Original Article
Decontamination of the Digestive Tract and Oropharynx in ICU Patients
N Engl J Med 2009; 360:20-31January 1, 2009
- Abstract
Background
Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting.
Methods
We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in the Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance.
Results
A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively.
Conclusions
In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)
Media in This Article
Figure 1
Detection of Gram-Negative Bacteria in Patients in the Intensive Care Unit Who Were Treated with Selective Digestive Tract Decontamination (SDD) or Selective Oropharyngeal Decontamination (SOD).Table 1
Baseline Characteristics of the Patients.Article Activity
- Article
Infections acquired in the intensive care unit (ICU) are important complications of the treatment of critically ill patients, increasing morbidity, mortality, and health care costs.1 Reductions in the incidence of respiratory tract infections have been achieved with the use of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD)2,3 and selective oropharyngeal decontamination (SOD).4,5
The SDD approach6,7, consists of prevention of secondary colonization with gram-negative bacteria, Staphylococcus aureus, and yeasts through application of nonabsorbable antimicrobial agents in the oropharynx and gastrointestinal tract, preemptive treatment of possible infections with commensal respiratory tract bacteria through systemic administration of cephalosporins during the patient's first 4 days in the ICU, and maintenance of anaerobic intestinal flora through selective use of antibiotics (administered both topically and systemically) without antianaerobic activity. 7 Despite the beneficial effects of SDD on infection rates, most studies have lacked sufficient statistical power to detect effects on survival. In meta-analyses and in three single-center, randomized studies, the use of SDD, including a short course of systemic antibiotics, was associated with improved survival.2,3,8-10
SOD (application of topical antibiotics in the oropharynx only) has been postulated as an alternative to SDD for the prevention of ventilator-associated pneumonia.4,5 Although several studies have identified the pivotal role of oropharyngeal colonization in the pathogenesis of ventilator-associated pneumonia11,12 and the efficacy of SOD in preventing ventilator-associated pneumonia appears to be similar to the efficacy of SDD,13,14 a head-to-head comparison of the two strategies is needed. Because of methodologic issues,15,16 such as single-center study designs with limited generalizability, and concern about increased selection of antibiotic-resistant pathogens,17,18 the routine use of SDD and SOD has remained controversial and has not been recommended in international guidelines.19,20
Methods
Study Design
We performed a controlled, crossover study using cluster randomization in 13 ICUs between May 2004 and July 2006. The participating ICUs differed in size and teaching status, reflecting all levels of intensive care in the Netherlands. (More information on the ICUs can be found in the Supplementary Appendix, available with the full text of this article at NEJM.org.) Since the interventions included ecologic changes in the ICU, an individualized, randomized design would have allowed the treatment of a patient in one study group to influence the treatment of a patient in another group. Therefore, cluster randomization was used, and all three study regimens (SDD, SOD, and standard care) were administered to all eligible patients over the course of 6 months, with the order of regimens randomly assigned. A crossover design was used to control for unit-specific characteristics. Randomization was performed by a clinical pharmacist who was not involved in patient care in any of the participating units and who was unaware of the identity of each ICU. The order in which the regimens were assigned was randomly generated by computer software (Design, version 2.0, a Systat Module), with allocation to the wards in consecutive order of study start. Study periods were preceded by washout and wash-in periods (for more information see the Supplementary Appendix). The antibiotics used were purchased by the hospitals. All authors vouch for the completeness and accuracy of the data presented.
Patients admitted to the ICU with an expected duration of mechanical ventilation of more than 48 hours or an anticipated ICU stay of more than 72 hours were eligible. Eligibility was assessed by physicians responsible for patient care in each unit. Pregnant patients and patients with documented or presumed allergy to any component of the antimicrobial study regimens were excluded.
The study protocol was approved by the institutional review board at each participating hospital. After reviewing the protocol, the boards waived the requirement for informed consent. Permission to use patient-specific medical data for analysis was obtained from patients or their representatives.
Inclusion rates were determined for each ICU and each study period. Research nurses visited each center regularly (at least twice per study period) and evaluated up to 50 consecutively admitted patients per visit (starting from a randomly chosen date) for eligibility and study inclusion.
The SDD regimen, which consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach, was identical to the regimen used by de Jonge et al.2 (for more information see the Supplementary Appendix). The use of antibiotics with antianaerobic activity, such as amoxicillin, penicillin, amoxicillin–clavulanic acid, and carbapenems, was discouraged during the SDD period. Surveillance cultures of endotracheal aspirates and oropharyngeal and rectal swabs were obtained on admission and twice weekly thereafter.
SOD consisted of oropharyngeal application of the same paste used for SDD, with surveillance cultures of endotracheal aspirates and oropharyngeal swabs obtained on admission and twice weekly thereafter; there were no restrictions on physicians' choices of systemic antibiotic therapy. During the period of standard care, no surveillance cultures were obtained from patients, and there were no restrictions on physicians' choices of systemic antibiotic therapy.
Antibiotic resistance was monitored with the use of point-prevalence studies on the third Tuesday of each month. On these days, rectal swabs and endotracheal aspirates or throat swabs for surveillance cultures were obtained from all ICU patients, whether or not they were included in the study. The prevalence of specific pathogen-resistance combinations was determined. (Details on the processing of surveillance cultures during SDD and SOD and on the monthly point-prevalence studies are available in the Supplementary Appendix.)
Approaches to infection control (other than the regimens being studied) did not change during the period of the study in any of the ICUs. (Oropharyngeal care is described in the Supplementary Appendix.)
Statistical Analysis
The original analysis plan, which specified in-hospital death as the primary end point, did not take into account analysis of cluster effects and failed to specify how to address imbalances in baseline characteristics between study groups. However, the study design did not preclude post-randomization selection bias.21 It was subsequently recognized that such an analysis plan failed to conform to the Consolidated Standards for the Reporting of Trials (CONSORT) guidelines for reporting cluster-randomization trials.22 Failure to account for cluster effects (e.g., with the use of a random-effects model) would have increased the chance of reporting spuriously significant findings, and in the event of selection bias, failure to adjust for baseline characteristics could have led to bias in either direction.21,23 When confronted with these problems, we consulted a panel of experts in the field of clinical epidemiology and data analysis with no prior involvement in the study and no knowledge of outcome data. The panel unanimously recommended a revised analysis plan that overcame these problems. This plan specified mortality at day 28 as the primary end point (because it was thought that knowledge of the intervention being applied at any given time could have influenced discharge policies, compromising the reliability of hospital discharge as an end point) and the use of a random-effects logistic-regression model to adjust for all available covariates (the score on the Acute Physiology and Chronic Health Evaluation [APACHE II], intubation status, medical specialty [classified as surgical or other], age, and sex).
This plan was adopted, with no further revisions, and day 28 mortality data were subsequently collected through hospital and government systems (these data had not been available when the analysis plan was formulated). In-hospital mortality, prevalence of antibiotic resistance, and duration of mechanical ventilation, ICU stay, and hospital stay for surviving patients were secondary end points. (Details on the power calculation and statistical analysis of secondary end points are available in the Supplementary Appendix.)
