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PubMed2001

Relationship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients.

CONTEXT: Although meta-analyses of randomized trials have shown that selective digestive decontamination (SDD) prevents nosocomial pneumonia in critically ill patients, the influence of trial quality on the effectiveness of SDD has not been rigorously evaluated. OBJECTIVE: To assess the methodological quality of individual studies of SDD and its relation to the reported effects on pneumonia and mortality. DESIGN: Thirty-two studies were identified in a MEDLINE and reference list search and their methodological quality was assessed using a scoring system (range, 0-13 points) based on allocation and concealment, patient selection, patient characteristics, blinding of the intervention, and the definition of pneumonia. MAIN OUTCOME MEASURE: Methodological quality of the primary trials and its effect on the relative risk reductions (RRRs) of SDD on pneumonia and mortality. RESULTS: The mean (SD) methodological quality score was 7.8 (2.9) (range, 1-11). The RRRs ranged from -0.1 to 1.0 for pneumonia and from -0.1 to 0.6 for mortality. The methodological quality score was associated with the RRR for pneumonia so that for each quality-point added, the RRR decreased by 5.8% (95% confidence interval, 2.4%-9.3%). No association between trial quality and the impact of SDD was found on mortality. Of the individual trial quality characteristics, patient selection, allocation of intervention, and blinding most strongly influenced the treatment effect. CONCLUSIONS: The inverse relationship between methodological quality score and the benefit of SDD on the incidence of pneumonia may have resulted in overly optimistic estimates of SDD in prior meta-analyses. This emphasizes the importance of rigorous trial design in evaluating preventive interventions in the intensive care unit.

Antibiotic Prophylaxis↗
PubMed1999

Decontaminating particles exposed to bacterial endotoxin (LPS).

Lipopolysaccharide (LPS), which comes from the cell wall of gram-negative bacteria, can stimulate murine macrophage cells to produce nitric oxide (NO), cytokines, such as tumor necrosis factor-alpha, and interleukins, such as IL-6. When examining the biological effects of particles on macrophages, it is important to have no contaminating LPS associated with the particles and none with any cell culture media or supplies since even very low levels of LPS are stimulatory. The presence or absence of LPS was observed in two ways: (1) the amount of NO produced by RAW 264.7 murine macrophage cells, and (2) the Limulus amebocyte lysate (LAL) test. Treating particles with 70% ethanol at room temperature for 48 h, followed by washing the polymethylmethacrylate (PMMA) particles with endotoxin-free phosphate-buffered saline three times, decontaminated LPS and LPS-treated PMMA particles. When given LPS that had been treated with 70% ethanol for 48 h at room temperature or at 37 degrees C, cells did not produce NO above control levels. Negative LAL tests indicated the presence of extremely low levels or the complete absence of LPS in 70% ethanol-treated LPS.

Animals↗
PubMed2005

Effects on instruments of the World Health Organization--recommended protocols for decontamination after possible exposure to transmissible spongiform encephalopathy-contaminated tissue.

It has been recommended by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) that rigorous decontamination protocols be used on surgical instruments that have been exposed to tissue possibly contaminated with Creutzfeldt-Jakob disease (CJD). This study was designed to examine the effects of these protocols on various types of surgical instruments. The most important conclusions are: (1) autoclaving in 1N NaOH will cause darkening of some instruments; (2) soaking in 1N NaOH at room temperature damages carbon steel but not stainless steel or titanium; (3) soaking in chlorine bleach will badly corrode gold-plated instruments and will damage some, but not all, stainless-steel instruments, especially welded and soldered joints. Damage became apparent after the first exposure and therefore long tests are not necessary to establish which instruments will be damaged.

Animals↗
PubMed2004

The role of selective digestive decontamination for reducing infection in patients undergoing liver transplantation: a systematic review and meta-analysis.

