Selective decontamination of the digestive tract is a four-component strategy
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Selective decontamination of the digestive tract is a four‑component strategy Hans Rommes1* , Nia Taylor2, Andy Petros3, Miguel de la Cal4 and Luciano Silvestri5 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Dear Editor, Finally, even those originally sceptical about the benefit of selective decontamination of the digestive tract (SDD), reluctantly and with ifs and buts admit that SDD reduces morbidity and mortality, is associated with less resistance and is cost-effective [1]. That is good news for all critically ill patients. Unfortunately, in their narrative review Wittekamp et al. do not adequately explain the concept of SDD. We would like to correct this and raise two points. Firstly, there is a difference between just the administration of SDD-antimicrobials and the employment of the full SDD-strategy. It is vital that intensivists intending to use the SDD-strategy know that it includes four components: 1. a 4-day course of systemic cefotaxime, 2. topical polymyxin, tobramycin and amphotericin B or nystatin delivered in throat and gut throughout the whole stay in the ICU, 3. strict adherence to hygiene rules and 4. twice weekly surveillance cultures of throat and rectum to monitor the efficacy of SDD. Secondly, all isolated Enterobacteriaceae, Staphylococcus aureus and fungi should be susceptible to the systemic and enteral antimicrobials. Adjustment of the systemic and enteral antimicrobials may be required in ICUs with moderate or high levels of antibiotic resistance, such as endemic methicillin-resistant S. aureus (MRSA) [2]. Topical vancomycin added to the classical SDD antimicrobials reduces MRSA carriage, infection *Correspondence: [email protected] 1 Bosweg 58, 7314 HD Apeldoorn, The Netherlands Full author information is available at the end of the article
and mortality without emergence of vancomycin resistant enterococci as has been shown in a systematic review and meta-analysis of 9 randomized controlled trials (RCTs) and 3 non-RCTs studies, including 1240 patients [3]. This enhanced SDD-strategy is valid in ICUs with endemic MRSA and should only be used when this develops. Correct application of the full four-component SDD strategy resulting in effective decontamination of throat and gut is associated with a 40% reduction of mortality [4]. Modification of the regimen by omitting one or more components by definition is not employing the SDDstrategy and reduces its effectiveness [5]. Author details 1 Bosweg 58, 7314 HD Apeldoorn, The Netherlands. 2 Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK. 3 Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK. 4 Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Spain. 5 Department of Cardiological, Thoracic, Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiolgy and Public Health, University of Padova, 35133 Padova, Italy. Compliance with ethical standards Conflicts of interest All authors d
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