Results
Characteristics of the Patients
From May 2004 through July 2006, a total of 5939 patients were enrolled in 13 participating centers: 1990 received standard care, 1904 received SOD, and 2045 received SDD. Permission for use of patient-specific medical data could not be obtained for 12 patients (11 in the SDD group and 1 in the standard-care group), who were excluded from all analyses except those for unadjusted mortality; 44 patients were discharged alive from the hospital but were lost to follow-up at day 28. Overall, 48 patients crossed over to a subsequent study period. The total number of patients included in the study per center ranged from 119 in a 4-bed ICU in a nonteaching hospital to 1013 patients in a 43-bed ICU in a university hospital. (Details on patient enrollment per center are available in the Supplementary Appendix.)
Eligibility was determined for a total of 6565 ICU admissions (with 300 to 1518 patients screened for eligibility per center). The average proportion of ICU patients eligible for study inclusion per center was 29.5% and ranged from 16.3 to 51.8%. Patients who were not eligible for the study had short ICU stays, in most cases after elective surgery. Of all eligible patients, 89.2% were included. Inclusion rates ranged from 51.8 to 100% per center. The mean inclusion rates for the SDD, SOD, and standard-care periods were 89.1%, 86.9%, and 91.6%, respectively (P=0.03 for standard care vs. SOD, P>0.05 for the other comparisons), and rates for the first, second, and third periods were 88.5%, 86.6%, and 92.8%, respectively (P=0.02 for the first period vs. the third period, P>0.05 for the other comparisons).
There were differences in baseline characteristics between patients in the standard-care group and those in the SOD and SDD groups (Table 1Table 1
Baseline Characteristics of the Patients.). Patients who received standard care had slightly lower APACHE II scores, were less likely to be receiving mechanical ventilation, and were more likely to have been admitted for surgical reasons. The proportions of patients who received antibiotics before admission to the ICU were similar in all three study groups. In the SOD and SDD groups, medication was administered according to protocol on 95.7% and 97.5% of all patient-days, respectively. Noncompliance, which was most frequent at the end of the ICU stay, was most often due to the patient's decision to decline medication.Primary and Secondary Clinical End Points
Crude mortality at day 28 for patients in the standard-care, SOD, and SDD groups was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model adjusted for age, sex, APACHE II score, intubation status, medical specialty, study site, and study period, odds ratios for death during the first 28 days for the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99; P=0.045) and 0.83 (95% CI, 0.72 to 0.97; P=0.02), respectively (Table 2Table 2
Primary and Secondary End Points.). When covariates were added to the model one at a time in order of statistical significance, it was evident that those with significant imbalances had the largest effect on the odds ratio (for more information see the Supplementary Appendix). The intracluster correlation coefficient was 0.010. With a baseline rate of death during the first 28 days of 27.5%, absolute and relative reductions in mortality at day 28 were 3.5% and 13%, respectively, for the SDD group and 2.9% and 11%, respectively, for the SOD group, corresponding with the needed-to-treat numbers of 29 and 34 to prevent one casualty at day 28 for SDD and SOD, respectively. There was a tendency for SDD and SOD to be associated with reductions in durations of mechanical ventilation, ICU stay, and hospital stay (Table 2). There was no evidence of an association of temporal trends, autocorrelation, or period-level effects with primary or secondary end points.Microbiologic Findings
Among patients receiving SDD or SOD as compared with those receiving standard care, crude incidences of ICU-acquired bacteremia were significantly reduced for S. aureus, glucose-nonfermenting gram-negative rods (mainly Pseudomonas aeruginosa), and Enterobacteriaceae (Table 3Table 3
Cumulative Incidence of ICU-Acquired Bacteremia and Candidemia.). Patients receiving SDD had a lower incidence of ICU-acquired bacteremia with Enterobacteriaceae than did those receiving SOD. The incidence of ICU-acquired candidemia tended to be lower in the SDD group than in either the SOD group or the standard-care group, although the difference was not significant. No significant differences among the three study groups were observed for infection with Streptococcus pneumoniae or Enterococcus species. Clostridium difficile toxin was detected in 15 patients (0.8%) in the standard-care group, 5 patients (0.3%) in the SOD group, and 9 patients (0.4%) in the SDD group.The estimated completeness of surveillance cultures per center was, on average, 87% (range, 70 to 97) for respiratory tract samples and 87% (range, 62 to 100) for rectal samples. The rate of isolation of gram-negative bacteria from rectal swabs among patients receiving SDD was reduced from 56% at day 3 to 25% at day 8 and 15% at day 14 (Figure 1Figure 1
Detection of Gram-Negative Bacteria in Patients in the Intensive Care Unit Who Were Treated with Selective Digestive Tract Decontamination (SDD) or Selective Oropharyngeal Decontamination (SOD).). The rate of culture positivity for gram-negative bacteria in oropharyngeal swabs from patients receiving SDD ranged from 18% at day 2 to 4% at day 8. Among patients treated with SOD, culture positivity ranged from 20% at day 2 to 7% at day 8 (Figure 1).In all, 2596 patients were included in the monthly point-prevalence surveillance studies for respiratory tract colonization (894 in the SDD group, 811 in the SOD group, and 891 in the standard-care group), and 2963 patients were included in the analysis of rectal colonization (988 in the SDD group, 947 in the SOD group, and 1028 in the standard-care group). Estimated completeness of culture surveillance per center was, on average, 87% (range, 67 to 98) for rectal samples and 82% (range, 69 to 95) for respiratory tract samples. The data from six point-prevalence measurements per study period were analyzed together. For all pathogen–antibiotic combinations, the rate of nonsusceptibility was less than 5% (Table 4Table 4
Detection of Antibiotic-Resistant, Gram-Negative Bacteria in Rectal and Respiratory Tract Samples during Point-Prevalence Surveys.). For multidrug resistance, the rate of nonsusceptibility was less than 2.5% for two antibiotics and less than or equal to 2% for three antibiotics. The proportion of patients with gram-negative bacteria in rectal swabs that were not susceptible to the marker antibiotics was lower with SDD than with standard care or SOD (Table 4). The proportions of patients with nonsusceptible bacteria in respiratory tract samples were similar in the SDD and SOD groups and were lower than the proportion in the standard-care group. There were no patients with methicillin-resistant S. aureus; eight patients had vancomycin-resistant enterococci in rectal swabs: six in the standard-care group (0.6%) and two in the SOD group (0.2%).Antibiotic Use
The median number of defined daily doses of systemic antibiotic agents (including antifungal agents) per patient-day did not differ significantly among the SDD, SOD, and standard-care periods: 0.72 (interquartile range, 0.44 to 1.33), 0.84 (interquartile range, 0.25 to 1.58), and 0.84 (interquartile range, 0.29 to 1.55), respectively. During treatment with SDD as compared with standard care, the use of antimicrobial agents with antianaerobic activity was reduced by 27.8% for broad-spectrum penicillins, 45.7% for carbapenems, and 11.6% for lincosamides (Table 5Table 5
Antibiotic Use.). Furthermore, quinolone use (mainly ciprofloxacin) was reduced by 31.4%. In contrast, systemic use of cephalosporins increased by 86.6%. There were less pronounced differences in antibiotic use between the SOD group and the standard-care group (Table 5). Total defined daily doses were 11.9% and 10.1% lower with SDD and SOD, respectively, than with standard care.Adverse Events
In one patient receiving SDD, esophageal obstruction developed as a result of clotted oropharyngeal medication, which was removed through endoscopy.24
Discussion
These data show an absolute reduction in mortality of 3.5 and 2.9 percentage points (corresponding to relative reductions of 13% and 11%) at day 28 with SDD and SOD, respectively, among patients admitted to Dutch ICUs. Patients were treated with topical components at a cost per day of $1 for SOD and $12 for SDD, without evidence of the emergence of antibiotic-resistant pathogens or increased rates of detection of C. difficile toxin (at least during the relatively short period of study). This benefit was discernible only after adjustment for covariates. The overall study period was not long enough to evaluate the effect of the prophylactic regimens on microbial flora.