Selective digestive decontamination (SDD) refers to the use of antimicrobials to reduce the burden of aerobic gram-negative bacteria and/or yeast in the intestinal tract to prevent infections caused by these organisms. Liver transplant patients are highly vulnerable to bacterial infection particularly with gram-negative organisms within the first month after transplantation, and SDD has been proposed as a potential measure to prevent these infections. However, the benefit of this procedure remains controversial. We undertook a systematic review and meta-analysis to determine whether SDD is beneficial in reducing infections overall and those caused by gram-negative bacteria in patients following liver transplantation. All studies that evaluated the efficacy of SDD in liver transplant patients were included. Randomized trials that included liver transplant patients given SDD versus either placebo or no treatment or minimal treatment (e.g., oral nystatin alone), and that provided adequate data to calculate a relative risk ratio, were included in the meta-analysis. Our review shows that most studies found SDD to be effective in reducing gram-negative infection. The nonrandomized and uncontrolled trials also showed benefit with SDD in reducing overall infection; however, the effect on overall infection was limited in the 4 randomized trials, in which the pooled relative risk was 0.88 (95% CI, 0.7-1.1), indicating no statistically significant reduction in infection with the use of SDD. The summary risk ratio for the association between SDD and gram-negative infection was 0.16 (95% CI, 0.07-0.37), indicating an 84% relative risk reduction in the incidence of infection caused by gram-negative bacteria in patients receiving SDD in randomized trials. In conclusion, the available literature supports a beneficial effect of SDD on gram-negative infection following liver transplantation; however, the risk of antimicrobial resistance must be considered. Larger multicenter randomized trials in this patient population to assess the effect of SDD in reducing infection and mortality, while assessing the risk of antimicrobial resistance, are needed.

Bacterial Infections↗
PubMed2000

A battery of toxicity tests as indicators of decontamination in composting oily waste.

Heterogeneous oily waste from an old dumping site was composted in three windrows constructed from different proportions of waste, sewage sludge, and bark. The objectives of this pilot study were to examine the usefulness of composting as a treatment method for this particular waste and to study decontamination in the composting process by using a battery of toxicity tests. Five samples from the windrow having intermediate oil concentrations were tested with toxicity tests based on microbes (Pseudomonas putida growth inhibition test, ToxiChromotest, MetPLATE, and three different modifications of a luminescent bacterial test), enzyme inhibition (reverse electron transport), plants (duckweed growth inhibition and red clover seed germination), and soil animals (Folsomia candida, Enchytraeus albidus, and Enchytraeus sp.). The luminescent bacterial tests were used as prescreening tests. Chemical analyses of samples were carried out simultaneously. Both toxicity and oil concentration, including those of polyaromatic hydrocarbons (PAHs), were reduced during composting and soil quality improved significantly. The total oil hydrocarbon concentration decreased from 90,000 to 19,000 mg/kg, measured with the IR method, in 4 months, and from 86,000 to 1400 mg/kg, measured with GC method. The concentration of PAHs decreased from 135 to 23.5 mg/kg. During the fourth month of composting (stabilization stage), the proportion of the heaviest oil fractions (asphaltenes) became dominant. Toxicity varied between different samples and between different bioassays; however, the first sample was significantly more toxic than the others, and most of the tests revealed a decrease in toxicity during the composting process.

Animals↗
PubMed1995

Decontamination procedures after in vitro topical exposure of human and rat skin to 4,4'-methylenebis[2-chloroaniline] and 4,4'-methylenedianiline.

4,4'-Methylenebis[2-chloroaniline] (MbOCA) and 4,4'-methylenedianiline (MDA) are widely used industrial chemicals classified as suspect human carcinogens. There is considerable occupational skin exposure to these compounds, and consequently, it is important to establish an efficient washing procedure after skin contamination. Four washing solutions were studied (100% ethanol, 100% water, 1 and 10% (v/v) aqueous soap) using fresh human and male F344 rat skin in flow-through diffusion cells. All solutions were equally effective at removing MbOCA and MDA from the surface of human skin, with 21-47% of the applied dose removed at 72 hr. In contrast, with rat skin 100% water and 1% soap solution were significantly less (p < 0.05) effective than 10% soap solution and 100% ethanol at removing MbOCA and MDA. Washing the skin surface at 3 or 30 min significantly reduced (p < 0.05) the absorption of MbOCA and MDA into and through human and rat skin at 72 hr by two- to threefold, compared with control unwashed skin. Washing the skin after this critical time point did not significantly reduce the absorption. These studies suggest that MbOCA and MDA are rapidly absorbed from the skin surface into the skin. Therefore, in order to reduce systemic exposure, the skin must be washed within the first 30 min after contamination has occurred. For human skin, the choice of washing solution employed was not as critical as the time of washing. This is in contrast to the rat, where the higher concentration soap and ethanol solutions were more effective for skin decontamination.

Administration, Topical↗
PubMed1995

Parenteral antibiotics and selective intestinal decontamination do not prevent enteric bacterial overgrowth or translocation observed in a swine model of small bowel transplantation.

