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PubMed2006

Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance.

OBJECTIVE: To assess the distribution of bacterial species and antimicrobial resistance in an ICU during long-term use of selective digestive decontamination (SDD) in the context of national reference data. DESIGN AND SETTING: Five-year prospective observational study in a 24-bed interdisciplinary surgical ICU of a university hospital (study ICU) participating in the project "Surveillance of Antimicrobial Use and Antimicrobial Resistance in German Intensive Care Units" (SARI; reference ICUs). PATIENTS: Resistance data were obtained from all patients; patients intubated for at least 2 days received SDD (colistin, tobramycin, amphotericin B). INTERVENTIONS AND MEASUREMENTS: SDD was performed in 1,913 of 7,270 patients. Antimicrobial resistance was examined in 4,597 (study ICU) and 46,346 (reference ICUs) isolates. RESULTS: Methicillin-resistant Staphylococcus aureus (MRSA) remained stable (2.76 and 2.58 isolates/1000 patient days) in the study ICU; this was below the German average (4.26 isolates/1000 patient days). Aminoglycoside- and betalactam-resistant Gram-negative rods did not increase during SDD use. Aminoglycoside resistance of Pseudomonas aeruginosa was 50% below the mean value of SARI (0.24 vs. 0.52 isolates/1,000 patient days). The relative frequency of enterococci and coagulase-negative staphylococci (CNS) was higher than in the SARI ICUs (23.2% vs. 17.3%, and 25.0% vs. 20.6%, respectively). CONCLUSION: Routine 5-year-use of SDD was not associated with increased antimicrobial resistance in our ICU with low baseline resistance rates. Vigorous surveillance and control measures to search and destroy MRSA were considered a mandatory component of the SDD program. The relative increase in enterococci and CNS is of concern requiring further investigation.

Amphotericin B↗
PubMed1997

Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD).

OBJECTIVE: To determine the influence of selective oropharyngeal decontamination (SOD) on the rate of colonization and infection of the respiratory tract in intensive care patients requiring mechanical ventilation for more than 4 days. A financial assessment was also performed. DESIGN: Randomized, prospective, controlled study using amphotericin B, colistin sulfate (polymyxin E), and tobramycin applied to the oropharynx and systemic cefotaxime prophylaxis. SETTING: Anesthesiology intensive care unit (ICU) of a 1500-bed hospital. PATIENTS: A total of 88 patients admitted as emergencies and intubated within less than 24 h were enrolled. Fifty-eight patients received SOD and 30 patients served as controls. Randomization was in the proportion of 2 : 1 study patients to controls. INTERVENTIONS: Microbiological samples from the oropharynx and other infected sites were taken at the time of admission, then twice a week and after extubation. MEASUREMENTS AND RESULTS: With the use of SOD, colonization was significantly reduced. Furthermore, the infection rate decreased from 77% in the controls to 22% in the study patients. Staphylococcus aureus was the main potential pathogen causing colonization and pneumonia. Number of days in the ICU, duration of ventilation, and mortality were not significantly decreased. The total cost of antibiotics was reduced. Development of resistance was not observed. CONCLUSIONS: The use of SOD significantly reduced the colonization and pneumonia and the total charge for antibiotics. The length of stay in the ICU, duration of ventilation, and mortality were similar. No resistance was observed. Staphylococcus aureus was selected by SOD in some patients and the clinical relevance needs further observation.

Adult↗
PubMed2002

Selective bowel decontamination in elective liver transplantation: no improvement in endotoxaemia, initial graft function and post-operative morbidity.

Peri-operative endotoxaemia during liver transplantation has been linked to compromised graft function and infection. Selective decontamination of the digestive tract (SDD) could prevent endotoxaemia by eradicating Gram-negative bacteria from the intestine. In a randomized placebo controlled study we investigated the effects of endotoxaemia and the efficacy of SDD to prevent its occurrence. Thirty-one patients undergoing elective orthotopic liver transplantation received either SDD ( n=15) or placebo ( n=16), which was started at least 7 days before transplantation. Endotoxin levels were measured in blood peroperatively. Patients were scored daily for signs of liver dysfunction and infection. Endotoxaemia was neither associated with initial poor function nor any routine liver function test. Infections were more prominent in patients without endotoxaemia. SDD did not prevent endotoxaemia. Endotoxaemia does not affect post-operative graft function or the incidence of post-operative infections. SDD cannot prevent peri-operative endotoxaemia. Translocation of endotoxin may not be relevant in liver transplantation.

