Clinical Investigations

The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia*

Oostdijk, Evelien A. N. MD; de Smet, Anne Marie G. A. MD, PhD; Kesecioglu, Jozef MD, PhD; Bonten, Marc J. M. MD, PhD on behalf of the Dutch SOD-SDD Trialists Group

Author Information

From the Departments of Medical Microbiology (EANO, MJMB) and Intensive Care Medicine (EANO, JK), Division of Perioperative and Emergency Care (AMGAdS), and Julius Center for Health Sciences and Primary Care (MJMB), University Medical Center Utrecht, Utrecht; and Department of Intensive Care Medicine (AMGAS), Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

The Dutch SOD-SDD Trialists Group includes the following persons and sites: Cor J. Kalkman, Hans (J.) C. A. Joore, Maurine A. Leverstein-van Hall, Hetty E. M. Blok, University Medical Center Utrecht, Utrecht; Jan A. J. W. Kluytmans, Nardo J. M. van der Meer, Amphia Hospital, Breda; Ellen M. Mascini, Karin Kaasjager, Frank H. Bosch, Rijnstate Hospital, Arnhem; Robin F. J. Benus, Tjip S. van der Werf, University Medical Center, Groningen; Johannes G. van der Hoeven, Peter Pickkers, Patrick D. J. Sturm, Andreas Voss, Radboud University, Nijmegen Medical Center, Nijmegen; Alexandra T. Bernards, Ed J. Kuijper, Hubertus I. J. Harinck, Leiden University Medical Center, Leiden; Alexander J. G. H. Bindels, Arjan R. Jansz, Catharina Hospital, Eindhoven; Ronald M. J. Wesselink, Bartelt M. de Jongh, St. Antonius Hospital, Nieuwegein; Paul J. W. Dennesen, Gerard J. van Asselt, Medical Center Haaglanden, The Hague; Leonard F. te Velde, Ine H. M. E. Frenay, Albert Schweitzer Hospital, Dordrecht; Mat van Iterson, Steven F. T. Thijsen, Diakonessen Hospital, Utrecht; Georg H. Kluge, Slotervaart Hospital, Amsterdam; Jacob W. de Vries, Jan A. Kaan, Mesos Medical Center, Utrecht—all in The Netherlands.

M. J. M. Bonten is supported by The Netherlands Organization of Scientific Research (NWO-VICI 918.76.611).

Presented, in part, at the 20th European Congress of Clinical Microbiology and Infectious Diseases, Vienna, Austria, April 10 to 14, 2010. Dr. Bonten received honoraria/speaking fees from Aventis, Novartis, Cepheid, Lea Losios, and Kimberly Clark and received an industry sponsored grant from Novartis. Dr. Kluytmans consulted for Destiny Pharmaceuticals, Cepheid, and Pfizer and received grants from Pfizer and Cepheid. Dr. Kuijper received grants from The Netherlands Organization for Scientific Research, ZonMW, and FP7. Dr. Harinck is employed by the University Hospital in Leiden. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 39(5):p 961-966, May 2011. | DOI: 10.1097/CCM.0b013e318208ee26

Abstract

Objective:

Selective digestive tract decontamination aims to eradicate Gram-negative bacteria in both the intestinal tract and respiratory tract and is combined with a 4-day course of intravenous cefotaxime. Selective oropharyngeal decontamination only aims to eradicate respiratory tract colonization. In a recent study, selective digestive tract decontamination and selective oropharyngeal decontamination were associated with lower day-28 mortality, when compared to standard care. Furthermore, selective digestive tract decontamination was associated with a lower incidence of intensive care unit-acquired bacteremia caused by Gram-negative bacteria. We quantified the role of intestinal tract carriage with Gram-negative bacteria and intensive care unit-acquired Gram-negative bacteremia.

Design:

Data from a cluster-randomized and a single-center observational study.

Setting:

Intensive care unit in The Netherlands.

Patients:

Patients with intensive care unit stay of >48 hrs that received selective digestive tract decontamination (n = 2,667), selective oropharyngeal decontamination (n = 2,166) or standard care (n = 1,945).

Interventions:

Selective digestive tract decontamination or selective oropharyngeal decontamination.

Measurements and Main Results:

Incidence densities (episodes/1000 days) of intensive care unit-acquired Gram-negative bacteremia were 4.5, 3.0, and 1.4 during standard care, selective oropharyngeal decontamination, and selective digestive tract decontamination, respectively, and the daily risk for developing intensive care unit-acquired Gram-negative bacteria bacteremia increased until days 36, 33, and 31 for selective digestive tract decontamination, standard care, and selective oropharyngeal decontamination and was always lowest during selective digestive tract decontamination. Rectal colonization with Gram-negative bacteria was present in 26% and 71% of patient days during selective digestive tract decontamination and selective oropharyngeal decontamination, respectively (p < .01). Irrespective of interventions, incidence densities of intensive care unit-acquired Gram-negative bacteremia was 4.5 during patient days with both intestinal and respiratory tract Gram-negative bacteria carriage. These incidence densities reduced with 33% (to 3.1) during days with intestinal Gram-negative bacteria carriage only and with another 45% (to 1.0) during days without Gram-negative bacteria carriage at both sites.

Conclusions:

Respiratory tract decolonization was associated with a 33% and intestinal tract decolonization was associated with a 45% reduction in the occurrence of intensive care unit-acquired Gram-negative bacteremia.

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Article Keywords

Keywords
selective digestive tract decontamination, selective oropharyngeal decontamination, intensive care, blood stream infection, decolonization, decontamination

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The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia*