Decontamination strategies and bloodstream infections with antibiotic-resistant microorganisms in ventilated patients : a randomized clinical trial
Importance: The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective: To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, setting, and participants: Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum [beta]-lactamase-producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions: Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main outcomes and measures: The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results: A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, -0.6% to 1.1%), 0.6% (95% CI, -0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and relevance: Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care.
© 2018 American Medical Association
2018
2020-11-09 10:50:23
1033
anti-infective agents -- therapeutic use, bacteremia -- prevention and control, chlorhexidine -- therapeutic use, cross infection -- prevention and control, disinfection -- methods, bacterial drug resistance, gastrointestinal tract -- microbiology, Gram-negative bacterial infections -- prevention and control, hospital mortality, intensive care units, mouthwashes -- therapeutic use, oropharynx -- microbiology, artificial respiration, multicenter study, randomized controlled trial
sredstva proti okužbam -- terapevtska raba, bakteriemija -- preprečevanje in nadzor, klorheksidin -- terapevtska raba, navzkrižne okužbe -- preprečevanje in nadzor, razkuževanje -- metode, bakterijska odpornost na zdravila, gastrointestinalni trakt -- mikrobiologija, Gramnegativne bakterijske okužbe -- preprečevanje in nadzor, bolnišnična umrljivost, enote za intenzivno oskrbo, ustne vode -- terapevtska raba, orofarinks -- mikrobiologija, umetna respiracija, multicentrična študija, naključni nadzorovani poskus
American Medical Association
Bastiaan H.
Wittekamp
70
Nienke L.
Plantinga
70
Ben S.
Cooper
70
Joaquin
Lopez-Contreras
70
Pere
Coll
70
Jordi
Mancebo
70
Matt P.
Wise
70
Matt P. G.
Morgan
70
Pieter
Depuydt
70
Jerina
Boelens
70
Viktorija
Tomič
70
Franc
Šifrer
70
UDK
4
616-084
ISSN pri članku
9
1538-3598
DOI
15
10.1001/jama.2018.13765
COBISS_ID
3
2048463473
OceCobissID
13
3669780
0
Izvorni URL
2020-11-09 10:50:31