Article

Selective decontamination of the digestive tract in surgical patients. A systematic review of the evidence

Department of Surgery, University of Toronto, Ontario, Canada.
Archives of Surgery (Impact Factor: 4.3). 03/1999; 134(2):170-6.
Source: PubMed

ABSTRACT To determine the comparative efficacy of selective decontamination of the digestive tract in critically ill surgical and medical patients, and in selected subgroups of surgical patients with pancreatitis, major burn injury, and those undergoing major elective surgery and transplantation.
The MEDLINE database was searched from January 1966 to December 1996 using the terms "decontamination or prophylaxis," "intensive care units," and "antibiotics." The search was limited to English-language studies evaluating the efficacy of selective decontamination of the digestive tract in human subjects.
The primary review was restricted to prospective randomized trials.
End points of interest included rates of nosocomial pneumonia, bacteremia, urinary tract infection, wound infection, mortality, and length of intensive care unit stay. Methodologic quality of individual studies was assessed using a previously described model.
Odds ratios (ORs) together with their (95% confidence interval [Cls]) were reported and determined using the Mantel-Haenszel method. Mortality was significantly reduced with the use of selective decontamination of the digestive tract in critically ill surgical patients (OR, 0.7, 95% CI, 0.52-0.93), while no such effect was demonstrated in critically ill medical patients (OR, 0.91; 95% CI, 0.71-1.18). The greatest effect was demonstrated in studies where both the topical and systemic components of the regimen were used. Rates of pneumonia were reduced in both subsets of patients, while those of bacteremia were significantly reduced only in surgical patients.
Selective decontamination of the digestive tract notably reduces mortality in critically ill surgical patients, while critically ill medical patients derive no such benefit. These data suggest that the use of selective decontamination of the digestive tract should be limited to those populations in whom rates of nosocomial infection are high and in whom infection contributes notably to adverse outcome.

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    • "1999 21/N.A. N.A. 0.70 [0.52–0.93] a Nathens [44] "
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    ABSTRACT: Selective decontamination of the digestive tract (SDD) has been subject of numerous randomized controlled trials in critically ill patients. Almost all clinical trials showed SDD to prevent pneumonia. Nevertheless, SDD has remained a controversial strategy. One reason for why clinicians remained reluctant to implement SDD into daily practice could be that mortality was reduced in only 2 trials. Another reason could be the heterogeneity of trials of SDD. Indeed, many different prophylactic antimicrobial regimes were tested, and dissimilar diagnostic criteria for pneumonia were applied amongst the trials. This heterogeneity impeded interpretation and comparison of trial results. Two other hampering factors for implementation of SDD have been concerns over the risk of antimicrobial resistance and fear for escalation of costs associated with the use of prophylactic antimicrobials. This paper describes the concept of SDD, summarizes the results of published trials of SDD in mixed medical-surgical intensive care units, and rationalizes the risk of antimicrobial resistance and rise of costs associated with this potentially life-saving preventive strategy.
    Critical care research and practice 10/2010; 2010(2090-1305):501031. DOI:10.1155/2010/501031
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    • "Prophylactic antimicrobials are unnecessary for low-risk patients undergoing elective laparoscopic cholecystectomy [34] [35] [36]. In elective colorectal surgery, selective decontamination of the gastrointestinal tract with oral neomycin and erythromycin is approximately as effective as parenteral antimicrobials [37]. Many clinicians use both, but it is not clear that this is more effective than either alone. "
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    ABSTRACT: The primary prophylactic measure against postoperative infection is antiseptic technique in patient preparation, during surgery, and in postoperative patient care. Antimicrobial prophylaxis against postoperative infection is not indicated for procedures with a low infection rate because the expected benefit of antimicrobial treatment is less than the risk of an adverse medication reaction. Antimicrobial prophylaxis has been demonstrated to be of greater benefit than risk in some procedures with higher infection rates; however, because the problem is complex and the data are limited, extra-polating these findings to the practitioner's setting and the individual patient remains a challenge (Table 1). Although antimicrobial prophylaxis for bacterial endocarditis is not effective for most patients, the seriousness of the potential infection has driven the creation of guidelines recommending prophylaxis for at-risk patients undergoing at-risk procedures. Applying these guidelines appropriately could help to reduce unwarranted use of antimicrobials. In the prophylactic use of antimicrobials, as in many medical interventions, the difficulty is balancing the risks of the intervention with the potential benefits. Although we do not have either the randomized, controlled trials or the detailed, patient-specific information to estimate this balance precisely, there are general guidelines to help the clinician choose treatment for most patients.
    Medical Clinics of North America 02/2003; 87(1):59-75. DOI:10.1016/S0025-7125(02)00145-1 · 2.80 Impact Factor
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    • "Amélioration de la mortalité (méta-analyses). Méta-analyse DDS locale et IV DDS locale seule (OR [IC95 %]) (OR [IC95 %]) Nathens et al. [2] Patients chirurgicaux 0,60 [0] [88] 0,86 [0] [45] Patients Médicaux 0,75 [0] [06] 1,14 [0] [68] D'amico et al. [1] 0,80 [0] [93] 1,01 [0] [22] De façon intéressante, la méta-analyse des 7 études qui ont comparé DDS plus antibiothérapie systémique et antibiothérapie systémique seule n'a pas retrouvé de différence de mortalité entre les groupes (OR 0,98 avec IC95 % [0] [32]), laissant penser que plus que la DDS en elle-même, c'est l'antibiothérapie systémique qui fait la différence dans les autres études [1]. Deux études récentes ont mis en évidence une diminution de la mortalité dans le groupe DDS par rapport au groupe contrôle. "
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