The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients

Abstract

122 multiple trauma patients staying in the ICU for 5 or more days and needing mechanical ventilation were investigated to determine the effect of selective decontamination of the digestive tract on prevention of infection. The (retrospectively studied) control group of 59 patients received no antibiotic prophylaxis. The infection rate during ICU-stay was 81%. Most infections were caused by potentially pathogenic microorganisms (PPM) from the oral cavity or the intestines (i.e. endogenous infections). The oropharynx and the intestines were rapidly colonised with ICU-associated gram-negative bacilli. After 2 weeks more than 80% of patients were found colonised. This secondary colonisation of the digestive tract is a very important stage in the pathogenesis of infections. Sixty-three patients were selectively decontaminated with nonabsorbable antibiotics, administered through the gastric tube even if peristalsis was absent. Emphasis was laid on the selective decontamination of the oral cavity, using topical application of an antibiotic paste. With this technique the oral cavity was free of PPM within 3 days in most patients. No secondary colonisation was found. Rectal colonisation decreased significantly after 5 days. Secondary colonisation occurred in 9 patients with PPM sensitive to the antibiotics used. The prophylactic regimen included systemic cefotaxim, directed against early endogenous infection. The suppression and after some time the absence of the endogenous source of PPM resulted in a significant reduction of colonisation and infection. The total infection rate decreased to 16%.

Treatment-induced mucositis: an old problem with new remedies

“…Use of antibiotic pastilles was strikingly less effective in the reduction of aerobic Gram-negative bacteria than when the same antibacterials were applied as a gel or a paste to the buccal mucosa in intensive care patients, when aerobic Gram-negative bacteria were reduced drastically within 3-4 days (Stoutenbeek et al, 1984;Ledingham et al, 1988). There seems to be a need for new formulations to allow the protracted delivery of antimicrobials to the oropharynx in patients receiving therapeutic irradiation.…”

The effect of selective decontamination of the digestive tract with the addition of systemic cefotaxime on the aerobic faecal flora of mice

“…The results show that SDD regime described by Stoutenbeek et al (1984) successfully removed potentially pathogenic aerobic gram-negative bacilli from the digestive tract of mice. Subsequent withdrawal of SDD was not associated with any obvious ill effects in the mice.…”

“…In humans, such techniques have been used with some success to reduce infection of endogenous origin in granulocytopoenic patients (Guiot et al 1983;Hargadon et al 1981;Sleijfer et al 1980). Recently, SDD has been applied to patients in an intensive therapy unit (ITU) and has achieved a striking reduction in infection rates (Stoutenbeek et al 1984). This application is currently the subject of a major clinical trial in a Glasgow ITU (S. R. Alcock and I. McA.…”

“…The following questions were asked. Firstly, what is the effect on aerobic intestinal flora of the particular SDD regime employed by Stoutenbeek et al (1984), and what further effects result from the addition of parenteral cefotaxime ? Secondly, how effective is CR in the period after stopping the regime?…”

“…Thirdly, is the translocation of bacteria from the lumen of the intestine to the mesenteric lymph nodes (MLN) and to the spleen affected by the drug regime? In order to investigate these questions, the SDD regime used in humans by Stoutenbeek et al (1984) was simulated as closely as possible in mice.…”