[Optimizing antibiotics policy in the Netherlands. VI. SWAB advice: no selective decontamination of intensive care patients on mechanical ventilation]

Abstract

The Working Party on Antibiotic Policy (Dutch acronym is SWAB) has issued a guideline in which the pro and cons of the routine use of selective decontamination (SD) in patients in intensive care (IC) on mechanical ventilation are compared in order to decide whether SD is indicated. The effectiveness of SD in IC patients was evaluated in 28 prospective, randomized studies. In most studies a significant reduction in the incidence of pneumonia was demonstrated. The incidence of pneumonia in the control groups varied from 5 to 85%. The reduction in the incidence of pneumonia seems to have no effect on duration of mechanical ventilation and IC unit stay or the use of antibiotics. No effect on IC mortality was demonstrated. However, only major reductions could have been demonstrated with the size of the studies carried out so far. A significant reduction of about 20% was suggested in two meta-analyses. The validity of these meta-analyses is questionable. Based on the data available, it is not possible to reach the conclusion that SD will be cost-effective. The size of the studies is too small and the study duration too short to prove that the use of SD, if applied on a large scale, might not eventually lead to development of resistance. Selection of micro-organisms that are already intrinsically resistant or had already acquired resistance to one of the agents used, has been demonstrated. In the absence of clearly demonstrated advantages (decrease in mortality, reduction in the use of antibiotics, cost-effectiveness), the routine use of SD in IC patients on mechanical ventilation is not recommended.