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Decontamination of the digestive tract and oropharynx in ICU patients - 10/2/2009

N Engl J Med 2009; 360: 20-31


Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) have been used to prevent infection in the treatment of some patients in intensive care, although conflicting effects on patient outcome have been reported.


The authors evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomisation in 13 intensive care units (ICUs) in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible for inclusion. In each ICU, three regimens (SDD, SOD and standard care) were implemented in random order over the course of 6 months. The primary end point was mortality at day 28. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyse antibiotic resistance.


A total of 5939 patients were enrolled in the study; 1990 were assigned to standard care, 1904 to SOD and 2045 to SDD. Crude mortality in the groups at day 28 was 27.5%, 26.6% and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively.


In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD.

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