The strengths of the study include its pragmatic, multicenter, crossover design and the monitoring of inclusion rates. Overall, an estimated 89% of eligible patients were included. Cluster randomization was needed to avoid the possibility that one study regimen would influence the outcome of another regimen. A consequence of this study design is the absence of concealment of randomization. Although randomized treatment assignments for study periods were concealed, the actual inclusion of patients was not randomized, and the physicians responsible for patient inclusion were aware of the assigned intervention. Blinding of physicians (or having a third person, who was unaware of the assigned interventions, overseeing inclusion) was deemed impossible. To minimize the risk of selection bias due to differences in patient inclusion among study centers and during different study periods, inclusion rates were monitored frequently for any instances of selective inclusion. Nevertheless, despite the use of objective inclusion criteria and the provision of continual feedback on inclusion rates to the participating centers, baseline differences were present between the standard-care group and both intervention groups, with patients in the intervention groups tending to be older, more likely to be intubated, and less likely to be surgical patients and tending to have a higher baseline APACHE II score. These differences were not consistent with chance, and they account for the differences between the crude and adjusted outcomes (Table 2).
The microbiologic aims of treatment with SDD or SOD were achieved in this study. During the SDD periods, all patients received intravenous prophylaxis with cefotaxime, and the desired microbiologic effects on carriage of gram-negative bacteria in the respiratory and intestinal tracts were achieved. Rates of eradication of gram-negative bacteria in the intestines and oropharynx were slightly higher than those reported by Stoutenbeek et al.7 and others.25,26 During the SDD and SOD study periods, prevalence rates for antibiotic-resistant gram-negative bacteria were lower than they were during the standard-care periods. These results are consistent with the finding, reported by de Jonge et al.2 and others,27,28 that in settings with low levels of circulating antibiotic-resistant organisms, SDD is not associated with increased selection or induction of antibiotic resistance in the short term. However, in settings with high levels of endemic, multidrug-resistant gram-negative bacteria17,29 or methicillin-resistant S. aureus, 18 SDD was associated with increased selection of such pathogens.
A limitation of our study is that the original analysis plan was not appropriate for the study design. Although analyses similar to that originally proposed have been widely used to assess data from cluster-randomization trials, they increase the chance of incorrect inferences. Conclusions based on such analyses cannot be considered reliable.21,22 Faced with the choice between performing an analysis known to be inappropriate and creating a new analysis plan, we decided that the latter was preferable. Very similar conclusions about the interventions would have been reached had the primary outcome been in-hospital mortality, as originally planned (with SDD very slightly less effective than SOD), after adjustment for baseline imbalances (Table 2). Evidence for the effectiveness of the interventions is supported by the significant reductions in the incidence of ICU-acquired bacteremia for important nosocomial pathogens in both intervention groups. Of note, the multiple comparisons of standard care with SDD and SOD increase the likelihood of type I errors.
Our finding that SDD and SOD have similar effects on survival raises questions about the relevance of systemic therapy with cefotaxime during the first 4 days of gastric and intestinal decontamination. Considering the importance of antibiotic resistance in ICUs, the SOD regimen seems preferable to the SDD regimen because it does not include widespread systemic prophylaxis with cephalosporins and involves a lower volume of topical antibiotics, thus minimizing the risk of selection for and development of antibiotic resistance in the long term. Furthermore, oropharyngeal decontamination with antiseptic agents, such as chlorhexidine, might be an alternative in environments with high levels of antibiotic resistance.13,30,31
Dr. Bonten reports receiving advisory-board fees from Ipsat Therapies, 3M, and Novartis; consulting fees from Novartis, 3M, and Bayer; and lecture fees from Cepheid and Pfizer. Dr. Kluytmans reports receiving consulting fees from 3M, NovaBay, and Wyeth and lecture fees from 3M and Becton Dickinson. Dr. Cooper reports receiving a lecture fee from Novartis. Dr. Voss reports receiving grants from 3M and Medica. No other potential conflict of interest relevant to this article was reported.
We thank the nursing and medical staff of the participating ICUs, the hospital pharmacists and medical microbiologists at the participating hospitals, the hospital pharmacists of ZNB of Leeuwarden for preparation of study medications, research nurses Fieke Kloosterman and Ilja te Paske for quality surveys, and Diederick Grobbee, Arno Hoes, Ale Algra, Martin Bootsma, and Jan Vandenbroucke for analytical advice. The study is dedicated to Hilly de Vries-Hospers, M.D., Ph.D., medical microbiologist at the UMC Groningen, who died in 2005.
Source Information
The authors' affiliations are listed in the Appendix.
Address reprint requests to Dr. de Smet at the Division of Perioperative and Emergency Care, University Medical Center Utrecht, Q04.2.313, P.O. Box 85500, 3508GA Utrecht, the Netherlands, or at a.desmet@umcutrecht.nl.
Appendix
The authors' affiliations are as follows: the Division of Perioperative and Emergency Care (A.M.G.A.S., E.S.T.G., M.E.P., C.J.K.), the Division of Intensive Care Medicine (J.C.A.J.), the Department of Medical Microbiology (M.A.L-H., H.E.M.B., M.J.M.B.), the Department of Clinical Pharmacy (E.V.U.), and the Julius Center for Health Sciences and Primary Care (M.J.M.B.), University Medical Center, Utrecht; the Laboratory for Microbiology and Infection Control (J.A.J.W.K., D.B.-H.) and the Department of Anesthesiology and Intensive Care (N.J.M.M.), Amphia Hospital, Breda; the Laboratory for Medical Microbiology and Immunology (E.M.M.) and the Department of Intensive Care (K.K., F.H.B.), Rijnstate Hospital, Arnhem; the Department of Medical Microbiology (R.F.J.B., J.P.A.), the Departments of Internal Medicine and Pulmonary Diseases and Tuberculosis (T.S.W.), and the Department of Anesthesiology (L.P.H.J.A.), University Medical Center, Groningen; the Department of Intensive Care (J.G.H., P.P.) and the Department of Medical Microbiology (P.D.J.S., A.V.), Radboud University, Nijmegen Medical Center, Nijmegen; the Department of Medical Microbiology (A.T.B., E.J.K.) and the Department of Intensive Care (H.I.J.H.), Leiden University Medical Center, Leiden; the Department of Intensive Care (A.J.G.H.B.) and the Laboratory for Medical Microbiology (A.R.J.), Laboratories for Pathology and Medical Microbiology, Catharina Hospital, Eindhoven; the Department of Anesthesiology and Intensive Care (R.M.J.W.) and the Department of Medical Microbiology and Immunology (B.M.J.), St. Antonius Hospital, Nieuwegein; the Department of Intensive Care (P.J.W.D.) and the Department of Medical Microbiology (G.J.A.), Medical Center Haaglanden, The Hague; the Department of Intensive Care (L.F.V.) and the Regional Laboratory for Medical Microbiology and Infectious Diseases, Dordrecht–Gorinchem (I.H.M.E.F.); Albert Schweitzer Hospital, Dordrecht; the Department of Intensive Care (M.I.) and the Department of Medical Microbiology (S.F.T.T.), Diakonessen Hospital, Utrecht; the Intensive Care Department (G.H.K.) and the Department of Clinical Microbiology (W.P.), Slotervaart Hospital, Amsterdam; and the Department of Intensive Care (J.W.V.) and the Department of Medical Microbiology and Immunology (J.A.K.), Mesos Medical Center, Utrecht — all in the Netherlands; and the Centre for Infections Health Protection Agency Statistics, Modelling and Bioinformatics Department, London (B.S.C.).
