000 ventilator days as mean ⫾ standard deviation (SD). Student’s t test was used for the evaluation of the association of VAP incidences before and after introduction of SOD/SDD. Significance was reported at a p value ⬍ 0.05. Bacteria causing VAP were grouped into gram-negative and gram-positive microorganisms.The distribution before and after introduction of SOD/SDD was compared and statistically analyzed by the χ2 test. Results Clinical data for 4945 ventilated adult patients accounting for 37 554 ventilator days treated in the ICU during the period of 2005–2013 were examined.
7 VAPs per 1000 ventilator days
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BAL, bronchoalveolar lavage, SDD, selective digestive tract decontamination; SOD, selective oropharyngeal decontamination. aSOD was used from December 2010. bSDD, which includes SOD, was used from January 2012.
6 5 4 3 2 1 0 2005
2006
2007
2008
2009 Year
2010
2011
2012
2013
Figure 1. Mean rates of ventilator-associated pneumonia (VAP) before and after introduction of selective oropharyngeal decontamination/ selective digestive tract decontamination (SOD/SDD) with 95% confidence interval.
VAP rates after introducing SOD/SDD
SOD/SDD (n=25)
before SOD/SDD (n=98)
0%
20%
40%
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Gram-negative
60%
80%
100%
Gram-positive
Figure 2. Distribution of gram-negative and gram-positive bacteria causing ventilator-associated pneumonia (VAP) before and after the introduction of selective oropharyngeal decontamination/ selective digestive tract decontamination (SOD/SDD) was not significantly changed (p ⫽ 0.11, χ2 test).
Table I provides the number of admitted patients, number of mechanically ventilated patients, ventilator days, the average length of mechanical ventilation, and the number of confirmed VAPs for each year of the studied period. Before the introduction of SOD/ SDD, the mean VAP rate was 4.38 ⫾ 1.64 per 1000 ventilator days and after SOD/SDD became standard of care the mean VAP rate was 1.64 ⫾ 0.43 (p ⫽ 0.007) ( Figure 1). The distribution of gramnegative and gram-positive bacteria causing VAP before and after the introduction of SOD/SDD was not significantly changed (p ⫽ 0.11) (Figure 2). Discussion Mean VAP rates declined significantly after SOD/ SDD became standard of care (from 4.38 to 1.64 per 1000 ventilator days). This finding is consistent with a previous review with regard to the efficacy of SOD/SDD [11]. Potentially confounding factors such as ICU organization, architecture, and the nurse to patient ratio were not altered during the study period. Other VAP preventive items (alcohol-based hand-washing policy, head-of-bed elevation, oral mouth wash, sedation holds, and a weaning protocol) were applied during the whole study period. However, increased compliance with the VAP preventive bundle items over the years cannot be ruled out, which might have influenced the incidence of VAP [12]. Overall, the annual number of ventilator days declined during the analyzed period, decreasing the average length of mechanical ventilation from 10 to 5 days. Increased use of noninvasive ventilation as an alternative for patients with acute cardiac decompensation or exacerbation of obstructive lung disease could have contributed to the observed decline in invasive mechanical ventilation. Undoubtedly, if the period of tracheal intubation and mechanical ventilation is reduced, less patients develop VAP [13].