Adult↗
PubMed2001

[Antimicrobial decontamination of corneal donor material: infection prevention and quality assurance].

BACKGROUND: Microbiological examinations in eye banks have found an increased contamination rate in preservation media. We studied the effect of prolonged submersion time for decontaminating donor globes. MATERIALS AND METHODS: We retrospectively analyzed the primary contamination of conjunctival smears in 76 cornea donors. The submersion time of donor eyes in PVP iodine solution before preparation was prolonged from 1 min to 5 min, and the contamination rate of storage vessels was compared. RESULTS: In 13 of the 76 conjunctival smears we found no contamination. Before prolonging submersion time, the preservation medium was contaminated in 15 cases, but after 5 min no contamination was observed. CONCLUSION: Prolonging the submersion time of donor globes from 1 to 5 min was effective. The model presented here provides guidelines for existing eye banks as well as for those yet to be established.

Antisepsis↗
PubMed2000

The effects of sucralfate and selective intestinal decontamination on bacterial translocation.

Sucralfate is widely used as a cytoprotective agent in patients with peptic ulcer and other intestinal mucosal damage. In this study, the effects of sucralfate and/or selective intestinal decontamination with gentamycin on bacterial translocation (BT) in rats with experimentally-induced mechanical jaundice were investigated. Seventy-five adult male Wistar albino rats were divided into five groups of 15 each. In all except a sham group, we performed ligation of the common bile duct (CBD) via a vertical laparatomy. After surgery, the rats in group 1 were treated with oral sucralfate (5 mg/kg per day); those in group 2 underwent oral gentamycin therapy (5 mg/kg per day) for 5 days. Group 3 rats were treated with sucralfate and gentamycin for 5 days subsequent to the operation. The rats in group 4 served as controls, and received only 0.9% saline solution. Group 5 was a sham group. After 5 days of surgery, all rats were killed; the mesenteric lymph nodes (MLN), liver, and a segment of terminal ileum were harvested aseptically. The collected tissues were cultured in McCaunkey medium and chocolate agar. For each specimen, the colony-forming units (CFU) were calculated and the percentage of viable translocated micro-organisms was counted. In all rats who had ligation of the CBD, high numbers of bacteria were demonstrated in the liver, MLN, and ileum. In the liver of rats with sucralfate and/or gentamycin treatment, there was a marked reduction in CFU compared to the control group. Similarly, in the MLN measurements of CFU were higher in the control rats than the study groups. In both McCaunkey and chocolate media, the numbers of bacteria in control rats were significantly higher than in the study groups (P < 0.001). However, among the study groups themselves there was no significant difference in CFU in any of the specimens or culture media (P > 0.05). Experimentally-induced mechanical jaundice from ligation of the CBD causes significant BT in rats. Sucralfate and/or gentamycin may reduce the degree of BT from the bowel mucosa. We did not find any difference in protection from BT between sucralfate and gentamycin or both in rats with experimentally-induced mechanical jaundice.

Animals↗
PubMed2004

A before-after study of multi-resistance and cost of selective decontamination of the digestive tract.