- References
References
1
Vincent J-L . Nosocomial infections in adult intensive-care units. Lancet 2003;361:2068-2077
CrossRef | Web of Science | Medline2
de Jonge E ,Schultz M ,Spanjaard L , et al. Effects of selective decontamination of the digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 2003;362:1011-1016
CrossRef | Web of Science | Medline3
D'Amico R ,Pifferi S ,Leonetti C ,Torri V ,Tinazzi A ,Liberati A . Effectiveness of antibiotic prophylaxis in critically ill adult patients: systemic review of randomised controlled trials. BMJ 1998;316:1275-1285
CrossRef | Web of Science | Medline4
Pugin J ,Auckenthaler R ,Lew DP ,Suter PM . Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia: a randomized, placebo-controlled, double-blind clinical trial. JAMA 1991;265:2704-2710
CrossRef | Web of Science | Medline5
Bergmans DC ,Bonten MJ ,Gaillard CA , et al. Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study. Am J Respir Crit Care Med 2001;164:382-388
Web of Science | Medline6
van der Waaij D ,Berghuis-de Vries JM ,Lekkerkerk-van der Wees JEC . Colonization resistance of the digestive tract in conventional and antibiotic-treated mice. J Hyg (Lond) 1971;69:405-411
CrossRef | Web of Science | Medline7
Stoutenbeek CP ,van Saene HKF ,Miranda DR ,Zandstra DF . The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intensive Care Med 1984;10:185-192
CrossRef | Web of Science | Medline8
Nathens AB ,Marshall JC . Selective decontamination of the digestive tract in surgical patients: a systematic review of the evidence. Arch Surg 1999;134:170-176
CrossRef | Web of Science | Medline9
Krueger WA ,Lenhart FP ,Neeser G , et al. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical trial. Am J Respir Crit Care Med 2002;166:1029-1037
CrossRef | Web of Science | Medline10
de la Cal MA ,Cerda E ,Garcia-Hierro P , et al. Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg 2005;241:424-430
CrossRef | Web of Science | Medline11
Bonten MJM ,Gaillard CA ,van Tiel FH ,Smeets HGW ,van der Geest S ,Stobberingh EE . The stomach is not a source for colonization of the upper respiratory tract and pneumonia in ICU patients. Chest 1994;105:878-884
CrossRef | Web of Science | Medline12
Garrouste-Orgeas M ,Chevret S ,Arlet G , et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients: a prospective study based on genomic DNA analysis. Am J Respir Crit Care Med 1997;156:1647-1655
Web of Science | Medline13
Chan EY ,Ruest A ,Meade MO ,Cook DJ . Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007;334:889-900
CrossRef | Web of Science | Medline14
Bonten MJ ,Kollef MH ,Hall JB . Risk factors for ventilator-associated pneumonia: from epidemiology to patient management. Clin Infect Dis 2004;38:1141-1149
CrossRef | Web of Science | Medline15
Bonten MJ ,Kluytmans J ,de Smet AM ,Bootsma M ,Hoes A . Selective decontamination of digestive tract in intensive care. Lancet 2003;362:2118-2119
CrossRef | Web of Science | Medline16
van Nieuwenhoven CA ,Buskens E ,van Tiel FH ,Bonten MJ . Relationship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients. JAMA 2001;286:335-340
CrossRef | Web of Science | Medline17
Verwaest C ,Verhaegen J ,Ferdinande P , et al. Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit Care Med 1997;25:63-71
CrossRef | Web of Science | Medline18
Lingnau W ,Berger J ,Javorsky F ,Fille M ,Allerberger F ,Benzer H . Changing bacterial ecology during a five-year period of selective intestinal decontamination. J Hosp Infect 1998;39:195-206
CrossRef | Web of Science | Medline19
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416
CrossRef | Web of Science | Medline20
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003. Atlanta: Centers for Disease Control and Prevention, 2003. (Accessed December 5, 2008, at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CDCpneumo_guidelines.pdf.)
21
Puffer S ,Torgerson D ,Watson J . Evidence for risk of bias in cluster randomised trials: review of recent trials published in three general medical journals. BMJ 2003;327:785-789
CrossRef | Web of Science | Medline22
Campbell MK ,Elbourne DR ,Altman DG . CONSORT statement: extension to cluster randomised trials. BMJ 2004;328:702-708
CrossRef | Web of Science | Medline23
Branson RD ,Davis K Jr ,Campbell RS ,Johnson DJ ,Porembka DT . Humidification in the intensive care unit: prospective study of a new protocol utilizing heated humidification and hygroscopic condenser humidifier. Chest 1993;104:1800-1805
CrossRef | Web of Science | Medline24
Smit MJ ,van der Spoel JI ,de Smet AM ,de Jonge E ,Kuiper RA ,van Lieshout EJ . Accumulation of oral antibiotics as an adverse effect of selective decontamination of the digestive tract: a series of three cases. Intensive Care Med 2007;33:2025-2026
CrossRef | Web of Science | Medline25
Kerver AJH ,Rommes JH ,Mevissen-Verhage EAE , et al. Prevention of colonization and infection in critically ill patients: a prospective randomized study. Crit Care Med 1988;16:1087-1093
CrossRef | Web of Science | Medline26
Hartenauer U ,Thulig B ,Diemer W , et al. Effect of selective flora suppression on colonization, infection, and mortality in critically ill patients: a one-year, prospective consecutive study. Crit Care Med 1991;19:463-473
CrossRef | Web of Science | Medline27
Stoutenbeek CP ,van Saene HK ,Little RA ,Whitehead A . The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial. Intensive Care Med 2007;33:261-270
CrossRef | Web of Science | Medline28
Heininger A ,Meyer E ,Schwab F ,Marschal M ,Unertl K ,Krueger WA . Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance. Intensive Care Med 2006;32:1569-1576
CrossRef | Web of Science | Medline29
Hammond JMJ ,Potgieter PD ,Saunders GL ,Forder AA . Double-blind study of selective decontamination of the digestive tract in intensive care. Lancet 1992;340:5-9
CrossRef | Web of Science | Medline30
Koeman M ,van der Ven AJ ,Hak E , et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 2006;173:1348-1355
