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American Journal of Respiratory and Critical Care Medicine Vol 173. pp. 131-133, (2006)
© 2006 American Thoracic Society

Correspondence

Adult Hospital and Ventilator-associated Pneumonia Guidelines: Eminence- rather than Evidence-based

To the Editor:

We read with interest the guidelines on the management of adult hospital and ventilator-associated pneumonia issued by the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) (1). However, we were disappointed by the subsection entitled "Modulation of colonization." The guidelines confirm that the oropharynx is the major source of potential pathogens that cause lower airway infections, an observation made by Johanson more than 30 years ago (2). Eradication of aerobic gram-negative bacilli (AGNB) carriage with chlorhexidine mouthwashes is a new message. In the randomized controlled trial (RCT) of DeRiso and colleagues (3), potential pathogens were not identified, although it is well known that AGNB, in particular Pseudomonas aeruginosa and Acinetobacter baumannii, are intrinsically resistant to chlorhexidine. A recent English RCT failed to confirm the DeRiso study (4).

We would like to make it quite clear that oropharyngeal decontamination on its own has never been shown to reduce mortality (5), and that the ATS/IDSA Guideline Committee is misleading the readers in mentioning the two individual RCTs of large sample size showing an absolute mortality reduction of 8% under the heading of oral decontamination. These two RCTs evaluated oral and gut decontamination using enteral and parenteral antimicrobials, which is quite different from only oropharyngeal decontamination. Those two RCTs were included in the most recent meta-analysis of 36 RCTs of selective decontamination of the digestive tract (SDD) showing a significant relative mortality reduction of 22% (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.68–0.89) (6). Unfortunately, the committee did not mention this meta-analysis, while meta-analyses were commonly included in the guidelines for other maneuvers.

A proper resistance analysis should distinguish multiresistant AGNB, methicillin-resistant Staphylococcus aureus (MRSA), from vancomycin-resistant enterococci (VRE). In a Parisian intensive care unit (ICU) with high endemic levels of Klebsiella pneumoniae producing extended spectrum {beta}-lactamase (ESBL), SDD cleared the resistant outbreak strain in a randomized design (7). Similarly, 5 years of SDD in an Innsbruck ICU rendered the unit free from multiresistant AGNB (8). In an observational study in a Manchester unit with endemicity of ESBL-producing Klebsiella, SDD given to all patients cleared the outbreak strain within 3 months (9). Therefore, SDD did not increase the AGNB resistance problem but solved the problem of endemicity of multiresistant AGNB.

Fair enough. SDD, by design, is not active against MRSA, and seven SDD RCTs undertaken in units with MRSA endemicity show a trend toward a higher MRSA infection rate (10–16). Under these circumstances, enteral vancomycin must be added to the classical polymyxin/tobramycin/amphotericin B (PTA) protocol (17). Two American RCTs evaluated PTA in an ICU setting with VRE endemicity, and reported the same carriage and infection rates in both groups (18, 19). Eight RCTs assessed SDD, including enteral vancomycin, and VRE problems did not emerge (17, 20–26). Three ecology studies demonstrated that the introduction of new potent antimicrobials, such as piperacillin/tazobactam, which disregard the ICU patient's normal flora, promoted VRE, while enteral vancomycin, given to treat Clostridium difficile in a VRE environment, did not promote VRE (27–29). Antimicrobial resistance, being a long-term issue, has been evaluated in eight SDD studies: bacterial resistance associated with SDD has not been a clinical problem (30–37). The recommendation of the ATS/IDSA Guideline Committee that routine SDD should be discouraged because of resistance is expert opinion and not supported by evidence.

