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Utility of Selective Digestive Decontamination in Mechanically Ventilated Patients

Miquel Ferrer, MD; Antoni Torres, MD; Julia Gonzalez, MD; Jorge Puig de la Bellacasa, MD; Mustafa El-Ebiary, MD; Merce Roca, PhD; Josep M. Gatell, MD; and Robert Rodriguez-Roisin, MD
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From Hospital Clnic, Universitat de Barcelona, Barcelona, Spain. Requests for Reprints: Antoni Torres, MD, Servei de Pneumologa, Hospital Clnic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain. Acknowledgments: The authors thank the nursing staff of the respiratory intensive care unit of Hospital Clnic of Barcelona for their technical support. Grant Support: In part by grant Hospital Clnic-1991 (Dr. Ferrer was a 1991 Postdoctoral Research Fellow of Hospital Clnic), a grant from the Beques de Formacio d'Investigadors del Departament d'Ensenyament de la Generalitat de Catalunya, 1992, and grant Fiss 92/0104.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(5):389-395. doi:10.7326/0003-4819-120-5-199403010-00006
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Objective: To assess selective digestive decontamination for preventing nosocomial pneumonia and mortality in mechanically ventilated patients.

Design: Prospective, randomized, placebo-controlled, double-blind study.

Setting: Respiratory intensive care unit of a 1000-bed teaching hospital.

Patients: 80 patients receiving mechanical ventilation for more than 72 hours.

Interventions: Patients received selective digestive decontamination using polymyxin E, tobramycin, and amphotericin B through a nasogastric tube and also topically in the oropharynx; control patients received placebo. All patients received intravenous cefotaxime for 4 days or other systemic antibiotics if required.

Measurements: Bacteriologic surveillance (three times a week) was done by quantitatively culturing tracheal aspirates, pharyngeal swabs, and gastric juice. The diagnosis of pneumonia was based on quantitative cultures of protected specimen brush samples (≥ 103 CFU/mL [colony forming units/mL]) or bronchoalveolar lavage fluid (≥ 104 CFU/mL) and autopsy findings.

Results: Bronchial, oropharyngeal, and gastric colonization by gram-negative bacilli and Candida species was lower in the selective digestive decontamination group compared with the placebo group. Nonsignificant differences were found in the incidence of nosocomial infections (28% compared with 37%; odds ratio, 0.66; 95% CI, 0.35 to 1.25) and nosocomial pneumonia (18% compared with 24%; odds ratio, 0.7; CI, 0.33 to 1.46) and in the crude mortality rate (31% compared with 27%; odds ratio, 1.21; CI, 0.63 to 2.34) when comparing digestive decontamination with placebo, respectively.

Conclusions: Selective digestive decontamination in our mechanically ventilated patients significantly decreased the colonization rate of gram-negative bacilli and of Candida species but not of Staphylococcus aureus. It did not decrease the incidence of nosocomial pneumonia, mortality, length of stay, or the duration of mechanical ventilation.





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