Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey

Contains fulltext : 89741.pdf (publisher's version ) (Open Access)INTRODUCTION: Use of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians. METHODS: A survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires. RESULTS: In all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0). CONCLUSIONS: Although perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies. TRIAL REGISTRATION: ISRCTN35176830

Selective decontamination of the oropharynx and the digestive tract in ICU patients

Background: Selective Digestive tract Decontamination (SDD) and Selective Oropharyngeal Decontamination (SOD) are effective infection prevention measures in intensive care patients, but reported effects on patient outcome are conflicting and the effects on infections and respiratory tract colonization with Highly-Resistant Microorganisms (HRMO, Dutch Guidelines) are unknown. Methods: SDD and SOD were evaluated in a pragmatic open clustered group-randomized cross-over study in 13 ICUs. Patients with expected duration of intubation >48 hours or expected ICU-stay >72 hours were eligible. In each unit, the three regimens (SDD, SOD and standard care (SC)) were applied during 6 months in random order. Mortality at day 28 was the primary endpoint. A post-hoc subgroup analysis was undertaken to quantify effects of SDD and SOD among surgical and non-surgical patients. SDD consisted of four days of intravenous cefotaxime and topical application of tobramycin, colistin and amphotericin B in the oropharynx and stomach. SOD consisted only of oropharyngeal application of the same antibiotics. Cultures of respiratory tract were obtained twice weekly during SDD and SOD, and on clinical indication only during SC. All blood and respiratory tract culture results were evaluated. Monthly point prevalence studies were performed to analyze antibiotic resistance. Results: 5939 patients were enrolled (1990 SC, 1904 SOD, 2045 SDD). Crude mortality at day 28 was 27.5%, 26.6% and 26.9% for patients in the SC, SOD and SDD groups, respectively. In a random effects logistic regression model with age, gender, APACHE II scores, intubation status and medical specialty as covariates, odds ratios (OR) for mortality at day 28 were 0.86(CI950.74-0.99) for SOD and 0.83(CI950.72-0.97) for SDD. Compared to SC, adjusted ORs of mortality at day 28 were comparable in SDD-treated surgical and non-surgical patients (0.86(CI950.69-1.09) and 0.85(CI950.70-1.03)), respectively, but durations of mechanical ventilation, ICU-stay and hospital stay were significantly reduced in surgical patients only. In contrast, SOD did not influence mortality at day 28 0.97(CI950.77-1.22) among surgical patients, whereas in non-surgical patients adjusted OR was 0.77(CI950.63-0.94). Compared to SC, ORs for ICU-acquired bacteremia were 0.48(CI950.38-0.60) during SDD and 0.66(CI950.53-0.82) during SOD. The OR for ICU-acquired bacteremia caused by HRMO during SDD was 0.41(CI950.18-0.94) as compared to SC and when comparing SDD to SOD 0.37(CI950.16-0.85). ICU-acquired respiratory tract colonization of Gram negative bacteria was highest among patients receiving SC. ORs for acquiring HRMO colonization, as compared to SC, were 0.58(CI950.43-0.78) and 0.65(CI950.49-0.87) for SDD and SOD respectively. Acquired colonization with cefotaxime-resistant or colistin-resistant pathogens was lowest during SDD. Conclusions: In an ICU population with a baseline mortality rate of 27.5%, ARRs at day 28 were, after adjustment for covariates, 3.5% and 2.9% for SDD and SOD, respectively. In the subgroup analysis SDD was equally effective in reducing 28 day mortality at day 28 in surgical and non-surgical patients, whereas SOD was only effective in non-surgical patients with an ARR of 5.5%. As compared to SC, without adjustments for covariates, ICU-acquired bacteremia and respiratory tract colonization with HRMO were 48% and 59% lower during SDD and acquired respiratory tract colonization with HRMO was 38% lower during SO

Decontamination of cephalosporin-resistant Enterobacteriaceae during selective digestive tract decontamination in intensive care units

Molecular basis of bacterial pathogenesis, virulence factors and antibiotic resistanc

Clinical examination for diagnosing circulatory shock: The Simple Intensive Care Studies-I

INTRODUCTION. The latest consensus on circulatory shock advocates clinical examination and ultrasonography for diagnosing circulatory shock. Propagation of daily clinical examination contrasts with available studies, which are of limited quality and quantity so that its level of evidence is considered 'best practice'. We hypothesize that clinical estimation of circulatory shock, should be based on multiple variables including combinations of clinical, laboratory and ultrasonography variables. OBJECTIVES. To evaluate the value of clinical examination, biochemical and ultrasonography variables in the critically ill, specifically for estimation which combinations of variables are associated with cardiac output. METHODS. We initiated the Simple Intensive Care Studies-I (SICS-I) which was designed as a prospective cohort study to include all patients acutely admitted to the intensive care unit. Clinical examination was performed in a standardized fashion in all patients according to predefined criteria including variables of heart rate, blood pressures, central venous pressure, mental state, auscultation of heart and lungs, respiratory rate, urine output, capillary refill times, central to peripheral temperatures gradients, skin mottling; biochemical variables including lactate; and ultrasonography of heart and lungs. These clinical, biochemical, and ultrasonography variables were recorded following a published protocol (NCT02912624). Circulatory shock was defined by the requirement of vasopressors and/or inotropes and measured by cardiac output using transthoracic ultrasonography. All researchers, including medical students, underwent focused training for recording of all variables, including obtaining specific ultrasonography images. Cardiac function was clinically estimated as well before being measured by ultrasonography. RESULTS. Between March 2015 and December 2016 a total of 704 out of 791 eligible patients were included. An independent Core laboratory assessed that ultrasonography images from 632 patients (90%) were of sufficient quality. Vasopressors and/or inotropes were used upon admission in 363 cases (52%). 173 patients (25%) had died at 90-day follow-up. The data of all patients included until July 1st, 2017 will be analysed to identify combinations of variables independently associated with cardiac output. At the congress, these results will be presented and these variables will inform the second phase of the on-going registry. CONCLUSIONS. Standardized clinical examination and ultrasonography in critically ill patients by novices is feasible. We will be able to answer whether clinical assessment of the presence of shock can reliably be established and if so, which combinations of variables are most informative for estimation of the patients' cardiac output

Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study

Item does not contain fulltextBACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: Widespread use of SDD and SOD in intensive-care units with low levels of antibiotic resistance is justified. FUNDING: None

Decontamination of the digestive tract and oropharynx in ICU patients.

Contains fulltext : 79996.pdf (publisher's version ) (Open Access)BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.