BACKGROUND: We compared standard antibiotic use with an antibiotic policy based on selective decontamination of the digestive tract (SDD) for cost and microbiology. PATIENTS AND METHODS: A 2-year before-after observational study was performed in an 11-bed, mixed medical and surgical intensive care unit (ICU). We included all consecutive patients admitted to the ICU 1 year before and 1 year after institution of SDD (patients admitted within the 2-month SDD run-in period were excluded from analysis). In the year before SDD, 513 patients were treated in the ICU (mean APACHE II 19.5), compared to 529 in the year with SDD (mean APACHE II 19.4). RESULTS: The duration of mechanical ventilation was shorter in the SDD-treated patients (median 3, interquartile range [IQR] 2-7 days vs median 4 days, IQR 2-10, p = 0.03). The total of ICU variable costs, microbiological costs and antibiotic costs were equal in both episodes: euro 1,171 versus euro 1,168 per patient). Aerobic gram-negative bacilli (AGNB) and multiresistant AGNB were found less frequently in SDD-treated patients, RR 0.37 (95% CI 0.33-0.42) and RR 0.28 (95% CI 0.19-0.42). Multi-resistant AGNB in tracheal secretions and urine more than 72 hours after admission were completely absent in SDD-treated patients. CONCLUSION: The overall cost per patient treated during an antibiotic policy including SDD was equal to a policy supporting standard antibiotic care. In addition, duration of ventilation decreased and a trend was shown towards a decreased Length of ICU and hospital stay. Less frequently, cultures from organ sites containing AGNB were found during SDD and the number of multi-resistant strains was significantly reduced at organ sites, in particular trachea and urine. Fewer patients were colonized with multi-resistant AGNB but these numbers did not reach statistical significance.

Anti-Bacterial Agents↗
PubMed1991

Comparison of three methods for decontamination of faeces for isolation of Mycobacterium tuberculosis.

Sputum and faeces were obtained from 276 patients on admission to a study of drug resistance in Hong Kong. Acid-fast bacilli were detected microscopically in 103 (37%) sputum specimens and 135 (49%) yielded Mycobacterium tuberculosis on culture. Three methods were used to decontaminate faeces prior to dilution and culture in selective liquid Kirchner medium. A total of 61 faecal specimens were positive for M. tuberculosis on culture and, of these, pretreatment with sodium hydroxide yielded 60 (98%), Portaels modification of Wolinsky and Rynearsons's method 28 (46%) and the combined use of benzalkonium chloride and 1-hexdecylpyridinium chloride yielded 32 (52%). It is recommended that faeces should be treated with sodium hydroxide followed by dilution and culture in selective media, although it may be necessary to formulate new selective media for mycobacterial species other than M. tuberculosis.

Bacteriological Techniques↗
PubMed1992

Double-blind study of selective decontamination of the digestive tract in intensive care.

Selective decontamination of the digestive tract (SDD), by means of non-absorbable antibiotics, to prevent infection in intensive-care units (ICUs) remains controversial; there is evidence that the regimen reduces the incidence of secondary infection, but no convincing reduction in morbidity or mortality has been shown and the costs and effect on microbial resistance patterns need further study. In a double-blind, placebo-controlled trial, we have tried to find out whether SDD should be used routinely in all ICU patients at high risk of secondary infection. All patients admitted to the ICU who were thought likely to stay in the unit for at least 5 days and to need intubation for longer than 48 h were enrolled and randomly allocated to groups receiving placebo or SDD (amphotericin, colistin, and tobramycin applied to the oropharynx and enterally); all patients received intravenous cefotaxime for 72 h. Of 322 patients randomised, 83 were withdrawn (80 ICU stay or duration of intubation too short, 3 protocol violations). 239 medical, trauma, and surgical patients completed the trial period (114 SDD, 125 placebo). There were no differences between SDD and placebo groups in incidence of infection (30 [26%] vs 43 [34%] patients; p = 0.22), duration of ICU stay (mean 16.2 [14.3] vs 16.8 [12.3] days), hospital stay (29.9 [SD 25.0] vs 31.9 [22.2] days), or mortality (21 [18%] vs 21 [17%]). SDD substantially increased the costs of intensive care. Mechanisms other than bacterial colonisation of the gut may bring about substantial numbers of secondary infections in ICUs. Routine use of SDD in multidisciplinary ICUs cannot be recommended.

Administration, Oral↗
PubMed1990

The effect of treatment with buffered lactic acid on microbial decontamination and on shelf life of poultry.