Luciano Silvestri

Presidio Ospedaliero di Gorizia, Gorizia, Italy

Hendrick K. F. van Saene

University of Liverpool, Liverpool, United Kingdom

Miguel A. de la Cal

Hospital Universitario de Getafe, Getafe, Madrid, Spain

Antonino Gullo

Cattinara University Hospital, Trieste, Italy

FOOTNOTES

Conflict of Interest Statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

  1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and health care–associated pneumonia. Am J Respir Crit Care Med 2005;171:388–416.[Free Full Text]
  2. Johanson WG Jr, Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract. Ann Intern Med 1972;77:701–706.[Abstract/Free Full Text]
  3. DeRiso AJ II, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest 1996;109:1556–1561.[Abstract/Free Full Text]
  4. Macnaughton PD, Bailey J, Donlin N, Branfield P, Williams A, Rowswell H. A randomized controlled trial assessing the efficacy of oral chlorhexidine in ventilated patients. Intensive Care Med 2004;30(Suppl 1): S12.
  5. de Jonghe E. Effects of selective decontamination of the digestive tract on mortality and antibiotic resistance in the intensive care unit. Curr Opin Crit Care 2005;11:144–149.[CrossRef][Medline]
  6. Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care [Cochrane Review]. In: The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons; 2004.
  7. Brun-Buisson C, Legrand P, Rauss A, Richard C, Montravers F, Besbes M, Meakins JL, Soussy CJ, Lemaire F. Intestinal decontamination for control of nosocomial multi-resistant gram-negative bacilli. Ann Intern Med 1989;110:873–881.[Abstract/Free Full Text]
  8. Lingnau W, Berger J, Javorsky F, Fille M, Allenberger F, Benzer H. Changing bacterial ecology during a five year period of selective intestinal decontamination. J Hosp Infect 1998;39:195–206.[CrossRef][Medline]
  9. Taylor ME, Oppenheim BA. Selective decontamination of the gastro-intestinal tract as an infection control measure. J Hosp Infect 1991;17: 271–278.[CrossRef][Medline]
  10. Ferrer M, Torres A, Gonzalez J. Puig de la Bellacasa J, El-Ebiary M. Roca M, Gatell JM, Rodriguez-Roisin R. Utility of selective digestive decontamination in mechanically ventilated patients. Ann Intern Med 1994;120:389–395.[Abstract/Free Full Text]
  11. Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S, for the French Study Group on Selective Decontamination of the Digestive Tract. A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. N Engl J Med 1992;326:594–599.[Abstract]
  12. Hammond JMJ, Potgieter PD, Saunders GL, Forder AA. Double-blind study of selective decontamination of the digestive tract in intensive care. Lancet 1992;340:5–9.[CrossRef][Medline]
  13. Lingnau W, Berger J, Javorsky F, Lejeune Ph, Mutz N, Benzer H. Selective intestinal decontamination in multiple trauma patients: prospective, controlled trial. J Trauma 1997;42:687–694.[Medline]
  14. Verwaest Ch, Verhaegen J, Ferdinande P, Schetz M, van den Berge G, Verbist L, Lauwers P. Randomised, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit Care Med 1997;25:63–71.[CrossRef][Medline]
  15. Wiener J, Itokazu G, Nathan C, Kabins SA, Weinstein RA. A randomized, double-blind, placebo-controlled trial of selective digestive decontamination in a medical-surgical intensive care unit. Clin Infect Dis 1995;20:861–867.[Medline]
  16. de la Cal MA, Cerda E, Garcia-Hierro P, van Saene HKF, Gomez-Santos D, Negro E, Lorente JA. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomised, placebo-controlled, double-blind trial. Ann Surg 2005;241:424–430.[CrossRef][Medline]
  17. Silvestri L, van Saene HKF, Milanese M, Fontana F, Gregori D, Oblach L, Piacente N, Blazic M. Prevention of MRSA pneumonia by oral vancomycin decontamination: a randomised trial. Eur Respir J 2004;23:921–926.[Abstract/Free Full Text]
  18. Arnow PM, Carandang GR, Zabner R, Irwin ME. Randomised controlled trial of selective bowel decontamination for prevention of infections following liver transplantation. Clin Infect Dis 1996;22:997–1003.[Medline]
  19. Hellinger WC, Yao JD, Alvarez S, Blair JE, Cawley JJ, Paya CV, O'Brien PC, Spivey JR, Dickson RC, Harnois DM, et al. A randomised, prospective, double-blind evaluation of selective bowel decontamination in liver transplantation. Transplantation 2002;73:1904–1909.[CrossRef][Medline]
  20. Bergmans DCJJ, Bonten MJM, Gaillard CA, Paling JC, van der Geest S, van Tiel FH, Beysens AJ, de Leeuw PW, Stobberingh EE. Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study. Am J Respir Crit Care Med 2001;164:382–388.[Abstract/Free Full Text]