3
On the other hand, the decrease in average duration of mechanical ventilation is also influenced by the reduced number of episodes of VAP, which are known to increase duration of mechanical ventilation [14]. A limitation of the present study is its observational design lacking a placebo controlled group. Influencing confounders cannot be excluded; however, their impact seemed limited. Overall, the results of the present study suggest a causal relationship between SOD/SDD and the observed decline in VAP incidence. Moreover, during the whole study period the diagnosis of VAP was methodologically standardized. The distribution of gram-negative and gram-positive bacteria causing VAP was not significantly changed, proving the effectiveness of the SOD/SDD components against both [3]. In conclusion, the implementation of SOD/SDD as standard of care in ICUs may thus be effective in preventing VAP. Due to limitations in sample size the present study cannot further discriminate if SOD alone or SDD (including SOD) are superior in any way. Currently, Dutch national guidelines dictate SOD or SDD to be used as a preventive strategy when treating mechanically ventilated patients for more than 48 h [15]. Future studies should deliver more evidence to support the effectiveness in countries with higher rates of hospital-acquired infections and antibiotic resistance [16]. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Ego A, Preiser JC, Vincent JL. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia. Chest 2015;147:347–55. [2] Melsen WG, Rovers MM, Groenwold RH, Bergmans DC, Camus C, Bauer TT, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 2013;13:665–71. [3] de Smet AM, Bonten MJ, Kluytmans JA. For whom should we use selective decontamination of the digestive tract? Curr Opin Infect Dis 2012;25:211–17. [4] Stoutenbeek CP, van Saene HK, Miranda DR, Zandstra DF. The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Med 1984;10:185–92. [5] van der Voort P, van Saene H, editors. Selective digestive tract decontamination in intensive care medicine: a practical guide to controlling infection. Springer; 2008. [6] de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009;360:20–31. [7] de Jonge E, Schultz MJ, Spanjaard L, Bossuyt PM, Vroom MB, Dankert J, et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 2003;362:1011–16.
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R. M. Schnabel et al.
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
[8] Bonten MJ, Bergmans DC, Stobberingh EE, van der Geest S, De Leeuw PW, van Tiel FH, et al. Implementation of bronchoscopic techniques in the diagnosis of ventilator-associated pneumonia to reduce antibiotic use. Am J Respir Crit Care Med 1997;156:1820–4. [9] De Brauwer EI, Jacobs JA, Nieman F, Bruggeman CA, Drent M. Bronchoalveolar lavage fluid differential cell count. How many cells should be counted? Anal Quant Cytol Histol 2002;24: 337–41. [10] Canadian Critical Care Trials G. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006;355:2619–30. [11] Schultz MJ, Haas LE. Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review. Crit Care 2011;15:R18. [12] Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al. Reducing ventilator-associated pneumo-
[13] [14]
[15]
[16]
nia in intensive care: impact of implementing a care bundle. Crit Care Med 2011;39:2218–24. Zolfaghari PS, Wyncoll DL. The tracheal tube: gateway to ventilator-associated pneumonia. Crit Care 2011;15:310. Warren DK, Shukla SJ, Olsen MA, Kollef MH, Hollenbeak CS, Cox MJ, et al. Outcome and attributable cost of ventilatorassociated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003;31:1312–17. SWAB. Selectieve decontaminatie bij patiënten op de intensive care. 2014. Available from: http://www.swab.nl/swab/ cms3.nsf/uploads/E6FA609CFB1010C3C1257D4D0031D AD6/$FILE/Richtlijn%20SDD%202014.pdf Francis JJ, Duncan ME, Prior EM, Maclennan SG, Dombrowski US, Bellingan G, et al. Selective decontamination of the digestive tract in critically ill patients treated in intensive care units: a mixed-methods feasibility study (the SuDDICU study). Health Technol Assess 2014;18:1–170.
BRIEF REPORT
Ventilator-associated pneumonia rates after introducing selective digestive tract decontamination
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
RONNY M. SCHNABEL, JOHANNES B.J. SCHOLTE, KIM E.H.M. VAN DER VELDEN, PAUL M.H.J. ROEKAERTS & DENNIS C.J.J. BERGMANS From the Department of Intensive Care Medicine, Maastricht University Medical Centre⫹, The Netherlands
Abstract The incidence of ventilator-associated pneumonia (VAP) before and after the introduction of selective oral decontamination (SOD) only and selective digestive tract decontamination (SDD) in a general intensive care population was examined. SOD as standard of care was introduced in December 2010 and SDD, including SOD, in January 2012 for all patients with an expected length of intensive care unit (ICU) stay of at least 48 h. The diagnosis of VAP was based on clinical criteria and quantitative cultures of bronchoalveolar lavage fluid. A total of 4945 mechanically ventilated patients accounting for 37 554 ventilator days in the period from 2005 to 2013 were analyzed. The incidence of VAP per 1000 ventilator days declined significantly from 4.38 ⫾ 1.64 before to 1.64 ⫾ 0.43 after introduction of SOD/SDD (p ⫽ 0.007). Implementation of SOD/SDD as standard of care in ICUs may thus be effective in preventing VAP.
