Selective decontamination of the digestive tract prevents secondary infection of the abdominal cavity, and endotoxemia and mortality in sterile peritonitis in laboratory rats.

BACKGROUND AND METHODS: This study was undertaken to find out whether translocation of bacteria to the abdominal cavity and endotoxemia in rats with sterile peritonitis could be prevented by selective decontamination of the digestive tract. Sterile peritonitis was caused by the intraperitoneal injection of either 100, 150, 200, or 300 mg of zymosan suspended in paraffin. RESULTS: The frequency of infection of the abdominal cavity depended on the dose of zymosan given, ranging from 20% in rats receiving 100 mg to 89% in rats receiving 300 mg of zymosan. In rats not receiving antibiotics for selective decontamination of the digestive tract (the control group). Gram-negative bacilli were isolated from the digestive tract in all rats, and Gram-negative bacilli were isolated from the abdominal cavity in ten of 19 rats. In rats receiving antibiotics for selective decontamination of the digestive tract, Gram-negative bacilli were isolated from the digestive tract in none of the 14 rats, and likewise, Gram-negative bacilli were isolated from the abdominal cavity in none of the 14 rats (p < .005). Moreover, in rats receiving antibiotics for selective decontamination of the digestive tract, endotoxin levels in feces and plasma were significantly lower, as compared with rats not receiving antibiotics for selective decontamination of the digestive tract. CONCLUSION: Selective decontamination of the digestive tract prevents translocation of Gram-negative bacilli to the abdominal cavity, and endotoxemia and mortality in rats with sterile peritonitis.     

Selective decontamination of the digestive tract improves survival in patients receiving differential lung ventilation

In a review of the literature on differential lung ventilation (DLV) the average mortality was found to be 47%. The major cause of death (66%) was infection. The effect of a novel infection prevention regimen on the colonisation and infection rate of the respiratory tract and on outcome was studied in polytrauma patients. Nineteen patients who presented with asymmetric pulmonary contusion were treated with DLV (103±72 h) and conventional mechanical ventilation (CMV) (16±10 days). They were treated with selective decontamination of the digestive tract with topical non-absorbable antibiotics in combination with systemic antibiotic prophylaxis starting immediately after admission. In one patient colonisation of the respiratory tract was found with Staphylococcus aureus. This disappeared after continued systemic antibiotic prophylaxis. Colonisation with hospital-acquired Gram-negative bacteria or yeasts was not observed. No patient developed pneumonia throughout the period on conventional mechanical ventilation or on DLV. One patient died from cerebral injury. It is concluded that prolonged endobronchial intubation for DLV can be used without increased risk for pneumonia with this antibiotic regimen and that the very low mortality in this study may be attributed to the prevention of infectious complications.     

Prevention of pneumonia by selective decontamination of the digestive tract (SDD)

Prevention of respiratory tract infections is only possible when the pathogenesis is known. Three types of infection can be distinguished: primary endogenous infections, caused by pathogens carried in the throat at the commencement of mechanical ventilation, generally develop early and can only be prevented by intravenous antibiotics. Secondary endogeneous infections, caused by hospital-acquired pathogens, generally develop later and can be prevented by selective decontamination of the digestive tract (SDD). The GI-tract is decontaminated by oral nonabsorbable antibiotics and for oropharyngeal decontamination a sticky antibiotic ointment is used. To date 16 controlled SDD trials in intensive care have been fully published. In all except one study, the pneumonia rate decreased significantly from 40%–50% in controls to about 10% in SDD-treated patients. All studies showed a consistent reduction of ventilator days, ICU-stay and an improved outcome in SDD-treated patients. However, in only few studies did these differences reach statistical significance. Seclection of resistant strains has not been observed during prolonged use of SDD. Sucralfate reduces the pneumonia rate compared to H₂-blockers or antacids by not interfering with the gastric barrier. However, gastric colonization is reduced rather than eliminated and sucralfate has almost no effect on oropharyngeal or tracheal colonization. Whether sucralfate is significantly better than a placebo remains to be established. SDD is superior to sucralfate in preventing both colonization and infection.     