Alterations in the luminal microflora and increased intestinal translocation have been reported to occur following experimental and clinical small bowel transplantation (SBT). Selective intestinal decontamination (SID) has been used to prevent luminal overgrowth and bacterial translocation. Despite the wide use of SID in clinical SBT, there are no data supporting its usefulness in this situation. Thus, the aim of this investigation was to examine the effects of cyclosporine A (CsA) and SID upon bacterial overgrowth and translocation in a swine model of SBT. Nineteen Large White female pigs weighing 30 +/- 2 kg underwent a total orthotopic SBT and were randomly allocated to one of the following experimental groups as follows: Group 1 (No. 8) CSA 25 mg/kg body weight (b.w.)/day administered subcutaneously and Cefazolin 2 g/day im. Group 2 (No. 6) received the identical immunosuppression but the Cefazolin 2 g/day im was discontinued on the 5th Postoperative Day (pod) and switched to a SID regimen consisting of Vancomycin, 1 g, Nystatin, 500,000 IU, Colistin, 1,500,000 IU, and Tobramycin, 100 mg, given through a gastrostomy tube. Group 3 (No. 5) received no immunosuppression but antibiotic consisting of Cefazolin 2 g im/day. Group 4 (No. 7) underwent a small bowel autotransplantation. Group 4 received SID as in group 2 but no immunosuppression was given. Finally, 17 normal animals were sham-operated and were used as normal controls (N group). The animals in groups 1, 2, and 4 were sacrificed on the 29th pod. Those in group 3 were sacrificed on the 7th pod.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMedDate not supplied

Selective decontamination of the colon before elective colorectal surgery. West of Scotland Surgical Infection Study Group.

The controversy over the route of administration of antibiotic prophylaxis in patients undergoing elective colorectal operations persists for oral, parenteral, and a combination of the two routes. The oral antibiotics commonly administered for colorectal prophylaxis, neomycin and eythromycin base, are not absorbed in the gastrointestinal tract (GIT). However, the 4-fluoroquinolones are absorbed in the upper GIT and are excreted in part by the colonic mucosa. Their action is then to remove, or severely depress, the gram-negative aerobic bacilli leaving the anaerobic flora unaffected. This action is the principle of selective decontamination. We have assessed the efficacy of oral ciprofloxacin in a prospective randomized clinical trial in which all patients received piperacillin 4 g i.v. as single-dose parenteral prophylaxis. A group of 327 evaluable patients were randomized to receive ciprofloxacin 500 mg b.i.d. with the preoperative cathartic (group OA, n = 159) or no oral antibiotic (group NOA, n = 168). Postoperative wound infection occurred in 18 (11.3%) patients in group OA and 39 (23.2%) patients in group NOA (chi 2 = 7.2, p = 0.007). Operation-related infection of any type occurred in 23 (14.5%) patients in group OA compared with 55 (32.7%) in group NOA (chi 2 = 14.0, p = 0.0002). The median postoperative hospital stay was 11 days (interquartile range 4.5 days) for group OA and 12 days (interquartile range 8 days) for group NOA (Mann Whitney U test, p = 0.005). Ignoring the treatment group, the median postoperative hospital stay was 17 days (interquartile range 10 days) for infected patients and 11 days (interquartile range 4 days) for those not infected.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Review of available trials of selective decontamination of the digestive tract (SDD).

Eighteen studies on Selective Decontamination of the Digestive Tract (SDD) have been published up to now. A statistically significant reduction of infection rate was found in fourteen out of the fifteen controlled studies. Although all the studies were designed to evaluate infection-related morbidity as the end point, ten centres have reported fatality rates. Six centres out of the ten showed a statistically significant reduction in mortality in patients receiving SDD versus control. A recent French study describes the eradication of an outbreak of a multi-resistant Klebsiella with SDD. The Paris trial suggests a major impact of the SDD maneuver on the ICU ecology. Emergence of resistance to the SDD agents among gram-positive cocci has been described, although the clinical impact of this antibiotic side effect has not been reported so far. There are three indications for SDD, as follows: (i) trauma patients; (ii) liver transplant recipients and (iii) outbreaks of multi-resistant organisms.

Decontamination↗
PubMed1990

How to improve infection prevention by selective decontamination of the digestive tract (SDD).

From the point of view of prevention, it is useful to divide infections in intensive care into exogenous infections and primary or secondary endogenous infections. Exogenous infections hardly play a role nowadays. With selective decontamination of the digestive tract (SDD) secondary endogenous infections can be effectively prevented, but for primary endogenous infections SDD comes too late. Primary endogenous infection is the major infectious problem in intensive care. A large number of these infections are postoperative infections and are responsible for a high morbidity and mortality in the intensive care unit. Many of these postoperative infections might be prevented if SDD were started before instead of after the operation when the patient is admitted to the ICU. A tentative list of indications for pre-operative SDD is presented with a flow diagram to determine the optimal infection prevention regimen.

