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 20 February 2018

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News

Decontamination of the digestive tract in intensive care patients

The latest issue of the New England Journal of Medicine examines decontamination of the digestive tract and oropharynx in intensive care unit patients.

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Selective digestive tract decontamination and selective oropharyngeal decontamination are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting.

Dr de Smet and colleagues from the Netherlands evaluated the effectiveness of selective digestive tract decontamination and selective oropharyngeal decontamination in a crossover study using cluster randomization in 13 intensive care units.

 

Patients with an expected duration of intubation of more than 48 hours or an expected intensive care unit stay of more than 72 hours were eligible.

 

In each intensive care unit, 3 regimens were applied in random order over the course of 6 months.

 

The 3 regimens included selective digestive tract decontamination, selective oropharyngeal decontamination, and standard care.

 

Mortality at day 28 was the primary end point.

 

Crude mortality at day 28 with standard care was 28%

New England Journal of Medicine
Selective digestive tract decontamination consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach.

 

Selective oropharyngeal decontamination consisted of oropharyngeal application only of the same antibiotics.

 

The research team performed monthly point-prevalence studies to analyze antibiotic resistance.

 

A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to selective oropharyngeal decontamination, and 2045 to selective digestive tract decontamination.

 

The team noted that crude mortality in the groups at day 28 was 28%, 27%, and 26%, respectively.

 

The team used a random-effects logistic-regression model using age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates,

 

The odds ratios for death at day 28 in the selective oropharyngeal decontamination and selective digestive tract decontamination, as compared with the standard-care group, were 0.9 and 0.8, respectively.

 

Dr de Smet’s team concludes, “In an intensive care unit population in which the mortality rate associated with standard care was 28% at day 28, the rate was reduced by an estimated 4% with selective digestive tract decontamination 3% with selective oropharyngeal decontamination.”  

NEJM 2008: 360(1): 20-31
06 January 2009

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