Prevention of pneumonia by selective decontamination of the digestive tract (SDD)

Prevention of respiratory tract infections is only possible when the pathogenesis is known. Three types of infection can be distinguished: primary endogenous infections, caused by pathogens carried in the throat at the commencement of mechanical ventilation, generally develop early and can only be prevented by intravenous antibiotics. Secondary endogeneous infections, caused by hospital-acquired pathogens, generally develop later and can be prevented by selective decontamination of the digestive tract (SDD). The GI-tract is decontaminated by oral nonabsorbable antibiotics and for oropharyngeal decontamination a sticky antibiotic ointment is used. To date 16 controlled SDD trials in intensive care have been fully published. In all except one study, the pneumonia rate decreased significantly from 40%–50% in controls to about 10% in SDD-treated patients. All studies showed a consistent reduction of ventilator days, ICU-stay and an improved outcome in SDD-treated patients. However, in only few studies did these differences reach statistical significance. Seclection of resistant strains has not been observed during prolonged use of SDD. Sucralfate reduces the pneumonia rate compared to H₂-blockers or antacids by not interfering with the gastric barrier. However, gastric colonization is reduced rather than eliminated and sucralfate has almost no effect on oropharyngeal or tracheal colonization. Whether sucralfate is significantly better than a placebo remains to be established. SDD is superior to sucralfate in preventing both colonization and infection.     

Selective decontamination of the digestive tract in cardiac surgical patients

OBJECTIVE: To test the hypothesis that selective decontamination of the digestive tract improves outcome in cardiac surgical patients. DESIGN: Prospective, consecutive, controlled trial over two 4-month periods. SETTING: Eight-bed, open-plan postcardiac surgery ICU. PATIENTS: All patients undergoing cardiac bypass surgery were eligible. Patients requiring endotracheal intubation for greater than 4 days were included in the analysis. In the initial 4 months, 12 (8.5%) of 141 patients required greater than 4 days of intubation. These 12 patients were not treated with selective decontamination of the digestive tract. We therefore used these patients as the control group. In the second 4-month period, 12 (6.6%) of 180 patients were treated with selective decontamination of the digestive tract and formed the study group. MAIN OUTCOME MEASURES: The primary measure was mortality. Secondary measures included oropharyngeal decontamination and the presence of lower airway infection. INTERVENTIONS: Cephradine prophylaxis. The study group received every 6 hrs 4 mL orally and 20 mL intragastrically a suspension of antimicrobial agents (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg), starting on postoperative day 1. The control group did not receive any oral antimicrobial agents. RESULTS: Mortality rate was significantly (p less than .05) reduced from eight (66%) of 12 patients in the control group to two (16.7%) of 12 patients in the selective decontamination of the digestive tract group. No differences in oropharyngeal decontamination or lower airway infection rates between the two groups were found. CONCLUSIONS: There is a reduced mortality rate in patients receiving selective decontamination of the digestive tract. However, the reader should recognize the small sample size studied. A simple suspension of the antimicrobial agents failed to rid the oropharynx of bacteria.     

Effects of selective decontamination on gram-negative colonisation,infections and development of bacterial resistance in esophageal resection

Patients undergoing an esophageal resection because of carcinoma are at risk of developing postoperative respiratory tract infections. These patients were studied with respect to preceding colonisation with gram-negative bacilli and the effect of selective decontamination (SD) in decreasing this phenomenon, thereby reducing gram-negative infections. We randomised prospectively 114 patients into a test group receiving SD-medication (n=56) and a control group receiving conventional prophylaxis. Postoperatively, all patients were admitted to the intensive care unit and mechanically ventilated. The preoperative administration of SD-medication resulted in adequate decontamination within 3–4 days in most patients, and SD could prevent gram-negative colonisation and infections effectively. Discontinuation of SD showed gram-negative (re-)colonisation, and resulted in 12 infections in 4 patients having late complications. This indicates that prolonged use in these patients might be beneficial. This new antibiotic prophylaxis proved effective, without causing an increase in bacterial resistance.     

