Is there an advantage to using local antimicrobial agents for infection prevention in patients in the intensive care unit and the intensive care unit?
The results of the study, published in October 2014 in the journal JAMA, showed that selective oropharyngeal decontamination (SOD) and selective intestinal decontamination (KDS) for the prevention of infections do not affect patient survival rates and length of stay in intensive care units (ICU). At the same time, the use of local antimicrobial agents for the treatment of the oral cavity and non-absorbable antibiotics for KFOR has not caused a significant spread of antibiotic resistant microorganisms in the ICU.
The study was conducted by a group of scientists from the University Medical Center of Utrecht (The Netherlands) to determine the optimal infection prevention regimen for ICU patients, in particular, the effectiveness of SOD and KDK and their effect on the selection of antibiotic resistance in bacteria. Despite the fact that numerous studies have been carried out on this subject, clinicians still do not have clear recommendations concerning the optimal conduct of SOD and KFOR in various categories of patients. SOD and KFOR have been shown to reduce the incidence of nosocomial respiratory tract infections in ICU patients, however, data on their effect on patient survival rates and the development of antibiotic resistance in bacteria are contradictory.
The researchers conducted a randomized crossover study in SOD and KFOR clusters in 16 intensive care units. The study included nearly 12,000 patients who were supposed to be in intensive care for more than 48 hours.
All patients underwent oral therapy with a paste containing colistin, tobramycin and amphotericin B (each at a concentration of 2%), every 6 hours for the entire time spent in intensive care. The KFM diet also included the administration by nasogastric route of 10 ml of a suspension containing 100 mg of colistin, 80 mg of tobramycin and 500 mg of amphotericin B every 6 hours during the first 4 days of stay in ICU, as well as intravenous administration of third generation cephalosporin (cefotaxime or ceftriaxone) during the first 4 days of intensive care.
A microbiological examination of respiratory tract material and perianal smears was performed monthly to identify microorganisms resistant to antibiotics. The results of microbiological studies have shown that the frequency of detection of Gram-negative bacteria resistant to antibiotics in perianal smears was significantly lower with KFOR than with SOD. In particular, the frequency of isolation of strains resistant to aminoglycosides was 5.6% with KFOR and 11.8% with SOD. Over time, however, a significantly higher frequency of carrying strains of gram-negative bacteria resistant to aminoglycosides in the perianal region was observed in patients with KDK (7% per month) than in the SOD group ( 4% per month).
KDK and routine intravenous administration of generation III cephalosporins led to a decrease in the incidence of bacteremia in intensive care, which was greatest compared to enterobacteria-induced bacteremia (odds ratio - OR = 0.42); and also with regard to the amino acid resistant isolates of gram-negative bacteria (OR = 0.54). According to the study results, there was no difference between the patient groups receiving KDK and SOD in clinical outcomes, in particular, in terms of patient survival and length of stay in intensive care.
In an editorial prepared by experts in the field of resuscitation and intensive care, MH Kollef and ST Micek, it should be noted that given the low incidence of bacteremia in the ICU, as well as the small differences between the SOD and KFOR, the number of patients who need KDK (in addition to SOD) to prevent an episode of bacteremia (number needed to treat - NNT) is 77 and 355 to prevent an episode of bacteremia caused by strains of gram- negative resistant to aminoglycosides. In this regard, it is not surprising that in this study, it was not possible to detect a decrease in the mortality of ICU patients, despite a decrease in the frequency of bacteremia with the appointment of KFOR. Due to the fact that this study did not show the advantages of KFOR compared to SOD compared to the most important clinical results (patient survival and length of stay in ICU), and that KFOR is a more expensive, it is therefore preferable to carry out an RNS in terms of "cost" - efficiency. "
From the point of view of experts, the use of RNS is a more rational approach to prevent excessive colonization by pathogenic bacteria in patients in ICU. Before recommending routine KFM in ICU patients, additional multicenter studies are needed in regions and hospitals where the prevalence of antibiotic resistant strains is high.