Keywords: Bronchoalveolar lavage, critical care, decontamination, preventive measures, antibacterial agents
Introduction Ventilator-associated pneumonia (VAP) is defined as a new-onset pneumonia that occurs in patients receiving mechanical ventilation for more than 48 h. It is a nosocomial infection in critically ill patients with an incidence that varies from 4 to 42% depending on the applied diagnostic criteria [1]. VAP is associated with an attributable mortality risk of 13% [2]. Selective oral decontamination (SOD) and selective digestive tract decontamination (SDD) are prophylactic strategies for VAP. In SOD, topical antibiotics (polymyxin E, tobramycin, amphotericin B) are applied to the oropharynx. SDD consists of oropharyngeal and gastric application of the same non-absorbable antibiotics along with a 4-day course of intravenous cefotaxime. Both strategies focus on prevention of pathogenic bacterial overgrowth in critically ill patients, secondary colonization, and infection with gram-negative bacteria, Staphylococcus aureus, and yeasts. The aim is to maintain the anaerobic intestinal flora through selective use of antibiotics without anti-anaerobic activity. The course of systemic antibiotic therapy in SDD is intended to treat incubating
infections at the time of ICU admission with commensal respiratory tract flora [3–5]. There has been growing evidence that SOD/SDD can prevent ICUacquired infections [6,7]. This study examined the VAP incidence at a tertiary ICU before and after the introduction of SOD/SDD as standard of care.
Materials and methods The study was conducted at the Maastricht University Medical Centre⫹, a tertiary care, university hospital in the Netherlands with 2 general 9-bed ICUs with approximately 700 admissions annually. Bronchoalveolar lavage (BAL) was the standard diagnostic modality in all patients who were suspected of having VAP, when presenting with three or more of the following clinical criteria: rectal temperature ⬎ 38.0°C or ⬍ 35.5°C; leukocytosis of ⬎ 10 000/μl, and/or left shift (the ratio of immature to mature neutrophils) or leukopenia ⬍ 3000/μl; more than 10 leukocytes per high power field in Gram stain of endotracheal aspirate; a positive culture of endotracheal aspirate; a new, persistent or progressive infiltrate on chest
Correspondence: R. Schnabel, Maastricht University Medical Centre⫹, Department of Intensive Care Medicine, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands. Tel: ⫹ 31 43 387 6543. Fax: ⫹ 31 43 387 4330. E-mail: [email protected] (Received 9 December 2014 ; accepted 9 March 2015) ISSN 2374-4235 print/ISSN 2374-4243 online © 2015 Informa Healthcare DOI: 10.3109/23744235.2015.1031172