Selective decontamination of the digestive tract to prevent postoperative infection: a randomized placebo-controlled trial in liver transplant patients

OBJECTIVE: To determine the efficacy of selective decontamination of the digestive tract (SDD) in patients undergoing elective transplantation of the liver. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Two academic teaching hospitals. PATIENTS: Adult patients undergoing elective liver transplantation: 26 patients receiving SDD and 29 patients receiving a placebo. INTERVENTIONS: Patients undergoing SDD were administered 400 mg of norfloxacin once daily as soon as they were accepted for transplantation. Postoperative treatment for this group consisted of 2 mg of colistin, 1.8 mg of tobramycin, and 10 mg of amphotericin B, four times daily, combined with an oral paste containing a 2% solution of the same drugs until postoperative day 30. Prophylactic intravenous administration of antibiotics was not part of the SDD regimen in this study. Control patients were given a similar regimen with placebo drugs. MEASUREMENTS: The mean number of postoperative bacterial and fungal infections in the first 30 days after transplantation was the primary efficacy end point. Days on a ventilator, days spent in the intensive care unit, and medical costs were registered as secondary outcome variables. MAIN RESULTS: Of the 26 patients undergoing SDD, 22 (84.5%) developed an infection in the postoperative study period; in the placebo group (n = 29), these numbers were not significantly different (25 patients, 86%). The mean number of postoperative infectious episodes per patient was also not significantly different: 1.77 (SDD) vs. 1.93 (placebo). Infections involving Gram-negative aerobic bacteria and Candida species were significantly less frequent in patients receiving SDD (p <.001 and p <.05). Total costs were higher in the group receiving SDD. CONCLUSIONS: Selective decontamination of the digestive tract does not prevent infection in patients undergoing elective liver transplantation and increases the cost of their care. It does, however, affect the type of infection. Infections with Gram-negative bacilli and with Candida species are replaced by infections with Gram-positive cocci.     

Effects of selective decontamination on gram-negative colonisation, infections and development of bacterial resistance in esophageal resection

Patients undergoing an esophageal resection because of carcinoma are at risk of developing postoperative respiratory tract infections. These patients were studied with respect to preceding colonisation with gram-negative bacilli and the effect of selective decontamination (SD) in decreasing this phenomenon, thereby reducing gram-negative infections. We randomised prospectively 114 patients into a test group receiving SD-medication (n=56) and a control group receiving conventional prophylaxis. Postoperatively, all patients were admitted to the intensive care unit and mechanically ventilated. The preoperative administration of SD-medication resulted in adequate decontamination within 3–4 days in most patients, and SD could prevent gram-negative colonisation and infections effectively. Discontinuation of SD showed gram-negative (re-)colonisation, and resulted in 12 infections in 4 patients having late complications. This indicates that prolonged use in these patients might be beneficial. This new antibiotic prophylaxis proved effective, without causing an increase in bacterial resistance.     

