Braucht jeder Intensivpatient Antibiotika?

Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial.

de Jonge E, Schultz MJ, Spanjaard L, et al.                                                                                                                       Lancet 2003; 362:1011-16

Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.

BACKGROUND:: Selective decontamination of the digestive tract (SDD) is an infection-prevention regimen used in critically ill patients. We assessed the effects of SDD on intensive-care-unit (ICU) and hospital mortality, and on the acquisition of resistant bacteria in adult patients admitted to intensive care.
METHODS: We did a prospective, controlled, randomised, unblinded clinical trial. 934 patients admitted to a surgical and medical ICU were randomly assigned oral and enteral polymyxin E, tobramycin, and amphotericin B combined with an initial 4-day course of intravenous cefotaxime (SDD-group n = 466), or standard treatment (controls n = 468). Primary endpoints were ICU and hospital mortality and the acquisition of resistant bacteria.
FINDINGS: In the SDD-group 69 (15%) patients died in the ICU compared with 107 (23%) in the control-group (p = 0,002). Hospital mortality was lower in the SDD- groups than in the control-group (113 [24%] vs 146 [31%], p = 0,02). During their stay in intensive care, colonisation with gram-negative bacteria resistant to ceftazidime, ciprofloxacin, imipenem, polymyxin E, or tobramycin occurred in 61 (16%) of 378 SDD-patients and in 104 (26%) of 395 patients in the control-group (p = 0,001). Colonisation with vancomycin-resistant enterococcus occurred in five (1%) SDD-patients and in four (1%) controls (p = 1,0). No patient in either group was colonised with meticillin-resistant Staphylococcus aureus.
INTERPRETATIONS: In a setting with low prevalence of vancomycin-resistant enterococcus and meticillin-resistant S aureus, SDD can decrease ICU and hospital mortality and colonisation with resistant gram-negative aerobic bacteria.