CrossRef | Web of Science | Medline31
Segers P ,Speekenbrink RG ,Ubbink DT ,van Ogtrop ML ,de Mol BA . Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006;296:2460-2466
CrossRef | Web of Science | Medline
- Citing Articles (107)
Citing Articles
1
W. G. Melsen, A. M. G. A. de Smet, J. A. J. W. Kluytmans, M. J. M. Bonten, . (2012) Selective decontamination of the oral and digestive tract in surgical versus non-surgical patients in intensive care in a cluster-randomized trial. British Journal of Surgery 99:2, 232-237
CrossRef2
L. M. Ytrebø. (2012) Selective decontamination of the oral and digestive tract in surgical versus non-surgical patients in intensive care in a cluster-randomized trial (Br J Surg 2012; 99: 232-237). British Journal of Surgery 99:2, 238-238
CrossRef3
Joe Brierley, Lorraine Highe, Sarah Hines, Garth Dixon. (2012) Reducing VAP by instituting a care bundle using improvement methodology in a UK Paediatric Intensive Care Unit. European Journal of Pediatrics 171:2, 323-330
CrossRef4
Paula Ramirez, Gianluigi L. Bassi, Antonio Torres. (2012) Measures to prevent nosocomial infections during mechanical ventilation. Current Opinion in Critical Care 18:1, 86-92
CrossRef5
Evelien A. N. Oostdijk, Bastiaan H. J. Wittekamp, Christian Brun-Buisson, Marc J. M. Bonten. (2012) Selective decontamination in European intensive care patients. Intensive Care Medicine
CrossRef6
Lisa Saidel-Odes, Hana Polachek, Nehama Peled, Klaris Riesenberg, Francisc Schlaeffer, Yafa Trabelsi, Seada Eskira, Baha Yousef, Rozalia Smolykov, Shlomi Codish, Abraham Borer. (2012) A Randomized, Double-Blind, Placebo-Controlled Trial of Selective Digestive Decontamination Using Oral Gentamicin and Oral Polymyxin E for Eradication of Carbapenem-Resistant Klebsiella pneumoniae Carriage. Infection Control and Hospital Epidemiology 33:1, 14-19
CrossRef7
M. Martin, I. Winterfeld, E. Kramme, I. Ewert, B. Sedemund-Adib, F. Mattner. (2012) Ausbruch mit Burkholderia-cepacia-Komplex durch kontaminierte Mundspüllösung. Der Anaesthesist 61:1, 25-29
CrossRef8
Eamonn MM Quigley. (2011) Gut microbiota and the role of probiotics in therapy. Current Opinion in Pharmacology 11:6, 593-603
CrossRef9
Eamonn M. Quigley, John G. Laffey. (2011) Selective digestive decontamination reduces bacteremia following eradication of gut overgrowth. Critical Care Medicine 39:12, 2786
CrossRef10
Pleun J. van Duijn, Mirjam J.D. Dautzenberg, Evelien A.N. Oostdijk. (2011) Recent trends in antibiotic resistance in European ICUs. Current Opinion in Critical Care 17:6, 658-665
CrossRef11
Armin D. Goralczyk, Wijdan Abu-Ajaj, Tung Yu Tsui, Martin Bauer, Thomas Lorf, Giuliano Ramadori, Aiman Obed. (2011) Liver transplantation in patients with liver cirrhosis and active pneumonia: an observational study. Transplant International 24:11, 1068-1074
CrossRef12
Mary Kay Bader. (2011) Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Therapeutic Hypothermia and Temperature Management 1:3, 165-171
CrossRef13
Enrique Fernández-Mondéjar, Francisco Guerrero-López. (2011) Prevención secundaria en patología traumática: ¿influye el interés comercial en la implementación de la evidencia científica?. Medicina Clínica
CrossRef14
Yu WANG, Xiaoyong XU, Min CHEN, Ziling LI. (2011) Oral chlorhexidine administration and ventilator-associated pneumonia: a meta-analysis. Chinese Journal of Multiple Organ Diseases in the Elderly 10:4, 333-336
CrossRef15
José Blanquer, Javier Aspa, Antonio Anzueto, Miguel Ferrer, Miguel Gallego, Olga Rajas, Jordi Rello, Felipe Rodríguez de Castro, Antonio Torres. (2011) SEPAR Guidelines for Nosocomial Pneumonia. Archivos de Bronconeumología (English Edition) 47:10, 510-520
CrossRef16
José Blanquer, Javier Aspa, Antonio Anzueto, Miguel Ferrer, Miguel Gallego, Olga Rajas, Jordi Rello, Felipe Rodríguez de Castro, Antonio Torres. (2011) Normativa SEPAR: neumonía nosocomial. Archivos de Bronconeumología 47:10, 510-520
CrossRef17
F. del Rio Gallegos. (2011) Increasing the number of valid lungs for transplantation: a necessity. Medicina Intensiva (English Edition) 35:7, 401-402
CrossRef18
F. del Rio Gallegos. (2011) Incrementar el número de pulmones válidos para trasplante: una necesidad. Medicina Intensiva 35:7, 401-402
CrossRef19
A. van Eck van der Sluijs, J. J. Oosterheert, M. B. Ekkelenkamp, I. M. Hoepelman, Edgar J. G. Peters. (2011) Bacteremic complications of intravascular catheter tip colonization with Gram-negative micro-organisms in patients without preceding bacteremia. European Journal of Clinical Microbiology & Infectious Diseases
CrossRef20
T Zuckerman, N Benyamini, H Sprecher, R Fineman, R Finkelstein, J M Rowe, I Oren. (2011) SCT in patients with carbapenem resistant Klebsiella pneumoniae: a single center experience with oral gentamicin for the eradication of carrier state. Bone Marrow Transplantation 46:9, 1226-1230
CrossRef21
Guy J. Oudhuis, Dennis C. Bergmans, Ellen E. Stobberingh, Annelies Verbon. (2011) Reply to Petros et al.: Gut overgrowth harms the critically ill. Intensive Care Medicine 37:9, 1561-1562
CrossRef22
María E. Ochoa-Ardila, Ana García-Cañas, Karen Gómez-Mediavilla, Ana González-Torralba, Inmaculada Alía, Paloma García-Hierro, Nia Taylor, Hendrick K. F. Saene, Miguel A. Cal. (2011) Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: a 5-year prospective cohort study. Intensive Care Medicine 37:9, 1458-1465
CrossRef23
D. Ramnarain, D. W. Lange, J. Meulenbelt. (2011) Acute renal failure due to tobramycin intoxication during selective digestive tract decontamination. Intensive Care Medicine 37:8, 1386-1387
CrossRef24
Martine E. Bos Eyssen, Pieter A. Doorn, Bart C. Jacobs, Ewout W. Steyerberg, Peter H. J. Voort, Durk F. Zandstra, Janneke Horn, Peter E. Spronk, Cornelia W. Hoedemaekers, Jan Bakker, Mathieu Jagt. (2011) Selective Digestive Tract Decontamination Decreases Time on Ventilator in Guillain–Barré Syndrome. Neurocritical Care 15:1, 128-133
CrossRef25