All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth

OBJECTIVE: The objective was to compare evidence of the effectiveness, costs and safety of the traditional parenteral antibiotic-only approach against that gathered from 53 randomised trials involving more than 8,500 patients and six meta-analyses on selective decontamination of the digestive tract (SDD) to control infection on the intensive care unit (ICU). PHILOSOPHY: Traditionalists believe that all infections are due to breaches of hygiene except those established in the first 2 days, and that all micro-organisms can cause death. In contrast, newer insights show that transmission via the hands of carers are responsible only for infections occurring after one week, and that only a limited range of 15 potential pathogens contribute to mortality. INTERVENTIONS TO PREVENT ICU INFECTION: The traditional approach is based on hand disinfection aiming at the prevention of transmission of all micro-organisms, to control all infections that occur after 2 days on the ICU. The second feature is the restrictive use of systemic antibiotics, only in cases of microbiologically proven infection. In contrast, SDD aims to control the three types of infection: primary, secondary endogenous and exogenous due to 15 potential pathogens. The classical SDD tetralogy comprises four components: (i) a parenteral antibiotic, cefotaxime, administered for three days to prevent primary endogenous infections typically occurring "early"; (ii) the oropharyngeal and enteral antimicrobials, polymyxin E, tobramycin and amphotericin B administered in throat and gut throughout the treatment on the ICU to prevent secondary endogenous infections tending to develop "late"; (iii) a high standard of hygiene to control transmission of potential pathogens; and (iv) surveillance samples of throat and rectum to monitor the efficacy of the treatment. ENDPOINTS: (i) Infectious morbidity; (ii) mortality; (iii) antimicrobial resistance; and (iv) costs. RESULTS: Properly designed trials on hand disinfection have never demonstrated a reduction in either pneumonia and septicaemia, or mortality. Two randomised trials using restrictive antibiotic policies failed to show a survival benefit at 28 days. In both trials the proportion of resistant isolates obtained from the lower ways was >60% despite significantly less use of antibiotics in the test group. A formal cost effectiveness analysis of the traditional antibiotic policies has not been performed. On the other hand, two meta-analyses have shown that SDD reduces the odds ratio for lower airway infections to 0.35 (0.29-0.41) and mortality to 0.80 (0.69-0.93), with a 6% overall mortality reduction from 30% to 24%. No increase in the rate of super infections due to resistant bacteria could be demonstrated over a period of 20 years of clinical research. Four randomised trials found the cost per survivor to be substantially lower in patients receiving SDD than for those traditionally managed. CONCLUSIONS: The traditionalists still rely on level 5 evidence, i.e. expert opinion, with a grade E recommendation, whilst the proponents of SDD are able to cite level 1 evidence allowing a grade A recommendation in their attempts to control infection on the ICU. The main reason for SDD not being widely used is the primacy of opinion over evidence.     

Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study

The efficacy of relatively cheap regimen of selective decontamination (SDD) was evaluated in a diverse population of ICU patients. Patients requiring prolonged ICU stay (>5 days) were randomly allocated to a treatment group or control group. Control patients (n=52) received perioperative antimicrobial prophylaxis and antibiotic treatment was instituted only on sound clinical and bacteriological criteria. Treated patients (n=48) received gastro-intestinal and oro-pharyngeal decontamination with polymyxin E, norfloxacin, amphotericin B and systemic antibiotic prophylaxis with trimethoprim until decontamination was achieved. The rate of gram-positive infections was not altered by SDD. The incidence of gram-negative respiratory tract, urinary tract and line infections was significantly reduced from 44%, 27% and 15% respectively in the control group to 6%, 4% and 0% in the treatment group. Mortality from nosocomial sepsis and overall mortality were also significantly reduced from 15% and 54% to 0% and 31% respectively. The ICU stay was not reduced by SDD, nor was time on the ventilator or use of therapeutic antibiotics. The reduction in morbidity and mortality was achieved at a relatively low cost.     

Selective decontamination of the digestive tract in intensive care patients: review and commentary.