The use of buffered lactic acid systems compared with unbuffered lactic acid solutions enhances the decontaminating effect and increases shelf life of chicken legs. A reduction of about 2 pH units of the chicken skin is obtained by treatment with 10% lactic acid buffer. The buffer keeps the pH of the skin lower than that of untreated legs. Legs treated with 10% lactic acid buffer have a shelf life of 12 days at 6 degrees C, which means an increase of 6 days compared with the shelf life of untreated legs.

Animals↗
PubMed1995

Lactic acid decontamination of fresh pork carcasses: a pilot plant study.

Lactic acid decontamination (LAD) was carried out in an abattoir on pork carcasses, artificially contaminated with Salmonella typhimurium in faeces suspensions. The surface contamination with S. typhimurium ranged from 1-2 log10 cfu/cm2. Before cold and hot LAD was undertaken, the inoculum was allowed to adhere to the meat surface for 20 min. Cold LAD consisted of treatment for 60 s with 2% (pH 2.3) or 5% (pH 1.9) lactic acid (LA); for hot LAD the exposure times were 30, 60, 90 and 120 s. The spray nozzle temperatures were 11 degrees C and 55 degrees C, and that of the treated meat surface 16-18 degrees C and 36-38 degrees C, respectively. Treatment with cold 2% and 5% LA for 60 s eliminated S. typhimurium from pork carcasses inoculated with ca. 1 log10 cfu/cm2, but not from those inoculated at ca. 2 log10 cfu/cm2. However, this could be achieved by hot 2% and 5% LA sprayed for 60-120 s. Also exposures of at least 30 s using these hot LA solutions eliminated S. typhimurium consistently from carcasses inoculated with ca. 1 log10 cfu/cm2. Rinsing-off contributed only marginally to contamination reduction. Application of 2% or 5% LA for 120 s led to an unacceptable deterioration of the organoleptic qualities of the meat. Addition of nicotinic and ascorbic acid as colour stabilizers to the spraying solutions reduced these changes to just acceptable levels when 2% LA was used.

Abattoirs↗
PubMed1991

Selective decontamination of the digestive tract (SDD) in intensive care patients: a critical evaluation of the clinical, bacteriological and epidemiological benefits.

Twenty trials (17 controlled and three observational cohort studies) on selective decontamination of the digestive tract (SDD) have been undertaken to date. SDD is defined as a technique which aims to eradicate carriage of disease-causing microorganisms by means of lethal oropharyngeal and faecal antimicrobial concentrations. The SDD concept and the criteria for the choice of the antimicrobials used in the SDD programme are explained. Abolition of the carrier state is thought to provide clinical, bacteriological and epidemiological benefits. Infection-specific morbidity and mortality, emergence of antibiotic resistance and outbreaks are the main endpoints evaluated in this review. Of the 15 controlled studies that considered carriage, 14 demonstrated a significant reduction of Gram-negative bacillary (GNB) carriage. Severe infections, including pneumonia and septicaemia, caused by enterobacteria and pseudomonads have been virtually eliminated in these trials. Five of the 12 centres that evaluated mortality showed a significant decrease among patients who received SDD. Two recent trials describe the control of an outbreak with a multiresistant Klebsiella by SDD. There are three indications for the use of SDD so far: (i) in trauma patients; (ii) in certain elective surgical procedures including liver transplantation and oesophageal resection; and (iii) in control of outbreaks of ICU infection. Future lines of research may include a properly designed trial with mortality as endpoint and studies on the transfer of SDD from the ICU into the ward as part of prophylaxis in major surgery.

Carrier State↗
PubMed1991

Selective decontamination of the gastrointestinal tract as an infection control measure.

An outbreak caused by a Klebsiella aerogenes resistant to ceftazidime, cefuroxime, cefotaxime, ampicillin and piperacillin and sensitive to aminoglycosides, imipenem and temocillin occurred in a teaching hospital's busy multi-disciplinary Intensive Care Unit over a 3-month period. Four patients had bacteraemia and a further four were colonized. Traditional infection control measures failed to eradicate the outbreak. The introduction of a selective gastrointestinal decontamination regimen consisting of tobramycin, amphotericin and colistin as a gel to the oropharynx, nose and rectum and a suspension via a nasogastric tube resulted in rapid disappearance of the outbreak strain with no new isolates being detected clinically or in surveillance specimens over an 8-week period.