Michael J. Morowitz, Erica M. Carlisle, John C. Alverdy. (2011) Contributions of Intestinal Bacteria to Nutrition and Metabolism in the Critically Ill. Surgical Clinics of North America 91:4, 771-785
CrossRef26
Rafael San-Juan, Jose M. Aguado, Carlos Lumbreras, Jesus Fortun, Oscar Len, Patricia Munoz, Miguel Montejo, Asunción Moreno, Elisa Cordero, Marino Blanes, Antonio Ramos, Julian Torre-Cisneros, Francisco López-Medrano, Jordi Carratala, Enrique Moreno, . (2011) Selective intestinal decontamination with fluoroquinolones for the prevention of early bacterial infections after liver transplantation. Liver Transplantation 17:8, 896-904
CrossRef27
Marin H. Kollef. (2011) Hospital-acquired pneumonia/ventilator-associated pneumonia prevention: Truth or dare!*. Critical Care Medicine 39:8, 2015-2016
CrossRef28
N.H.J. Leenders, J.J. Oosterheert, M.B. Ekkelenkamp, D.W. De Lange, A.I.M. Hoepelman, E.J.G. Peters. (2011) Candidemic complications in patients with intravascular catheters colonized with Candida species: an indication for preemptive antifungal therapy?. International Journal of Infectious Diseases 15:7, e453-e458
CrossRef29
Jeremy J. Mathers, Sondra C. Flick, L. Anthony Cox. (2011) Longer-duration uses of tetracyclines and penicillins in U.S. food-producing animals: Indications and microbiologic effects. Environment International 37:5, 991-1004
CrossRef30
R. Lawrence Reed. (2011) Prevention of Hospital-Acquired Infections by Selective Digestive Decontamination. Surgical Infections 12:3, 221-229
CrossRef31
Marin H. Kollef. (2011) Prevention of Nosocomial Pneumonia in the Intensive Care Unit: Beyond the Use of Bundles. Surgical Infections 12:3, 211-220
CrossRef32
Oleksa Rewa, John Muscedere. (2011) Ventilator-Associated Pneumonia: Update on Etiology, Prevention, and Management. Current Infectious Disease Reports 13:3, 287-295
CrossRef33
Irene P. Jongerden, Anton G. Buiting, Maurine A. Leverstein-van Hall, Ben Speelberg, Shimriet Zeidler, Jozef Kesecioglu, Marc J. Bonten. (2011) Effect of open and closed endotracheal suctioning on cross-transmission with Gram-negative bacteria: A prospective crossover study*. Critical Care Medicine 39:6, 1313-1321
CrossRef34
Ian M. Seppelt. (2011) Trial designs for old problems in a new era*. Critical Care Medicine 39:6, 1561-1562
CrossRef35
J. C. Hurley. (2011) Lack of impact of selective digestive decontamination on Pseudomonas aeruginosa ventilator-associated pneumonia: benchmarking the evidence base. Journal of Antimicrobial Chemotherapy 66:6, 1365-1373
CrossRef36
Eamonn M. M. Quigley. (2011) Passing the bug—Translocation, bacteremia, and sepsis in the intensive care unit patient: Is intestinal decontamination the answer?*. Critical Care Medicine 39:5, 1202-1203
CrossRef37
(2011) Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. Intensivmedizin und Notfallmedizin 48:4, 291-344
CrossRef38
Anne Marie GA de Smet, Jan AJW Kluytmans, Hetty EM Blok, Ellen M Mascini, Robin FJ Benus, Alexandra T Bernards, Ed J Kuijper, Maurine A Leverstein-van Hall, Arjan R Jansz, Bartelt M de Jongh, Gerard J van Asselt, Ine HME Frenay, Steven FT Thijsen, Simon NM Conijn, Jan A Kaan, Jan P Arends, Patrick DJ Sturm, Martin CJ Bootsma, Marc JM Bonten. (2011) Selective digestive tract decontamination and selective oropharyngeal decontamination and antibiotic resistance in patients in intensive-care units: an open-label, clustered group-randomised, crossover study. The Lancet Infectious Diseases 11:5, 372-380
CrossRef39
Jean-Louis Vincent, Frédérique Jacobs. (2011) Effect of selective decontamination on antibiotic resistance. The Lancet Infectious Diseases 11:5, 337-338
CrossRef40
Evelien A. N. Oostdijk, Anne Marie G. A. de Smet, Jozef Kesecioglu, Marc J. M. Bonten. (2011) The role of intestinal colonization with Gram-negative bacteria as a source for intensive care unit-acquired bacteremia*. Critical Care Medicine 39:5, 961-966
CrossRef41
Vani Venkatachalam, J. Owen Hendley, Douglas F. Willson. (2011) The diagnostic dilemma of ventilator-associated pneumonia in critically ill children*. Pediatric Critical Care Medicine 12:3, 286-296
CrossRef42
J.-C. Lucet, L. Bouadma. (2011) Reply to Cadena et al. Clinical Infectious Diseases 52:8, 1084-1085
CrossRef43
J. R. Prowle, S. Heenen, M. Singer. (2011) Infection in the critically ill--questions we should be asking. Journal of Antimicrobial Chemotherapy 66:Supplement 2, ii3-ii10
CrossRef44
Zaccaria Ricci, Andrea Polito, Angelo Polito, Claudio Ronco. (2011) The implications and management of septic acute kidney injury. Nature Reviews Nephrology 7:4, 218-225
CrossRef45
Alessandro Di Filippo, Andrea Casini, Angelo Raffaele de Gaudio. (2011) Infection prevention in the intensive care unit: Review of the recent literature on the management of invasive devices. Scandinavian Journal of Infectious Diseases 43:4, 243-250
CrossRef46
Raquel Albertos, Berta Caralt, Jordi Rello. (2011) Ventilator-associated pneumonia management in critical illness. Current Opinion in Gastroenterology 27:2, 160-166
CrossRef47
Jerry M. Zuckerman. (2011) Prevention of Health Care–Acquired Pneumonia and Transmission of Mycobacterium tuberculosis in Health Care Settings. Infectious Disease Clinics of North America 25:1, 117-133
CrossRef48
Francisco Abecasis, Richard E. Sarginson, Steve Kerr, Nia Taylor, Hendrik K.F. van Saene. (2011) Is Selective Digestive Decontamination Useful in Controlling Aerobic Gram-Negative Bacilli Producing Extended Spectrum Beta-Lactamases?. Microbial Drug Resistance 17:1, 17-23
CrossRef49
T. Perl, M. Quintel. (2011) Nosokomiale Pneumonie. Der Anaesthesist 60:3, 236-242
CrossRef50
Massimo Antonelli, Elie Azoulay, Marc Bonten, Jean Chastre, Giuseppe Citerio, Giorgio Conti, Daniel Backer, Herwig Gerlach, Goran Hedenstierna, Michael Joannidis, Duncan Macrae, Jordi Mancebo, Salvatore M. Maggiore, Alexandre Mebazaa, Jean-Charles Preiser, Jerôme Pugin, Jan Wernerman, Haibo Zhang. (2011) Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Medicine 37:2, 196-213
CrossRef51
S. Hagel, F. Brunkhorst. (2011) Sepsis. Intensivmedizin und Notfallmedizin 48:1, 57-73
