Open Access

Withholding selective decontamination of the digestive tract from critically ill patients must now surely be ethically questionable given the vast evidence base

  • Durk F Zandstra1Email author,
  • Andy J Petros2,
  • Nia Taylor3,
  • Luciano Silvestri4,
  • Miguel A de la Cal5 and
  • Hendrick KF van Saene3
Critical Care201014:443

https://doi.org/10.1186/cc9255

Published: 06 October 2010

Shibli and colleagues recently commented [1] on the Dutch randomised controlled trial in which selective digestive decontamination (SDD) and selective oro-pharyngeal decontamination (SOD) were associated with significantly lower odds of death as compared with standard care, with odds ratios of 0.83 (P = 0.02) and 0.86 (P = 0.045), respectively [2]. We disagree with the authors' conclusion that, because there were similar mortality reductions, SOD may be preferred as this avoids routinely exposing patients to intravenous antibiotics and involves less resistance.

Cephalosporin consumption was higher in the SDD group, but defined daily doses of penicillins, carba-penems, quinolones and other antibiotics increased by 31%, 37%, 25% and 15%, respectively, in SOD compared with SDD in the Dutch randomised controlled trial [2].

In citing the monthly point prevalence survey [3] of the Dutch randomised controlled trial, Shibli and colleagues failed to mention that the average prevalence of aerobic Gram-negative bacilli resistant to ceftazidime, tobramycin and ciprofloxacin in the respiratory tract was significantly lower during SDD/SOD than in the pre-intervention and post-intervention periods, and that aerobic Gram-negative bacilli resistance to ciprofloxacin and tobramycin in rectal swabs was significantly reduced during SDD compared with standard care/SOD [2, 3].

Finally, two recent meta-analyses evaluated the effectiveness of SDD [4] and of SOD [5]: lower airway infections were significantly reduced by both SDD and SOD, but only SDD was associated with a significant survival benefit.

We believe that withholding SDD is now ethically questionable given the vast body of evidence on the technique reducing severe infections and mortality, requiring less antibiotic use, and providing less resistance.

Abbreviations

SDD: 

selective digestive decontamination

SOD: 

selective oropharyngeal decontamination.

Declarations

Authors’ Affiliations

(1)
Department of Intensive Care, Onze Lieve Vrouwe Gasthuis
(2)
Paediatric Intensive Care Unit, Great Ormond Street Children's Hospital
(3)
School of Clinical Sciences,University of Liverpool
(4)
Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero
(5)
Unidad de Cuidados Intensivos y Grandes Quemados, Hospital Universitario de Getafe

References

  1. Shibli AB, Milbrandt EB, Baldisseri M: Dirty mouth? Should you clean it out? Decontamination for the prevention of pneumonia and mortality in the ICU. Crit Care 2010, 14: 314. 10.1186/cc9048PubMed CentralView ArticlePubMedGoogle Scholar
  2. Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, van der Hoeven JG, Pickkers P, Bogaers-Hofman D, van der Meer NJ, Bernards AT, Kuijper EJ, Joore JC, Leverstein-van Hall MA, Bindels AJ, Jansz AR, Wesselink RM, de Jongh BM, Dennesen PJ, van Asselt GJ, te Velde LF, Frenay IH, Kaasjager K, Bosch FH, van Iterson M, Thijsen SF, Kluge GH, Pauw W, de Vries JW, Kaan JA, et al.: Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009, 360: 20-31. 10.1056/NEJMoa0800394View ArticlePubMedGoogle Scholar
  3. Oostdijk EAN, de Smet AMGA, Blok HEM, Thieme Groen ES, van Asselt GJ, Benus RFJ, Bernards SAT, Frenay IHME, Jansz AR, de Jongh BM, Kaan JA, Leverstein-van Hall MA, Mascini EM, Pauw W, Sturm PDJ, Thijsen SFT, Kluytmans JAJW, Bonten MJM: Ecological effects of selective decontamination on resistant Gram-negative bacterial colonisation. Am J Respir Crit Care Med 2010, 181: 452-457. 10.1164/rccm.200908-1210OCView ArticlePubMedGoogle Scholar
  4. Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E: Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 2009, 4: CD000022.PubMedGoogle Scholar
  5. Silvestri L, van Saene HKF, Zandstra DF, Viviani M, Gregori D: SDD, SOD, or oropharyngeal chlorhexidine to prevent pneumonia and to reduce mortality in ventilated patients: which manoeuvre is evidence based? Intensive Care Med 2010, 36: 1436-1437. 10.1007/s00134-010-1809-5View ArticlePubMedGoogle Scholar

Copyright

© BioMed Central Ltd 2010

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