Decontamination↗
PubMed1990

Infection surveillance and selective decontamination of the digestive tract (SDD) in critically ill patients--results of a controlled study.

All ICU patients were continuously monitored for infections according to a standard protocol by the physician in charge and an infection control nurse during the first quarter of five consecutive years (1980-1984). The number of patients surveyed was 1,009. The average age was 45.5 years and the average period of stay about four days. 733 patients (72.6%) were intubated and artificially ventilated for three days. A fatal outcome resulted in 13.2% of all patients, 1,129 nosocomial infections were registered in 331 patients, which means an infection rate of 32.8%. The most frequent nosocomial infections were those of the respiratory tract (24.3%). Wound infections developed in 16.6%. The urinary tract was affected in 8.8%. Nosocomial septicaemias were observed in 8.7%. Catheter-associated infections were found in 6.7% of the patients. A fatal outcome resulted in 26% of the patients with nosocomial infections and in 6.9% of the non-infected patients, respectively. There was no significant reduction in nosocomial infections over the five-year period in our ICU. Therefore, a study was designed to evaluate the concept of selective decontamination of the digestive tract (SDD) in critically ill patients in our two surgical/traumatological ICUs. A prospective, consecutive, placebo-controlled study in two ICUs was carried out during four six-month periods. 200 patients who were intubated for at least three days, required intensive care for a minimum of five days, and belonged to either class III or IV according to the "Therapeutic Intervention Scoring System" were included in the study. They received either placebo or a prophylaxis regimen, consisting of polymyxin E, tobramycin and amphotericin B.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Transport of digested decontaminated sputum specimens to a central laboratory for testing for M. tuberculosis by Amplicor MTB test.

Rapid diagnosis of tuberculosis may improve management of infected patients and facilitate infection control procedures. The relatively slow growth rate of M. tuberculosis and the limited sensitivity and specificity of microscopy make rapid diagnosis difficult. Nucleic acid amplification techniques have been extensively studied for the detection of M. tuberculosis DNA and a number of commercial products for detection of M. tuberculosis nucleic acid in clinical specimens are now available. As performance of diagnostic PCR at central reference laboratories may be desirable, the impact of specimen transport on the performance of the Amplicor MTB PCR assay is of practical importance. We have assessed the performance of the Amplicor MTB PCR on specimens submitted and initially processed in laboratories in 3 cities and then transported to a single laboratory for PCR assay. The overall sensitivity of the PCR test was 97 per cent and the corrected specificity was 100 per cent. All of 23 culture positive specimens collected locally were PCR positive compared with 10 of 11 culture positive specimens transported from elsewhere. In this study transportation of digested decontaminated specimens to a central laboratory either frozen at -20 degrees, or overnight at room temperature had no apparent effect on the performance characteristic of the Amplicor MTB PCR assay.

Decontamination↗
PubMed2003

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.

Anti-Bacterial Agents↗
PubMed2006

Influence of severity of illness, medication and selective decontamination on defecation.

OBJECTIVE: To describe the pattern of defecation in critically ill ventilated patients and the influence of selective decontamination (SDD) and other medication. DESIGN: Descriptive cohort study. SETTING: Mixed surgical-medical ICU in a university Hospital. PATIENTS: Ventilated patients with a length of stay >or=7 days taking part in a study on SDD. MEASUREMENTS: Daily registration of defecation, SOFA (sepsis-related organ failure assessment score) score, administration of dopamine, noradrenaline, morphine and other medications. RESULTS: The first defecation occurred after a mean of 6.2 days. Patients with defecation within 6[Symbol: see text]days had lower mean SOFA scores, received more cisapride and lactulose and less dopamine, noradrenaline and morphine, and had a shorter duration of mechanical ventilation and ICU stay. On 57% of the days, no stools were produced; on 31% diarrhea, and on 12%, normal stools. Patients receiving SDD had more days with normal stools and less with diarrhea. Diarrhea was preceded by the administration of lactulose in the majority of patients. CONCLUSION: Time to first defecation correlated with severity of illness, vasoactive medication, administration of morphine, cisapride and lactulose, duration of mechanical ventilation and length of stay. Diarrhea seemed at least partially iatrogenic.

Adult↗
PubMed1998

Prognostic importance of gram-negative intestinal colonization preceding pancreatic infection in severe acute pancreatitis. Results of a controlled clinical trial of selective decontamination.

