• Oostdijk Evelien A N EAN Department of Medical Microbiology, University Medical Center Utrecht, Utrecht2Department of Intensive Care Medicine, University Medical Center U, Jozef Kesecioglu, Marcus J Schultz, Caroline E Visser, Evert de Jonge, van Essen Einar H R EHR Department of Intensive Care Medicine, Leiden University Medical Center, Leiden., Alexandra T Bernards, Ilse Purmer, Roland Brimicombe, Dennis Bergmans, Frank van Tiel, Frank H Bosch, Ellen Mascini, Arjanne van Griethuysen, Alexander Bindels, Arjan Jansz, van Steveninck Fred A L FAL Department of Intensive Care, Deventer Hospital, Deventer., Wil C van der Zwet, Jan Willem Fijen, Steven Thijsen, Remko de Jong, Joke Oudbier, Adrienne Raben, Eric van der Vorm, Mirelle Koeman, Philip Rothbarth, Annemieke Rijkeboer, Paul Gruteke, Helga Hart-Sweet, Paul Peerbooms, Lex J Winsser, van Elsacker-Niele Anne-Marie W AW Izore, Centre for Infectious Diseases Friesland, Leeuwarden., Kees Demmendaal, Afke Brandenburg, de Smet Anne Marie G A AMGA Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen., and Bonten Marc J M MJM Department of Medical Microbiology, University Medical Center Utrecht, Utrecht32Julius Center for Health Sciences and Primary Care, University Medical.
• Department of Medical Microbiology, University Medical Center Utrecht, Utrecht2Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht.
• JAMA. 2014 Oct 8;312(14):1429-37.

ImportanceSelective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance.ObjectiveTo compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome.Design, Setting, And ParticipantsPragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively.InterventionsIntensive care units were randomized to administer either SDD or SOD.Main Outcomes And MeasuresUnit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay.ResultsIn point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6% (95% CI, 4.6%-6.7%) during SDD and 11.8% (95% CI, 10.3%-13.2%) during SOD (P < .001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77).Conclusions And RelevanceUnit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria.Trial Registrationtrialregister.nlIdentifier: NTR1780.

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