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Observational Study
. 2018 Sep 29;22(1):243.
doi: 10.1186/s13054-018-2170-2.

Carriage of antibiotic-resistant Gram-negative bacteria after discontinuation of selective decontamination of the digestive tract (SDD) or selective oropharyngeal decontamination (SOD)

E de Jonge  1 , R B P de Wilde  2 , N P Juffermans  3 , E A N Oostdijk  4 , A T Bernards  5 , E H R van Essen  2 , E J Kuijper  5 , C E Visser  6 , J Kesecioglu  7 , M J M Bonten  4
Affiliations
Observational Study

Carriage of antibiotic-resistant Gram-negative bacteria after discontinuation of selective decontamination of the digestive tract (SDD) or selective oropharyngeal decontamination (SOD)

E de Jonge et al. Crit Care. .

Abstract

Background: Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) reduce colonization with antibiotic-resistant Gram-negative bacteria (ARGNB), incidence of nosocomial infections and improve survival in ICU patients. The effect on bacterial gut colonization might be caused by growth suppression by antibiotics during SDD/SOD. We investigated intestinal colonization with ARGNB after discharge from ICU and discontinuation of SDD or SOD.

Methods: We performed a prospective, observational follow-up study in regular hospital wards of three teaching hospitals in the Netherlands in patients discharged from the ICU, who were participating in a cluster randomized trial comparing SDD with SOD. We determined rectal carriage with ARGNB at ICU discharge (time (T) = 0) and 3, 6 and 10 days after discharge. The primary endpoint was time to first colonization with ARGNB that was not present at T = 0. Bacteria that are intrinsically resistant to antibiotics were not included in the primary analysis, but were included in post-hoc analysis.

Results: Of 1370 patients screened for inclusion, 996 patients had samples at T = 0 (507 after SDD and 489 after SOD). At ICU discharge, the prevalence of intestinal carriage with any ARGNB was 22/507 (4.3%) after SDD and 87/489 (17.8%) after SOD (p < 0.0001): 426 (SDD) and 409 (SOD) patients had at least one follow-up sample for analysis. The hazard rate for acquiring carriage of ARGNB after discontinuation of SDD, compared to SOD, in the ICU was 0.61 (95% CI 0.40-0.91, p = 0.02), and cumulative risks of acquisition of at least one ARGNB until day 10 were 13% (SDD) and 18% (SOD). At day 10 after ICU discharge, the prevalence of intestinal carriage with ARGNB was 11.3% (26/230 patients) after SDD and 12.5% (28/224 patients) after SOD (p = 0.7). In post-hoc analysis of all ARGNB, including intrinsically resistant bacteria, colonization at ICU discharge was lower after SDD (4.9 vs. 22.3%, p < 0.0001), but acquisition rates after ICU discharge were similar in both groups.

Conclusions: Intestinal carriage at ICU discharge and the acquisition rate of ARGNB after ICU discharge are lower after SDD than after SOD. The prevalence of intestinal carriage with ARGNB at 10 days after ICU discharge was comparable in both groups, suggesting rapid clearance of ARGNB from the gut after ICU discharge.

Trial registration: Netherlands Trial Registry, NTR3311 . Registered on 28 february 2012.

Keywords: Antibiotic resistance; Decolonization; Gram-negative bacteria; Intensive care; Selective digestive tract decontamination; Selective oropharyngeal decontamination.

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Conflict of interest statement

Ethics approval and consent to participate

Ethical approval was granted by the Medical Ethical Committee of the Leiden University Medical Center (CME-V006). The need for informed consent was waived in view of the observational character of the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Trial profile. SDD, selective decontamination of the digestive tract; SOD, selective oropharyngeal decontamination
Fig. 2
Fig. 2
Time to first colonization with any Gram-negative bacteria resistant to tobramycin, ceftazidime, ciprofloxacin, meropenem or colistin in patients who were not already colonized with that specific resistant Gram-negative bacteria at time of ICU discharge. Bacteria that are intrinsically resistant to the antibiotics are excluded. Analysis after adjustment for individual ICU. p = 0.02 by Cox regression analysis for the difference between patients treated with selective decontamination of the digestive tract (dashed line; n = 426) or selective oropharyngeal decontamination (solid line; n = 409)
Fig. 3
Fig. 3
Additional analysis on all antibiotic-resistant Gram-negative bacteria (ARGNB), including intrinsically resistant bacteria. Time to first colonization with any Gram-negative bacteria resistant to tobramycin, ceftazidime, ciprofloxacin, meropenem or colistin in patients who were not already colonized with that specific resistant Gram-negative bacteria at time of ICU discharge. Analysis after adjustment for individual ICU. p = 0.16 by Cox regression analysis for the difference between patients treated with selective decontamination of the digestive tract (dashed line; n = 426) or selective oropharyngeal decontamination (solid line; n = 409)
See this image and copyright information in PMC

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