OBJECTIVE: To evaluate the benefits, risks, and costs of antimicrobial regimens used for selective decontamination of the digestive tract (SDD) in intensive care unit (ICU) patients. DATA SOURCES: Information was obtained from clinical trials, review articles, abstracts, and textbooks. Key indexing terms included antibiotics, selective decontamination, and infections. STUDY SELECTION: Research articles describing controlled clinical trials of SDD in medical or surgical ICU patients were reviewed. Trials that investigated transplant, cirrhotic, leukemic, or oncology patient populations were excluded. DATA EXTRACTION: The details of studies that evaluated nosocomial infection or nosocomial pneumonia rates were extracted. These included study design, demographics, SDD regimens, severity of illness scores, and colonization, infection, and mortality rates. DATA SYNTHESIS: The use of SDD in mechanically ventilated surgical or trauma ICU patients reduces the incidence of colonization, nosocomial pneumonia, and overall infection rates, but does not change the overall mortality rate. Administration of antibiotic and antifungal agents in a nasogastric suspension is required for SDD. The addition of systemic prophylactic antibiotics or oropharyngeal paste was not required to decrease nosocomial infections. The most frequently studied SDD regimen (colistin/amphotericin B/tobramycin) is not feasible for use in the US because of exorbitant drug costs. Less expensive alternatives include norfloxacin/nystatin, or colistin/nystatin/gentamicin. CONCLUSIONS: Additional research is required before SDD regimens can be routinely recommended in surgical and trauma ICU patients. A multicenter study is warranted to determine the long-range benefits, potential for resistance, and cost-effectiveness of SDD.     

Bacterial translocation of intestinalPseudomonas aeruginosa in post-burn infection of mice

The significance of intestinalPseudomonas aeruginosa as a pathogen of post-burn infection in mice was established. Mice with and withoutP. aeruginosa intestinal colonization were scorched with a deep dermal burn by ethanol flame on the shaven back, involving approximately 25% of the total body surface area. Eight hours later,P. aeruginosa of a serotype similar to that previously administered (per os) was detected in the burn site, liver, and spleen ofP. aeruginosa-treated, but not the control, animals. Within three post-burn days, 33.3% of theP. aeruginosa-treated, burned mice died of infection-derived sepsis, whereas none of the control mice died. In addition, when the orally nonabsorbable antibiotics, polymyxin B (12 mg/kg) and vancomycin (30 mg/kg), were administered by intragastric injection toP. aeruginosa-treated mice immediately after burn exposure, the mortality rate significantly decreased to 16.1±6.1% compared with 35.0±5.0% in similarly colonized, burned mice not given these oral antibiotics (P<0.05). These findings suggest thatP. aeruginosa colonized in the intestinal tract is noxious and can be fatal as a pathogen of post-burn infection. Furthermore, our report suggests that selective digestive decontamination (decontamination of endogenous pathogens in the intestinal tract) is essential in preventing post-burn infection associated with bacterial translocation.     

Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomized controlled trials

Objective To determine the impact of the antifungal component of selective decontamination of the digestive tract on fungal carriage, infection and fungaemia.Design Meta-analysis of randomized controlled trials of selective decontamination of the digestive tractStudy selection Data sources included Medline, Embase, Cochrane Register of Controlled Trials, previous meta-analyses, personal communications and conference proceedings, without restriction of language or publication status. All randomized trials were selected that compared oropharyngeal and/or intestinal administration of antifungals amphotericin B or nystatin, as part of selective decontamination protocol, with no treatment in the controls. There were 42 randomized controlled trials with a total of 6,075 critically ill patients.Methods Three reviewers independently applied selection criteria, performed quality assessment and extracted the data. The main outcome measures were patients with fungal carriage, patients with fungal infections and patients with fungaemia. Odds ratios were pooled with the random effect model.Measurements and results Enteral antifungals significantly reduced fungal carriage (odds ratio 0.32, 95% confidence interval 0.19–0.53) and overall fungal infections (0.30, 0.17–0.53). Fungaemia was not significantly reduced in the treatment group (0.89, 0.16–4.95).Conclusions Antifungals, as part of selective decontamination of the digestive tract, reduce fungal carriage and infection but not fungaemia in critically ill patients and may justify the inclusion of an antifungal component in the decontamination protocol.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at .     