OBJECTIVES: To establish, firstly, whether gram-negative (re)-colonization of the gut leads to an increased risk of gram-negative pancreatic infections and whether this event is time-related and, secondly, whether the difference in the quantity and quality of micro-organisms colonizing the digestive tract influences morbidity and mortality. DESIGN: Prospective analysis of the results of systematic semi-quantitative cultures of several body areas taken from patients with severe acute pancreatitis, during a controlled multicenter trial of adjuvant selective decontamination. SETTING: Surgical intensive care units of 16 hospitals. PATIENTS: A total of 2,159 semi-quantitative cultures from the oropharynx, rectum and pancreatic tissues taken from 90 patients were analyzed. INTERVENTIONS: Surveillance cultures from the oropharynx and rectum were taken on admission and repeated twice weekly and from the (peri)-pancreatic devitalized tissues (i. e. necrosis) at every relaparotomy and from drainage. MEASUREMENTS AND RESULTS: All gram-negative pancreatic infections were preceded by intestinal colonization with the same micro-organisms. The risk of developing a pancreatic infection following gram-negative intestinal colonization (15/42 patients) was significantly higher as compared to patients without gram-negative colonization (0/10 patients) (p < 0.001) or to patients in whom E. coli was the only intestinal micro-organism cultured (0/30 patients) (p < 0.001). The occurrence of intestinal E. coli did not increase the risk of pancreatic infection. Gram-negative colonization of the rectum and oropharynx significantly correlated with the later development of pancreatic infection: relative risks 73.7 (p < 0.001) and 13.6 (p < 0.001), respectively. However, when both areas were evaluated simultaneously, the rectum was more significant (p < 0.001). The severity of intestinal intestinal colonization until the moment of pancreatic infection showed an increase in time in all 15 patients. In 11 of 15 patients (73%) these infections occurred within 1 week following the first isolation from the digestive tract. Gram-negative intestinal colonization was associated with a 3.7 fold increased mortality risk (p = 0.004). CONCLUSIONS: Gram-negative intestinal colonization, E. coli excepted, is an early prognostic parameter in patients in whom pancreatic infection has not yet occurred and represents a significantly increased risk of pancreatic infections and mortality.

Actuarial Analysis↗
PubMed1998

Selective gut decontamination in intensive care and surgical practice: where are we?

Selective decontamination of the digestive tract (SDD) has been widely studied in the intensive care setting. Despite the publication of more than 50 controlled trials, it remains a controversial subject, with widely disparate views on the role of SDD. This article reviews the use of SDD primarily by examining the areas of controversy. The published data seem to show clear evidence that SDD can reduce acquired infection during intensive care. Most individual studies have shown no effect on mortality, but meta-analyses suggest a 10% overall reduction in mortality. Despite the large number of publications to date, there remain several aspects worthy of further study.

Bacterial Infections↗
PubMed1990

Selective bowel decontamination results in gram-positive translocation.

UNLABELLED: Colonization by enteric gram-negative bacteria with subsequent translocation is believed to be a major mechanism for infection in the critically ill patient. Selective bowel decontamination (SBD) has been used to control gram-negative infections by eliminating these potentially pathogenic bacteria while preserving anaerobic and other less pathogenic organisms. Infection with gram-positive organisms and anaerobes in two multivisceral transplant patients during SBD led us to investigate the effect of SBD on gut colonization and translocation. METHODS: Twenty-four rats received enteral polymixin E, tobramycin, amphotericin B, and parenteral cefotaxime for 7 days (PTA + CEF); 23 received parenteral cefotaxime alone (CEF), 19 received the enteral antibiotics alone (PTA), 21 controls received no antibiotics. Cecal homogenates, mesenteric lymph node (MLN), liver, and spleen were cultured. RESULTS: Only 8% of the PTA + CEF group had gram-negative bacteria in cecal culture vs 52% CEF, 84% PTA, and 100% in controls. Log Enterococcal colony counts were higher in the PTA + CEF group (8.0 + 0.9) vs controls (5.4 + 0.4) P less than 0.01. Translocation of Enterococcus to the MLN was significantly increased in the PTA + CEF group (67%) vs controls (0%) P less than 0.01. SBD effectively eliminates gram-negative organisms from the gut in the rat model. Overgrowth and translocation of Enterococcus suggests that infection with gram-positive organisms may be a limitation of SBD.

Animals↗
PubMed1992

Antibiotic resistance associated with selective decontamination of the digestive tract.

Selective decontamination of the digestive tract (SDD) appears to reduce infection, particularly pneumonia, in intensive care, and some patients benefit markedly. Gram-positive overgrowth and antibiotic resistance in both Gram-positive and Gram-negative organisms has been recorded. However, the clinical and epidemiological significance of these observations is still debated. Future studies will need to be of sufficient size and duration to provide good quality data on which the safety and efficacy of SDD can be properly judged.

Anti-Bacterial Agents↗