Amphotericin B↗
PubMed1992

Epidemiology of Pseudomonas aeruginosa in an intensive care unit using selective decontamination of the digestive tract.

Selective decontamination of the digestive tract (SDD) aims to reduce the rate of nosocomial infections in critical care patients. Pseudomonas spp. are common nosocomial pathogens and in this study isolates collected from patients and the environment during an SDD trial were examined. The study enrolled 161 SDD cases and 170 controls. Pseudomonads were isolated from 27% of SDD patients and 30% of controls. SDD partially suppressed colonization in the 'gastro-respiratory' mucosae but not in the rectum. A total of 108 isolates of pseudomonads were recovered from the environment. Resistance in rectal isolates was minimal but isolates from 'gastro-respiratory' sites showed increasing aminoglycoside resistance. Eighty-six per cent of aminoglycoside-resistant isolates from both patient groups and environment were pyocine type 1x. Episodes of infection were reduced in the SDD patients (6) compared with the controls (16), aminoglycoside-resistant strains being associated with zero episodes in SDD patients but with five in the control group.

Cross Infection↗
PubMed1993

Selective decontamination with nystatin for control of a Candida outbreak in a neonatal intensive care unit.

Selective decontamination of the digestive tract (SDD) with oral nystatin was evaluated as a measure to control an outbreak of Candida infection in a neonatal intensive care unit (NICU). Seventy-six out of 106 neonates who carried Candida spp. received the main study manoeuvre (the application of oral nystatin in the throat and stomach) during the 12-month open trial. One third of the neonates weighed < 1500 g whilst about half were being ventilated. The mean stay was 33.2 d (SD +/- 46.9). Two cases with candidaemia within a fortnight were associated with a yeast carriage rate in the NICU of about 50%; more than 80% of the isolates were Candida parapsilosis. During the implementation period there were four new neonates with fungaemia caused by C. parapsilosis. Once the carriage rate dropped below 5% (P < 0.001), no new cases of systemic infection with the outbreak strain were recognized in the following 8 months. It took 3.5 months to control the outbreak. The observation that all other clinical diagnostic samples were free from Candida suggests that translocation from throat or gut into the systemic circulation occurred. SDD with oral nystatin was effective in reducing the yeast carriage index (mean index 1.93, before SDD; 0.45, after SDD; P < 0.001). A significant reduction of carriage, both in rates and indices, is thought to have contributed to the control of this candida outbreak.

Candidiasis↗
PubMed1995

Endoscope decontamination: automated vs. manual.

Automated endoscope washer disinfectors are widely used for the decontamination of flexible endoscopes. They are more effective than manual techniques and reduce the likelihood of skin contact with irritant disinfectants. Suitable machines are those which effectively clean, disinfect and rinse all channels and external surfaces without damaging the instrument. If glutaraldehyde is used, fumes should be removed or contained to protect endoscopy and processing staff. Machines should also be equipped with a self-disinfect facility and the rinse water should be of a suitable microbiological quality for the instruments processed, i.e. bacteria-free (sterile or filtered) water should be used for bronchoscopes and all invasive endoscopes. The choice of machine and cycle will depend on the following: whether a mobile or fixed unit is required; the type of disinfectant used; instrument throughput; and whether or not it is necessary to process more than one endoscope at a time. Purchasers are advised to request independent test reports which substantiate manufacturers' claims.

Automation↗
PubMed1995

Endoscope decontamination: where do we go from here?