  21. Gaussorges Ph, Salord F, Sirodot M, Tigaud S, Cagnin S, Gerard M, Robert D. Nosocomial bacteremia in patients under mechanical ventilation and receiving beta-inotropic drugs: efficacy of digestive decontamination. Réanimation Soins Intensifs et Medicine Urgences 1991;7:169–174.
  22. Korinek AM, Laisne MJ, Nicolas MH, Raskine L, Deroin V, Sanson-Lepors MJ. Selective decontamination of the digestive tract in neuro-surgical intensive care unit patients: a double-blind, randomized, placebo-controlled study. Crit Care Med 1993;21:1466–1473.[Medline]
  23. Krueger WA, Lenhart F-P, Neeser G, Ruckdeschel G, Schreckhase H, Eissner H-J, Forst H, Eckart J, Peter K, Unertl KE. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients. A prospective, stratified, randomized, double-blind, placebo-controlled clinical trial. Am J Respir Crit Care Med 2002;166: 1029–1037.[Abstract/Free Full Text]
  24. Pugin J, Auckenthaler R, Lew DP, Suter PM. Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia. A randomized, placebo-controlled, double-blind clinical trial. JAMA 1991;265:2704–2710.[Abstract/Free Full Text]
  25. Schardey HM, Joosten U, Finke U, Staubach KH, Schauer R, Heiss A, Kooistra A, Rau HG, Nibler R, Ludeling S, et al. The prevention of anastomotic leakage after total gastrectomy with local decontamination: a prospective, randomized, double-blind, placebo-controlled multicenter trial. Ann Surg 1997;225:172–180.[CrossRef][Medline]
  26. Sanchez M, Mir N, Canton R, Lugue R, Lopez B, Baguero F. The effect of topical vancomycin on acquisition, carriage and infection with methicillin-resistant Staphylococcus aureus in critically ill patients: a double-blind, randomized, placebo-controlled study. 37th ICAAC; 1997; Toronto, Canada. Abstract J-119, p. 310.
  27. Stiefel U, Pultz NJ, Harmoinen J, Koski P, Lindevall K, Helfand MS, Donskey CJ. Oral administration of {beta}-lactamase preserves colonisation resistance of piperacillin-treated mice. J Infect Dis 2003;188:1605–1609.[CrossRef][Medline]
  28. Stiefel U, Paterson DL, Pultz NJ, Gordon SM, Aron DC, Donskey CJ. Effect of the increasing use of piperacillin/tazobactam on the incidence of vancomycin-resistant-enterococci in four academic medical centers. Infect Control Hosp Epidemiol 2004;25:380–383.[CrossRef][Medline]
  29. Salgado CD, Giannetta ET, Farr BM. Failure to develop vancomycin-resistant Enterococcus with oral vancomycin treatment of Clostridium difficile. Infect Control Hosp Epidemiol 2004;25:413–417.[CrossRef][Medline]
  30. Hammond JMJ, Potgieter PD. Long-term effects of selective decontamination on antimicrobial resistance. Crit Care Med 1995;23:637–645.[CrossRef][Medline]
  31. Stoutenbeek CP, van Saene HKF, Zandstra DF. The effect of oral non-absorbable antibiotics on the emergence of resistant bacteria in patients in an intensive care unit. J Antimicrob Chemother 1987;19: 513–520.[Abstract/Free Full Text]
  32. Lingnau W, Berger J, Javorsky F, Fille M, Allenberger F, Benzer H. Changing bacterial ecology during a five year period of selective intestinal decontamination. J Hosp Infect 1998;39:195–206.[CrossRef][Medline]
  33. Sarginson RE, Taylor N, Reilly N, Baines PB, van Saene HKF. Infection in prolonged pediatric critical illness. A prospective four-year study based on knowledge of the carrier state. Crit Care Med 2004;32:839–847.[CrossRef][Medline]
  34. Leone M, Albanese J, Antonini F, Nguyen-Michel A, Martin C. Long-term (6 year) effect of selective digestive decontamination on antimicrobial resistance in intensive care, multitrauma patients. Crit Care Med 2003;31:2090–2095.[Medline]
  35. de la Cal MA, Cerda E, van Saene HKF, Garcia-Hierro P, Negro E, Parra ML, Arias S, Ballestreros D. Effectiveness and safety of enteral vancomycin to control endemicity of methicillin-resistant Staphylococcus aureus in a medical/surgical intensive care unit. J Hosp Infect 2004;56:175–183.[CrossRef][Medline]
  36. Tetteroo GWM, Wagenvoort JHT, Bruining HA. Bacteriology of selective decontamination: efficacy and rebound colonization. J Antimicrob Chemother 1994;34:139–148.[Abstract/Free Full Text]
  37. Abella A, de la Cal MA, Cerda E, Lopez L, Alia I, Garcia-Hierro P, Aranguren A. Control of MRSA endemicity with enteral vancomycin in a burn intensive care unit. Intensive Care Med 2004;30(Suppl 1):S145.



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L. Silvestri, H. K.F. van Saene, R. E. Sarginson, and A. Gullo
Selective Decontamination of the Digestive Tract and Ventilator-Associated Pneumonia: We Cannot Let Misinformation Go Uncorrected
J Intensive Care Med, May 1, 2007; 22(3): 181 - 182.
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