2
R. M. Schnabel et al.
Table I. Intensive care unit (ICU) characteristics including incidence of ventilator-associated pneumonia (VAP). Before introduction of SOD/SDD
Characteristic Year General ICU admissions Mechanically ventilated patients Ventilator days Ø length of ventilation (days) BALs performed VAP VAP/1000 ventilator days
2005 642 475 4747 10 73 18 3.79
2006 630 464 4780 10 61 19 3.97
2007 574 416 4601 11 75 29 6.3
2008 743 579 4222 7 68 26 6.16
After introduction of SOD/SDD 2010 a 714 592 4217 7 50 9 2.13
2009 706 561 4608 8 72 18 3.91
2011 778 603 3492 6 40 4 1.15
2012b 786 607 3331 5 35 6 1.8
2013 866 648 3556 5 48 7 1.97
radiograph [8]. A fiberoptic bronchoscope (Pentax FB-15H/FB-15X, Pentax Medicals, Tokyo, Japan) was introduced and ‘wedged’ into the affected segmental or subsegmental bronchus. Sterile saline (0.9% sodium chloride at room temperature) was instilled in four aliquots of 50 ml, immediately aspirated, and recovered. Further analysis was highly standardized as described by de Brauwer et al. [9]. BAL fluid analysis was considered to support the diagnosis of VAP when ⱖ 2% BAL fluid cells contained intracellular organisms, and/or bacterial microorganisms grew at a concentration of ⱖ 104 colony forming units (cfu)/ml. Commensal flora was considered nonpathogenic and subsequently the BAL fluid sample was classified as negative [10]. SOD consists of topical application of 0.5 g of a paste containing amphotericin B (2%), polymyxin E (2%), and tobramycin (2%) in the oropharynx. SDD consists of SOD plus 4 days of intravenous cefotaxime (1000 mg, every 6 h) and application of amphotericin B, polymyxin, and tobramycin (10 ml, with doses of 500 mg, 100 mg, and 80 mg, respectively)
in the stomach every 6 h. Topical antibiotics were used until discharge from the ICU. SOD was introduced as standard of care in December 2010 and SDD (including SOD) in January 2012. This study was an evaluation of standard care and according to hospital regulations approved by the institutional medical ethics committee. The incidences of VAP were expressed per 1000 ventilator days as mean ⫾ standard deviation (SD). Student’s t test was used for the evaluation of the association of VAP incidences before and after introduction of SOD/SDD. Significance was reported at a p value ⬍ 0.05. Bacteria causing VAP were grouped into gram-negative and gram-positive microorganisms.The distribution before and after introduction of SOD/SDD was compared and statistically analyzed by the χ2 test. Results Clinical data for 4945 ventilated adult patients accounting for 37 554 ventilator days treated in the ICU during the period of 2005–2013 were examined.
7 VAPs per 1000 ventilator days
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
BAL, bronchoalveolar lavage, SDD, selective digestive tract decontamination; SOD, selective oropharyngeal decontamination. aSOD was used from December 2010. bSDD, which includes SOD, was used from January 2012.
6 5 4 3 2 1 0 2005
2006
2007
2008
2009 Year
2010
2011
2012
2013
Figure 1. Mean rates of ventilator-associated pneumonia (VAP) before and after introduction of selective oropharyngeal decontamination/ selective digestive tract decontamination (SOD/SDD) with 95% confidence interval.
VAP rates after introducing SOD/SDD
SOD/SDD (n=25)
before SOD/SDD (n=98)
0%
20%
40%
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Gram-negative
60%
80%
100%
Gram-positive
Figure 2. Distribution of gram-negative and gram-positive bacteria causing ventilator-associated pneumonia (VAP) before and after the introduction of selective oropharyngeal decontamination/ selective digestive tract decontamination (SOD/SDD) was not significantly changed (p ⫽ 0.11, χ2 test).
Table I provides the number of admitted patients, number of mechanically ventilated patients, ventilator days, the average length of mechanical ventilation, and the number of confirmed VAPs for each year of the studied period. Before the introduction of SOD/ SDD, the mean VAP rate was 4.38 ⫾ 1.64 per 1000 ventilator days and after SOD/SDD became standard of care the mean VAP rate was 1.64 ⫾ 0.43 (p ⫽ 0.007) ( Figure 1). The distribution of gramnegative and gram-positive bacteria causing VAP before and after the introduction of SOD/SDD was not significantly changed (p ⫽ 0.11) (Figure 2). Discussion Mean VAP rates declined significantly after SOD/ SDD became standard of care (from 4.38 to 1.64 per 1000 ventilator days). This finding is consistent with a previous review with regard to the efficacy of SOD/SDD [11]. Potentially confounding factors such as ICU organization, architecture, and the nurse to patient ratio were not altered during the study period. Other VAP preventive items (alcohol-based hand-washing policy, head-of-bed elevation, oral mouth wash, sedation holds, and a weaning protocol) were applied during the whole study period. However, increased compliance with the VAP preventive bundle items over the years cannot be ruled out, which might have influenced the incidence of VAP [12]. Overall, the annual number of ventilator days declined during the analyzed period, decreasing the average length of mechanical ventilation from 10 to 5 days. Increased use of noninvasive ventilation as an alternative for patients with acute cardiac decompensation or exacerbation of obstructive lung disease could have contributed to the observed decline in invasive mechanical ventilation. Undoubtedly, if the period of tracheal intubation and mechanical ventilation is reduced, less patients develop VAP [13].