Thorough cleaning and disinfection or sterilization of endoscopes and associated equipment will reduce the likelihood of misdiagnosis and post-procedural infection. It will also prevent instrument deterioration and malfunction. With a rapid escalation in demand for endoscopy, particularly that associated with minimally invasive surgery, it is important that we have the processing technology to match the diagnostic and therapeutic value of these instruments without exposing staff and patients to unnecessary risk. Wherever possible staff should purchase heat tolerant endoscopic equipment that is readily accessible for cleaning. Automated processors, e.g. washer disinfectors and ultrasonic cleaners, improve the quality of the decontamination process but machines must have a self-disinfect function to prevent instrument recontamination during processing. Sterile, or filtered bacteria-free, water is essential for bronchoscopes and invasive instruments. Glutaraldehyde is still the most widely used disinfectant, particularly for the heat sensitive flexible endoscopes, but it is irritant and sensitizing and a safer alternative is sought. Peracetic acid is more rapidly efficacious and probably less irritant and, provided it does not damage endoscopes and processing equipment, may prove a suitable alternative. Unfortunately there are no nationally agreed test methods for assessing this and other new endoscope disinfectants and therefore no register of suitable or approved products. There is also no proven safe alternative to ethylene oxide for sterilizing invasive heat labile flexible endoscopes. It is important that, if toxic disinfectants and sterilants are used, staff and patients are suitably protected from exposure. Update training is essential for all processing staff if infection risks are to be minimized and sensitization problems avoided.

Cross Infection↗
PubMed1993

Selective bowel decontamination, nutritional therapy and bacterial translocation after burn injury.

We studied the influence of selective bowel decontamination (SBD) with neomycin, on bacterial translocation (BT) in rats treated with early post-burn parenteral nutrition (TPN) or enteral nutrition (TEN). Male Wistar rats were randomly assigned to receive either TPN (groups 1, 2) or an isonitrogenous, isocaloric polymeric diet (TEN, groups 3, 4) or a standard rat chow ad libitum (group 5), for 5 days after burn injury (30% b. s. area). In addition, groups 1 and 3 received a daily oral dose of neomycin (30 mg/kg) during the same period. At the end of the study, animals were killed and the mesenteric lymph nodes (MLN), liver (L) and spleen (S) were removed for microbiological cultures. The overall incidence of BT was MLN: 67%, L: 58% and S: 42% with a mortality rate of 12.2% In MLN and L, group 5 showed significantly less BT than groups 1 and 2 (30% vs 84%, p < 0.02) and groups 3 and 4 (38% vs 76%, p < 0.05), respectively. No differences were found between TPN and TEN groups. SBD (groups 1 and 3) resulted in a significantly lower mortality rate (26% vs 0%, p < 0.05) and BT in the liver (38% vs 100%, p < 0.001) than rats without antibiotic treatment (groups 2 and 4). It is concluded that early post-injury TPN or TEN promote BT to a greater extent than a standard chow. In addition, SBD with neomycin prevents mortality and BT after burn injury.

Journal Article↗
PubMed1991

Glyphosate skin binding, absorption, residual tissue distribution, and skin decontamination.

Glyphosate is a broad-spectrum postemergence translocated herbicide. Its interactions with skin and potential systemic availability through percutaneous absorption was studied by skin binding, skin absorption, residual tissue distribution, and skin decontamination. Glyphosate in a final formulation (Roundup) undiluted and diluted with water 1:20 and 1:32, would not partition into powdered human stratum corneum (less than 1%). In vitro percutaneous absorption through human skin into human plasma as receptor fluid was no more than 2% over a concentration range of 0.5-154 micrograms/cm2 and a topical volume range of 0.014-0.14 ml/cm2. Disposition of glyphosate following iv administration of 93 and 9 micrograms doses to rhesus monkeys was mainly through urine excretion, 95 +/- 8 and 99 +/- 4% in 7 days, respectively. Percutaneous absorption in vivo in rhesus monkey was 0.8 +/- 0.6% for the low dose (25 micrograms/cm2) and 2.2 +/- 0.8% for the high dose (270 micrograms/cm2). No residual 14C was found in organs of the monkeys euthanized 7 days after the topical application. Washing the skin application site with soap and water removed 90 +/- 4% of applied dose, and washing with water only removed 84 +/- 3% of applied dose. Both soap and water and water only were equal in ability to remove glyphosate from skin over a 24 hr skin application period. About 50% of the initially applied dose could be recovered after 24 hr. Glyphosate is very soluble in water and insoluble in most organics (octanol/water log P = -1.70) and therefore not compatible with the lipid-laden stratum corneum.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Topical↗