CrossRef52
Luciano Silvestri, Nia Taylor, Durk F Zandstra, Hendrick KF van Saene. (2011) Selective digestive decontamination is superior to selective oropharyngeal decontamination. Critical Care 15:2, 411
CrossRef53
Volker Strenger, Tanja Gschliesser, Andrea Grisold, Gernot Zarfel, Gebhard Feierl, Lilian Masoud, Martin Hoenigl, Bernhard Resch, Wilhelm Müller, Berndt Urlesberger. (2011) Orally administered colistin leads to colistin-resistant intestinal flora and fails to prevent faecal colonisation with extended-spectrum β-lactamase-producing enterobacteria in hospitalised newborns. International Journal of Antimicrobial Agents 37:1, 67-69
CrossRef54
Claudia Pileggi, Aida Bianco, Domenico Flotta, Carmelo GA Nobile, Maria Pavia. (2011) Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. Critical Care 15:3, R155
CrossRef55
Marlijn Kamps, Laurens A Bisschops, Johannes G van der Hoeven, Cornelia WE Hoedemaekers. (2011) Hypothermia does not increase the risk of infection: a case control study. Critical Care 15:1, R48
CrossRef56
Heleen M Oudemans-van Straaten, Henrik Endeman, Robert J Bosman, Milly E Attema-de Jonge, Marc L van Ogtrop, Durk F Zandstra, Eric JF Franssen. (2011) Presence of tobramycin in blood and urine during selective decontamination of the digestive tract in critically ill patients, a prospective cohort study. Critical Care 15:5, R240
CrossRef57
S.N. Mutsaers, D. Roos, H.M. Oudemans-van Straaten, L.T. de Wit, D.J. Gouma, M.F. Gerhards. (2011) Current Application of Selective Decontamination of the Digestive Tract, Perioperative Antibiotics and Mechanical Bowel Preparation in Surgical Departments in the Netherlands. Digestive Surgery 28:5-6, 338-344
CrossRef58
Guy J. Oudhuis, Dennis C. Bergmans, Tom Dormans, Jan-Harm Zwaveling, Alfons Kessels, Martin H. Prins, Ellen E. Stobberingh, Annelies Verbon. (2011) Probiotics versus antibiotic decontamination of the digestive tract: infection and mortality. Intensive Care Medicine 37:1, 110-117
CrossRef59
M. J. M. Bonten. (2011) Healthcare Epidemiology: Ventilator-Associated Pneumonia: Preventing the Inevitable. Clinical Infectious Diseases 52:1, 115-121
CrossRef60
Kees H Polderman. (2011) Hypothermia, immune suppression and SDD: can we have our cake and eat it?. Critical Care 15:2, 144
CrossRef61
Charles Weijer, Jeremy M Grimshaw, Monica Taljaard, Ariella Binik, Robert Boruch, Jamie C Brehaut, Allan Donner, Martin P Eccles, Antonio Gallo, Andrew D McRae, Raphael Saginur, Merrick Zwarenstein. (2011) Ethical issues posed by cluster randomized trials in health research. Trials 12:1, 100
CrossRef62
Gwendolyn M. P. Diepenhorst, Oddeke van Ruler, Marc G. H. Besselink, Hjalmar C. van Santvoort, Paul R. Wijnandts, Willem Renooij, Dirk J. Gouma, Hein G. Gooszen, Marja A. Boermeester. (2011) Influence of Prophylactic Probiotics and Selective Decontamination on Bacterial Translocation in Patients Undergoing Pancreatic Surgery. Shock 35:1, 9-16
CrossRef63
Tracie Northway, Joanne M. Langley, Peter Skippen. 2011. Health Care–Associated Infection in the Pediatric Intensive Care Unit. , 1349-1363.
CrossRef64
Arielle Butterly, Ulrich Schmidt, Jeanine Wiener-Kronish. (2010) Methicillin-resistant Staphylococcus Aureus Colonization, Its Relationship to Nosocomial Infection, and Efficacy of Control Methods. Anesthesiology 113:6, 1453-1459
CrossRef65
S. Gatermann, I.F. Chaberny, M. Pletz, B. Schaaf. (2010) Multiresistente pulmonale Erreger auf der Intensivstation. Der Pneumologe 7:6, 412-422
CrossRef66
Jean-Louis Vincent, Mervyn Singer. (2010) Critical care: advances and future perspectives. The Lancet 376:9749, 1354-1361
CrossRef67
Andrés Canut, Blanca García-San Vicente. (2010) Respuesta de los autores. Enfermedades Infecciosas y Microbiología Clínica 28:8, 570-571
CrossRef68
R. F. Benus, H. J. Harmsen, T. S. Werf. (2010) SDD: don’t be selective in considering pros and cons. Intensive Care Medicine 36:10, 1785-1786
CrossRef69
Matthew E Falagas, Ioanna P Korbila, Drosos E Karageorgopoulos. (2010) Probiotics for the prevention of ventilator-associated pneumonia. Expert Review of Respiratory Medicine 4:5, 567-571
CrossRef70
Robin F. Benus, Hermie J. Harmsen, Gjalt W. Welling, Rob Spanjersberg, Jan G. Zijlstra, John E. Degener, Tjip S. Werf. (2010) Impact of digestive and oropharyngeal decontamination on the intestinal microbiota in ICU patients. Intensive Care Medicine 36:8, 1394-1402
CrossRef71
Courtney Hebert, Ari Robicsek. (2010) Decolonization therapy in infection control. Current Opinion in Infectious Diseases 23:4, 340-345
CrossRef72
Luciano Silvestri, Hendrick K. F. Saene, Durk F. Zandstra, Marino Viviani, Dario Gregori. (2010) SDD, SOD, or oropharyngeal chlorhexidine to prevent pneumonia and to reduce mortality in ventilated patients: which manoeuvre is evidence-based?. Intensive Care Medicine 36:8, 1436-1437
CrossRef73
Lee E. Morrow, Marin H. Kollef. (2010) Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation. Critical Care Medicine 38, S352-S362
CrossRef74
F.M. Brunkhorst, P. Gastmeier, W. Kern, W. Krüger, K. Mayer, A. Weimann, T. Welte, C. Putensen, K. Werdan, K. Reinhart. (2010) Prävention und Nachsorge der Sepsis. Der Internist 51:7, 925-932
CrossRef75
Michael Klompas. (2010) Prevention of ventilator-associated pneumonia. Expert Review of Anti-infective Therapy 8:7, 791-800
CrossRef76
Tomislav Ćabov, Darko Macan, Ino Husedžinović, Jasenka Škrlin-Šubić, Danica Bošnjak, Sandra Šestan-Crnek, Berislav Perić, Zoran Kovač, Vesna Golubović. (2010) The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wiener klinische Wochenschrift 122:13-14, 397-404
CrossRef77
Marcus J. Schultz. (2010) Symbiotics as a preventive measure against ventilator-associated pneumonia. Critical Care Medicine 38:6, 1506-1507
CrossRef78
Jan G. Zijlstra, L. Marjon Dijkema, Jack J. M. Ligtenberg, Armand R. J. Girbes. (2010) Severity scoring abuse. Critical Care Medicine 38:6, 1502
CrossRef79