3
On the other hand, the decrease in average duration of mechanical ventilation is also influenced by the reduced number of episodes of VAP, which are known to increase duration of mechanical ventilation [14]. A limitation of the present study is its observational design lacking a placebo controlled group. Influencing confounders cannot be excluded; however, their impact seemed limited. Overall, the results of the present study suggest a causal relationship between SOD/SDD and the observed decline in VAP incidence. Moreover, during the whole study period the diagnosis of VAP was methodologically standardized. The distribution of gram-negative and gram-positive bacteria causing VAP was not significantly changed, proving the effectiveness of the SOD/SDD components against both [3]. In conclusion, the implementation of SOD/SDD as standard of care in ICUs may thus be effective in preventing VAP. Due to limitations in sample size the present study cannot further discriminate if SOD alone or SDD (including SOD) are superior in any way. Currently, Dutch national guidelines dictate SOD or SDD to be used as a preventive strategy when treating mechanically ventilated patients for more than 48 h [15]. Future studies should deliver more evidence to support the effectiveness in countries with higher rates of hospital-acquired infections and antibiotic resistance [16]. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Ego A, Preiser JC, Vincent JL. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia. Chest 2015;147:347–55. [2] Melsen WG, Rovers MM, Groenwold RH, Bergmans DC, Camus C, Bauer TT, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 2013;13:665–71. [3] de Smet AM, Bonten MJ, Kluytmans JA. For whom should we use selective decontamination of the digestive tract? Curr Opin Infect Dis 2012;25:211–17. [4] Stoutenbeek CP, van Saene HK, Miranda DR, Zandstra DF. The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Med 1984;10:185–92. [5] van der Voort P, van Saene H, editors. Selective digestive tract decontamination in intensive care medicine: a practical guide to controlling infection. Springer; 2008. [6] de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009;360:20–31. [7] de Jonge E, Schultz MJ, Spanjaard L, Bossuyt PM, Vroom MB, Dankert J, et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 2003;362:1011–16.
4
R. M. Schnabel et al.
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
[8] Bonten MJ, Bergmans DC, Stobberingh EE, van der Geest S, De Leeuw PW, van Tiel FH, et al. Implementation of bronchoscopic techniques in the diagnosis of ventilator-associated pneumonia to reduce antibiotic use. Am J Respir Crit Care Med 1997;156:1820–4. [9] De Brauwer EI, Jacobs JA, Nieman F, Bruggeman CA, Drent M. Bronchoalveolar lavage fluid differential cell count. How many cells should be counted? Anal Quant Cytol Histol 2002;24: 337–41. [10] Canadian Critical Care Trials G. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006;355:2619–30. [11] Schultz MJ, Haas LE. Antibiotics or probiotics as preventive measures against ventilator-associated pneumonia: a literature review. Crit Care 2011;15:R18. [12] Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al. Reducing ventilator-associated pneumo-
[13] [14]
[15]
[16]
nia in intensive care: impact of implementing a care bundle. Crit Care Med 2011;39:2218–24. Zolfaghari PS, Wyncoll DL. The tracheal tube: gateway to ventilator-associated pneumonia. Crit Care 2011;15:310. Warren DK, Shukla SJ, Olsen MA, Kollef MH, Hollenbeak CS, Cox MJ, et al. Outcome and attributable cost of ventilatorassociated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 2003;31:1312–17. SWAB. Selectieve decontaminatie bij patiënten op de intensive care. 2014. Available from: http://www.swab.nl/swab/ cms3.nsf/uploads/E6FA609CFB1010C3C1257D4D0031D AD6/$FILE/Richtlijn%20SDD%202014.pdf Francis JJ, Duncan ME, Prior EM, Maclennan SG, Dombrowski US, Bellingan G, et al. Selective decontamination of the digestive tract in critically ill patients treated in intensive care units: a mixed-methods feasibility study (the SuDDICU study). Health Technol Assess 2014;18:1–170.
