A Controlled Trial in Intensive Care Units of Selective Decontamination of the Digestive Tract with Nonabsorbable Antibiotics


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Abstract

Background.Selective decontamination of the digestive tract with topical nonabsorbable antibiotics has been reported to prevent nosocomial infections in patients receiving mechanical ventilation, and the procedure is used widely in Europe. However, it is unclear whether selective decontamination improves survival.Methods.We conducted a randomized, double-blind multicenter study in which 445 patients receiving mechanical ventilation in 15 intensive care units were given either prophylactic nonabsorbable antibiotics (n = 220) or a placebo (n = 225). Topical antibiotics (tobramycin, colistin sulfate, and amphotericin B) or placebo was administered through a nasogastric tube and applied to the oropharynx throughout the period of ventilation. The main end points were the mortality rate in the intensive care unit and the mortality rate within 60 days of randomization.Results.A total of 142 patients died in the intensive care unit: 75 (34 percent) in the treatment group and 67 (30 percent) in the placebo group (P = 0.37). Mortality within 60 days of randomization was similar in the two groups (P = 0.40), even after adjustment for factors that were either unbalanced or individually predictive of survival in the two groups (P = 0.70). Pneumonia developed in 59 patients (13 percent) in the intensive care unit within 30 days of enrollment in the study (33 in the placebo group and 26 in the treatment group, P = 0.42). Pneumonia acquired in the intensive care unit and due to gramnegative bacilli was less frequent (P = 0.01) in the treatment group than in the placebo group. The total charges for antibiotics were 2.2 times higher in the treatment group.Conclusions.Selective decontamination of the digestive tract does not improve survival among patients receiving mechanical ventilation in the intensive care unit, although it substantially increases the cost of their care. (N Engl J Med 1992;326:594–9.)INFECTIONS acquired in the intensive care unit are a major cause of death in hospitalized patients. Infection is also the main cause of multiple-organ failure, which usually ends in death.1,2 Recent reports have suggested that selective decontamination of the digestive tract can reduce the incidence of nosocomial infections in patients in the intensive care unit. The rationale for this approach is the well-documented observation that colonization of the gastrointestinal tract by gram-negative bacilli frequently occurs before the onset of infection.345 Decontamination could also help prevent the failure of multiple organ systems by reducing the bacterial load in the gastrointestinal tract …

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