M. Bernhard, G. Marx, K. Weismüller, C. Lichtenstern, K. Mayer, F.M. Brunkhorst, M.A. Weigand. (2010) Ergebnisse intensivmedizinischer Studien des Jahres 2009. Der Anaesthesist 59:5, 453-476
CrossRef80
Ariel L. Shiloh, Lewis A. Eisen, Richard H. Savel. (2010) Selective decontamination of the digestive tract: What outcomes matter?*. Critical Care Medicine 38:5, 1386-1387
CrossRef81
K. Reinhart, F.M. Brunkhorst, H.-G. Bone, J. Bardutzky, C.-E. Dempfle, H. Forst, P. Gastmeier, H. Gerlach, M. Gründling, S. John, W. Kern, G. Kreymann, W. Krüger, P. Kujath, G. Marggraf, J. Martin, K. Mayer, A. Meier-Hellmann, M. Oppert, C. Putensen, M. Quintel, M. Ragaller, R. Rossaint, H. Seifert, C. Spies, F. Stüber, N. Weiler, A. Weimann, K. Werdan, T. Welte. (2010) Prävention, Diagnose, Therapie und Nachsorge der Sepsis. Intensivmedizin und Notfallmedizin 47:3, 185-207
CrossRef82
K. Reinhart, F.M. Brunkhorst, H.-G. Bone, J. Bardutzky, C.-E. Dempfle, H. Forst, P. Gastmeier, H. Gerlach, M. Gründling, S. John, W. Kern, G. Kreymann, W. Krüger, P. Kujath, G. Marggraf, J. Martin, K. Mayer, A. Meier-Hellmann, M. Oppert, C. Putensen, M. Quintel, M. Ragaller, R. Rossaint, H. Seifert, C. Spies, F. Stüber, N. Weiler, A. Weimann, K. Werdan, T. Welte. (2010) Prävention, Diagnose, Therapie und Nachsorge der Sepsis. Der Anaesthesist 59:4, 347-370
CrossRef83
Jean Carlet. (2010) Anti-, pre-, or . . . probiotics to prevent ventilator-associated pneumonia in the intensive care unit?*. Critical Care Medicine 38:3, 1009-1010
CrossRef84
Luciano Silvestri, Miguel A. de la Cal, Nia Taylor, Hendrick K.F. van Saene, Pier Camillo Parodi. (2010) Selective Decontamination of the Digestive Tract in Burn Patients: An Evidence-Based Maneuver That Reduces Mortality. Journal of Burn Care & Research 31:2, 372-373
CrossRef85
Michael J. Mosier, Tam N. Pham. (2010) Selective Decontamination of the Digestive Tract in Burn Patients: An Evidence-Based Maneuver That Reduces Mortality. Journal of Burn Care & Research 31:2, 374
CrossRef86
L. Silvestri, H. K. F. van Saene, D. F. Zandstra, J. C. Marshall, D. Gregori, A. Gullo. (2010) Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: Systematic review of randomized controlled trials. Critical Care Medicine1
CrossRef87
Zongdao Shi, Huixu Xie, Ping Wang, Yan Wu, E Chen, Linda Ng, Helen V Worthington, Mervyn Singer, Ian Needleman, Zongdao Shi. 2010. Oral hygiene care for critically ill patients to prevent ventilator associated pneumonia. .
CrossRef88
Blanca García-San Vicente, Andrés Canut, Alicia Labora, Maritxu Otazua, Esther Corral. (2010) Descontaminación digestiva selectiva: repercusión en la carga de trabajo y el coste del laboratorio de microbiología y tendencias en la resistencia bacteriana. Enfermedades Infecciosas y Microbiología Clínica 28:2, 75-81
CrossRef89
P. Gastmeier. (2010) Nosokomiale Infektionen. Der Internist 51:2, 129-135
CrossRef90
Jie Hae Park, Jin Nyeong Chae, Won-Il Choi. (2010) Critical Care Medicine. Tuberculosis and Respiratory Diseases 69:2, 75
CrossRef91
C. Lichtenstern, S. Swoboda, M. Hirschburger, E. Domann, T. Hoppe-Tichy, M. Winkler, C. Lass-Flörl, M.A. Weigand. (2010) Update: invasive Pilzinfektionen. Der Anaesthesist 59:1, 30-52
CrossRef92
Lenneke E. M. Haas, Marcus J. Schultz. (2010) Selective Decontamination of the Digestive Tract Reduces Pneumonia and Mortality. Critical Care Research and Practice 2010, 1-11
CrossRef93
Deverick J. Anderson, Keith S. Kaye. (2009) Controlling Antimicrobial Resistance in the Hospital. Infectious Disease Clinics of North America 23:4, 847-864
CrossRef94
Thierry Gustot, François Durand, Didier Lebrec, Jean-Louis Vincent, Richard Moreau. (2009) Severe sepsis in cirrhosis. Hepatology 50:6, 2022-2033
CrossRef95
Alessandro Liberati, Roberto D'Amico, Silvia Pifferi, Valter Torri, Luca Brazzi, Elena Parmelli, Alessandro Liberati. 2009. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. .
CrossRef96
Patrique Segers, Bas A. Mol. (2009) Prevention of ventilator-associated pneumonia after cardiac surgery: prepare and defend!. Intensive Care Medicine 35:9, 1497-1499
CrossRef97
S. Froh. (2009) Selektive Dekontamination des Magen-Darm-Traktes und des Oropharynx bei kritisch kranken Patienten. Intensivmedizin und Notfallmedizin 46:6, 450-454
CrossRef98
John Dallas, Marin Kollef. (2009) Severe hospital-acquired pneumonia: A review for clinicians. Current Infectious Disease Reports 11:5, 349-356
CrossRef99
Anne Marie G. A. Smet, Titia E. M. Hopmans, Albertus L. C. Minderhoud, Hetty E. M. Blok, Annelies Gossink-Franssen, Alexandra T. Bernards, Marc J. M. Bonten. (2009) Decontamination of the digestive tract and oropharynx: hospital acquired infections after discharge from the intensive care unit. Intensive Care Medicine 35:9, 1609-1613
CrossRef100
Barry A. Mizock. (2009) The Multiple Organ Dysfunction Syndrome. Disease-a-Month 55:8, 476-526
CrossRef101
Emilio Bouza, Almudena Burillo. (2009) Advances in the prevention and management of ventilator-associated pneumonia. Current Opinion in Infectious Diseases 22:4, 345-351
CrossRef102
Kees H. Polderman. (2009) Mechanisms of action, physiological effects, and complications of hypothermia. Critical Care Medicine 37:Supplement, S186-S202
CrossRef103
(2009) Decontamination of the Digestive Tract in ICU Patients. New England Journal of Medicine 360:20, 2138-2141
Full Text104
Joachim Wilhelm, Henning Ebelt, Michael Buerke, Axel Schlitt. (2009) Selective decontamination of the digestive tract and oropharynx: new findings for an old approach still under discussion. Expert Review of Anti-infective Therapy 7:4, 399-402
CrossRef105
Christine Cutugno. (2009) Decontamination of the Digestive Tract and Oropharynx in ICU Patients. AJN, American Journal of Nursing 109:5, 64C-64D
CrossRef106
Michael W Ellis. (2009) Effect of linezolid in ventilator-associated pneumonia caused by MRSA. Expert Review of Anti-infective Therapy 7:2, 183-188
CrossRef107
Jacyntha A. Sterling. (2009) Hospital Pharmacy Pulse - Recent Publications on Medications and Pharmacy. Hospital Pharmacy 44:3, 265-272
CrossRef
