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Creative strategies are needed to reduce infection and mortality rates among ICU patients, which are unacceptably high. Because of methodological issues with previous studies and concern about selection of antibiotic-resistant organisms, the routine use of two such strategies — selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) — remains controversial, and neither approach is recommended in international guidelines. Now, in a multicenter crossover trial using cluster randomization, researchers have investigated the effect of SDD and SOD on mortality. The 13 participating ICUs, all in the Netherlands, varied in size and teaching status.
Three regimens (SDD, SOD, and standard care) were administered to all eligible patients over the course of 6 months. SOD involved oropharyngeal application of tobramycin, colistin, and amphotericin B; SDD involved topical application of the same antibiotics in the oropharynx and stomach, plus intravenous cefotaxime. Approximately 2000 patients were enrolled in each of the three trial arms.
In a random-effects logistic-regression model with pertinent factors used as covariates, the odds ratios for death during the first 28 days were 0.83 (95% confidence interval, 0.72–0.97) and 0.86 (95% CI, 0.74–0.99) for the SDD and SOD groups, respectively, compared with the standard-care group. Absolute reductions in mortality rates at day 28 were 3.5% for the SDD group and 2.9% for the SOD group, compared with 27.5% for the standard-care group.
de Smet AMGA et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 2009 Jan 1; 360:20.
Comment
The effectiveness of selective decontamination demonstrated in this superb trial is tempered by concern for the likelihood of enhanced resistance among ICU pathogens to the agents used for SDD and SOD. Because SDD’s effect on mortality was similar to SOD’s, and the SDD regimen included intravenous cefotaxime, SOD seems preferable. A fourth arm in the trial — SOD using antiseptic agents, as mentioned by the investigators — would have been ideal.