Colonization and infection in surgical intensive care patients —a prospective study

Nosocomial infections are a major problem in intensive care patients. Thirty-nine patients, requiring intensive care for 5 days or more (mean 15.8 days) were prospectively investigated, to determine the relation between colonisation and nosocomial infection. Thrice weekly, cultures from the oropharynx, respiratory and digestive tract were obtained. Colonization with aerobic gram-negative microorganisms of the oropharynx, respiratory and digestive tract significantly increased during the stay in the Intensive Care Unit. In 29 patients (74%) 78 nosocomial infections were diagnosed. The most frequent nosocomial infections were pneumonia (26 patients, 66.6%), catheterrelated bacteraemia (11 patients, 28.2%), and wound infections (7 patients, 17.9%). In 59 instances (75.6%), colonization with the same potential pathogenic microorganism preceeded the nosocomial infection. The overall mortality was 25.6% (10 patients), bacteraemia with aerobic gram-negative microorganisms being the cause of death in 7 patients.     

Antibiotic levels in bronchial tree and in serum during selective digestive decontamination

Selective digestive decontamination has been found to prevent pulmonary infections in mechanically ventilated patients. The aims of this study were: 1) to determine whether detectable levels of antibiotics could be found in bronchial tree secretions of patients receiving SDD, and 2) to evaluate antibiotic serum levels. In 15 patients receiving mechanical ventilation and SDD for 10 days or more, tobramycin and amphotericin B levels were determined every 3 days in the following specimems: tracheal aspirates, distal bronchial secretions and blood samples. 82% of tracheal aspirates contained detectable (>0.18 mg/l), tobramycin concentrations; the levels varied widely between patients and large day-to-day variations were observed. Every patient had at least 1 tracheal aspirate with tobramycin level higher than 0.5 mg/l during his course. 40% of distal specimens contained detectable tobramycin levels (10 patients). Serum determinations showed detectable concentration of tobramycin in 50% of the specimens (9 patients). Two patients with renal failure had serum tobramycin levels higher than 2 mg/l. In 13 tracheal aspirates cultures were positive and 15 species were isolated; 13 had a MIC higher than the corresponding tobramycin level in tracheal secretions. We conclude than substantial levels of antibiotics can be found frequently in respiratory tract specimens of patients receiving SDD. Therefore, the usual microbiological criteria used to assess respiratory tract infection may be unreliable in this setting and other criteria may be required. Follow-up of antibiotic serum levels is required, especially in patients with renal failure.     

重症监护病房中选择性消化道脱污染对院内获得性肺炎的临床价值

目的探讨在重症监护病房（intonsive cane tmit,ICU）行选择性消化道脱污染（selective digestivedecontamination,SDD）的临床实用价值。方法选取2007年1月～2010年1月危重症患者376例,随机分为两组,对照组予常规口腔护理治疗,治疗组予选择性消化道脱污染治疗,比较两组患者病情疗效的参数。结果治疗组院内获得性肺炎发生率为18.4%、院内获得性肺炎发生时间（7.2±3.2）d、人工气道（气管插管/切开）保留天数（10.5±3.8）d、机械通气天数（8.4±3.1）d、入住ICU天数（14.7±4.8）d、病死率11.6%;对照组院内获得性肺炎发生率为30.1%、院内获得性肺炎发生时间（5.6±3.6）d、人工气道（气管插管/切开）保留天数（12.5±4.6）d、机械通气天数（10.2±4.2）d、入住ICU天数（17.2±6.2）d、病死率19.4%;两组比较差异均有统计学意义（P〈0.05）。结论在ICU内行选择性消化道脱污染可有效控制院内获得性肺炎,改善患者病情,减少住院天数,降低病死率。     

Reduction of colonization and infection rate during pediatric intensive care by selective decontamination of the digestive tract

