© 2006 American Thoracic Society
From the Authors:Silvestri and coworkers raise concern over the prevention section on "modulation of colonization" in the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) guidelines for the management of adults with hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health care–associated pneumonia (HCAP) (1). The primary goal of the guidelines was to focus on diagnosis and treatment. The section on "modifiable risk factors" was added to underscore the importance of prevention, but not to overlap with the recently published detailed recommendations contained in the 2004 Guidelines for Preventing Health Care–associated Pneumonia published by the Centers for Disease Control and Hospital Infection Control Practices Advisory Committee (2) and by Kollef (3). Modulation of colonization and particularly the use of selective decontamination of the digestive tract (SDD) is a complicated and controversial topic that has been studied in over 50 controlled trials, analyzed in at least 10 meta-analyses, and been the subject of many reviews and chapters. "Modulation of colonization" using oral and/or gastrointestinal topical antimicrobials, with and without concomitant systemic antibiotics, was briefly described in the ATS/IDSA guidelines (1). In contrast to the interpretations and comments by Silvestri and colleagues, the ATS/IDSA guidelines clearly stated that that SDD (and not oral decontamination) effectively reduced the frequency of HAP and cited two large, recent, prospective, randomized trials of SDD, where there was a reduction in pneumonia frequency and a mortality benefit (4, 5). The objective of the ATS/IDSA guidelines was to put in perspective some of the risks, benefits, questions, and concerns that remain about SDD as a prevention strategy. In addition, we attempted to emphasize that the risks and benefits of strategies like SDD to modulate colonization with combinations of antibiotics should be put in perspective with other effective prevention strategies. There were also concerns about the impact of increased antibiotic use on antimicrobial resistance and long-term patient outcomes. Finally, the use of short-term SDD to control specific multidrug-resistant pathogens, as discussed in Brun-Buisson and coworkers' and Taylor and Oppenheim's articles cited by Silvestri and coworkers (References 7 and 9 in their letter), is very different from the constant use of SDD for all patients over a prolonged period of time. We believe the recommendations in the ATS/IDSA guidelines were accurate and supported by the evidence available at that time. The guidelines required review by committee members, peer review, and the approval of both governing boards before they were submitted for publication in December 2004. We appreciate the more recent references cited by Silvestri and coworkers. Unfortunately, the randomized trial of oral chlorhexidine by MacNaughton and colleagues (Reference 4 in their letter) was published in a supplement to Intensive Care Medicine in September 2004 after the draft of the ATS/IDSA guidelines had been submitted for review, and the references by Kallet and coworkers (6), Silvestri and coworkers (Reference 17 in their letter), and Liberati (the Cochrane Review, Reference 6 in their letter) were also published in 2005 after the ATS/IDSA guidelines were in press. It has been 9 years between the publication of the 2005 ATS/IDSA guidelines and the initial ATS nosocomial pneumonia guidelines in 1996, a period that has seen major changes in the management of this disease, which underscores the dynamic nature of pneumonia management and the need for better methods to update guidelines and recommendations as new data become available.
Winthrop University Hospital, Mineola, New York and State University of New York at Stony Brook, Stony Brook, New York
Lahey Clinic Medical Center, Burlington, Massachusetts and Tufts University School of Medicine, Boston, Massachusetts FOOTNOTES Conflict of Interest Statement: Conflict of Interest Statement: Neither of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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