May 072011

De Smet et al reheat the data from their 2009 NEJM study, in which they cluster-randomized and crossed-over 5,939 patients staying >48hrs in 13 Dutch ICUs to receive either 1) standard care; 2) selective oropharyngeal decontamination (topical amphotericin B, colistin, and tobramycin in the oropharynx), or 3) selective digestive tract decontamination (the same drugs in the mouth, stomach, and also IV cefotaxime for 4 days). Drugs were open-label, randomized by a blinded pharmacist. Back then, they reported a ~3% absolute mortality reduction in the treated groups.

Here, they report that patients in the standard-care group had more bacteremias (239 of 1837 or 13%), compared with 7-9% in the antibiotic-prophylaxed groups. Tracheal aspirates were obtained in ~50% of patients in all groups after ICU day 3. Cultures showed 15% of the patients in standard care had highly resistant bugs, compared to 8-10% in the prophylaxed groups. All values were statistically significant. Authors recommend these antibiotic regimens become standard care in ICUs. Lancet Infect Dis 2011;11:372-380.

They also report elsewhere that the IV+oral+stomach decontamination group had 1.4 gram-negative bacteremias per 1,000 days; the oral-only group, 3.0; and the standard-care group, 4.5. In their analysis, they argue against using the IV cefotaxime, saying it probably didn't help. Crit Care Med 2011;39:961-966.

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Oral / gastric antibiotic decontamination reduced bacteremias in ICU