Division of Perioperative and Emergency Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
Lancet Infect Dis. 2011 May;11(5):372-80. doi: 10.1016/S1473-3099(11)70035-4. Epub 2011 Mar 21.
Previously, we assessed selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) on survival and prevention of bacteraemia in patients in intensive-care units. In this analysis, we aimed to assess effectiveness of these interventions for prevention of respiratory tract colonisation and bacteraemia with highly resistant microorganisms acquired in intensive-care units.
We did an open-label, clustered group-randomised, crossover study in 13 intensive-care units in the Netherlands between May, 2004, and July, 2006. Participants admitted to intensive-care units with an expected duration of mechanical ventilation of more than 48 h or an expected stay of more than 72 h received SOD (topical tobramycin, colistin, and amphotericin B in the oropharynx), SDD (SOD antibiotics in the oropharynx and stomach plus 4 days' intravenous cefotaxime), or standard care. The computer-randomised order of study regimens was applied by an independent clinical pharmacist who was masked to intensive-care-unit identity. We calculated crude odds ratios (95% CI) for rates of bacteraemia or respiratory tract colonisation with highly resistant microorganisms in patients who stayed in intensive-care units for more than 3 days (ie, acquired infection). This trial is registered at http://isrctn.org, number ISRCTN35176830.
Data were available for 5927 (>99%) of 5939 patients, of whom 5463 (92%) were in intensive-care units for more than 3 days. 239 (13%) of 1837 patients in standard care acquired bacteraemia after 3 days, compared with 158 (9%) of 1758 in SOD (odds ratio 0·66, 95% CI 0·53-0·82), and 124 (7%) of 1868 in SDD (0·48, 0·38-0·60). Eight patients acquired bacteraemia with highly resistant microorganisms during SDD, compared with 18 patients (with 19 episodes) during standard care (0·41, 0·18-0·94; rate reduction [RR] 59%, absolute risk reduction [ARR] 0·6%) and 20 during SOD (0·37, 0·16-0·85; RR 63%, ARR 0·7%). Of the patients staying in intensive-care units for more than 3 days, we obtained endotracheal aspirate cultures for 881 (49%) patients receiving standard care, 886 (50%) receiving SOD, and 828 (44%) receiving SDD. 128 (15%) patients acquired respiratory tract colonisation with highly resistant microorganisms during standard care, compared with 74 (8%) during SDD (0·58, 0·43-0·78; RR 38%, ARR 5·5%) and 88 (10%) during SOD (0·65, 0·49-0·87; RR 32%, ARR 4·6%). Acquired respiratory tract colonisation with Gram-negative bacteria or cefotaxime-resistant and colistin-resistant pathogens was lowest during SDD.
Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified.
None.
此前，我们评估了选择性消化道去污染（SDD）和选择性口咽去污染（SOD）对重症监护病房患者的生存和菌血症预防作用。在此分析中，我们旨在评估这些干预措施对预防重症监护病房获得的高度耐药微生物引起的呼吸道定植和菌血症的有效性。
我们在荷兰的 13 家重症监护病房进行了一项开放标签、集群分组随机交叉研究，时间为 2004 年 5 月至 2006 年 7 月。预计机械通气时间超过 48 小时或预计住院时间超过 72 小时的患者接受 SOD（局部妥布霉素、多粘菌素 B 和两性霉素 B 用于口咽）、SDD（口咽和胃中的 SOD 抗生素加上 4 天静脉头孢噻肟）或标准护理。独立临床药剂师应用计算机随机化的研究方案，该药剂师对重症监护病房的身份进行了屏蔽。我们计算了在重症监护病房停留超过 3 天（即获得性感染）的患者发生高度耐药微生物菌血症或呼吸道定植的粗比值比（95%CI）。该试验在 http://isrctn.org 上注册，编号 ISRCTN35176830。
我们获得了 5927 名（99%）>5939 名患者中的 5927 名（>99%）患者的数据，其中 5463 名（92%）患者在重症监护病房停留超过 3 天。在标准护理组中，239 名（13%）患者在 3 天后发生菌血症，而 SOD 组为 158 名（9%）（比值比 0.66，95%CI 0.53-0.82），SDD 组为 124 名（7%）（0.48，0.38-0.60）。8 名患者在 SDD 期间发生了高度耐药微生物引起的菌血症，而 18 名患者（19 例）在标准护理期间（0.41，0.18-0.94；率降低[RR]59%，绝对风险降低[ARR]0.6%）和 20 名患者在 SOD 期间（0.37，0.16-0.85；RR 63%，ARR 0.7%）发生了菌血症。在重症监护病房停留超过 3 天的患者中，我们对 881 名（49%）接受标准护理、886 名（50%）接受 SOD 和 828 名（44%）接受 SDD 的患者进行了气管内抽吸培养。128 名（15%）患者在标准护理期间发生了高度耐药微生物引起的呼吸道定植，而 SDD 组为 74 名（8%）（0.58，0.43-0.78；RR 38%，ARR 5.5%）和 SOD 组为 88 名（10%）（0.65，0.49-0.87；RR 32%，ARR 4.6%）。在 SDD 期间，革兰氏阴性菌或头孢噻肟耐药和多粘菌素耐药病原体引起的获得性呼吸道定植最低。
在重症监护病房中广泛使用 SDD 和 SOD 以降低抗生素耐药性是合理的。
无。
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