OBJECTIVE: To compare the effects of two different antibiotic regimes on the colonization and infection rates of critically ill pediatric patients. DESIGN: A prospective randomized trial. SETTING: A pediatric ICU in a university hospital. PATIENTS: Fifty critically ill pediatric patients who required intensive care for at least 4 days were randomly allocated to either the selective parenteral and enteral antisepsis regimen (treatment group, n = 25) or the control group (n = 25). INTERVENTIONS: The treatment group received oral nonabsorbable antimicrobial agents (polymyxin E, gentamicin, and amphotericin B) and parenteral cefotaxime, whereas the control group received either perioperative antibiotic prophylaxis or antibiotic therapy according to clinical or microbiological evidence of infection. RESULTS: Both groups were comparable for age, body weight, sex, and severity of illness. Colonization with Gram-negative microorganisms and yeasts in the oropharynx, and digestive and respiratory tracts increased rapidly up to 52% in the control group, whereas there was no colonization with these microorganisms in the treatment group. The occurrence rates of acquired secondary infections in the control and treatment groups were 36% and 8%, respectively (p less than .025). There were no differences between groups in the duration of intensive care or mortality rate. CONCLUSION: Selective oropharyngeal and gastrointestinal decontamination combined with systemic cefotaxime application allows for a significant reduction of the colonization rate with Gram-negative bacteria and yeasts in critically ill pediatric patients undergoing prolonged intensive care. In addition, it significantly reduces the Gram-negative infection rate of the respiratory system. However, this therapeutic approach does not alter ICU length of stay or mortality rate.     

系统性红斑狼疮病人并发真菌感染的观察及护理

[目的]总结系统性红斑狼疮（SLE）病人并发真菌感染的观察及护理。[方法]回顾性分析63例SLE并发真菌感染病人的临床资料。[结果]521例住院SLE病人发生真菌感染6 3例,发生率为12.1%;感染类型主要为白色念珠菌,其次为光滑念珠菌、热带念珠菌及克柔念珠菌等;感染部位以口腔最常见,其次为消化道、肺部、泌尿道及中枢神经系统。[结论]SLE病人易并发真菌感染,且以口腔感染发生率较高,应采取针对性的护理措施。     

Prevention of severe Candida infections in nonneutropenic,high-risk,critically ill patients: a randomized,double-blind,placebo-controlled trial in patients treated by selective digestive decontamination

OBJECTIVE: Infections caused by Candida spp. are a major cause of morbidity and mortality in critically ill patients and usually develop from endogenous colonization. We assessed the effectiveness of adding fluconazole to a selective digestive decontamination regimen to prevent candidal infections. DESIGN AND SETTING: We performed a prospective, randomized, double-blind, placebo-controlled trial among medical and surgical intensive care unit patients at a large university hospital. PATIENTS: All adult patients mechanically ventilated for at least 48 h with an expectation to remain so for at least an additional 72 h, and receiving selective decontamination of the digestive tract. INTERVENTIONS: Patients were randomly assigned fluconazole 100 mg daily (n=103) or placebo (n=101). MEASUREMENTS AND RESULTS: Candida infections occurred less frequently in the fluconazole group (5.8%) than in the placebo group (16%; rate ratio 0.35; Cl(95) 0.11-0.94). Some 90% of candidemia episodes occurred in the placebo group (rate ratio for fluconazole use 0.10; Cl(95) 0.02-0.74). The rate of treatment failure, development of candidal infection, or increased colonization, was 32% in the fluconazole group and 67% in the placebo group (P<0.001). Crude in-hospital mortality was similar in the two groups (39% fluconazole vs. 41% placebo). CONCLUSIONS: Prophylactic use of fluconazole in a selected group of mechanically ventilated patients at high risk for infection reduces the incidence of Candida infections, in particular candidemia.     

Prevention of ventilator-associated pneumonia,mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units

Introduction  

Given the high morbidity and mortality attributable to ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, prevention plays a key role in the management of patients undergoing mechanical ventilation. One of the candidate preventive interventions is the selective decontamination of the digestive or respiratory tract (SDRD) by topical antiseptic or antimicrobial agents. We performed a meta-analysis to investigate the effect of topical digestive or respiratory tract decontamination with antiseptics or antibiotics in the prevention of VAP, of mortality and of all ICU-acquired infections in mechanically ventilated ICU patients.