Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials
Free accessResearch articleFirst published online May, 2008
Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials
Meta-analyses of randomised controlled trials of selective digestive decontamination have clinical outcome measures, mainly pneumonia and mortality. This meta-analysis has a microbiological endpoint and explores the impact of selective digestive decontamination on Gram-negative and Gram-positive carriage and severe infections. We searched electronic databases, Cochrane Register of Controlled Trials, previous meta-analyses and conference proceedings with no language restrictions. We included randomised controlled trials which compared the selective digestive decontamination protocol with no treatment or placebo. Three reviewers independently applied selection criteria, performed the quality assessment and extracted the data. The outcome measures were carriage and severe infection due to Gram-negative and Gram-positive bacteria. Odds ratios were pooled with the random effect model. Fifty-four randomised controlled trials comprising 9473 patients were included; 4672 patients received selective digestive decontamination and 4801 were controls. Selective digestive decontamination significantly reduced oropharyngeal carriage (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.07 to 0.23), rectal carriage (OR 0.15, 95% CI 0.07 to 0.31), overall infection (OR 0.17, 95% CI 0.10 to 0.28), lower respiratory tract infection (OR 0.11, 95% CI 0.06 to 0.20) and bloodstream infection (OR 0.35, 95% CI 0.21 to 0.67) due to Gram-negative bacteria. Reduction in Gram-positive carriage was not significant. Gram-positive lower airway infections were significantly reduced (OR 0.52, 95% CI 0.34 to 0.78). Gram-positive bloodstream infections were not significantly increased (OR 1.03, 95% CI 0.75 to 1.41). The association of parenteral and enteral antimicrobials was superior to enteral antimicrobials in reducing carriage and severe infections due to Gram-negative bacteria. This meta-analysis confirms that selective digestive decontamination mainly targets Gram-negative bacteria; it does not show a significant increase in Gram-positive infection.
van SaeneH.K.F., PetrosA.J., RamsayG., BaxbyD.All great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth.Intensive Care Med2003; 29: 677–690.
2.
SilvestriL., MannucciF., van SaeneH.K.F.Selective decontamination of the digestive tract: a life saver.J Hosp Infect2000; 45: 185–190.
3.
Vandenbroucke-GraulsC.M.J., VandenbrouckeJ.P.Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit.Lancet1991; 338: 859–862.
4.
Selective Decontamination of the Digestive Tract Trialists’ Collaborative Group.Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract.BMJ1993; 307: 525–532.
5.
KollefM.The role of selective digestive tract decontamination on mortality and respiratory tract infections. A meta-analysis.Chest1994; 105: 1101–1108.
6.
HeylandD.K., CookD.J., JaeschkeR., GriffithL., LeeH.N., GuyattG.H.Selective decontamination of the digestive tract: an overview.Chest1994; 105: 1221–1229.
7.
HurleyJ.C.Prophylaxis with enteral antibiotics in ventilated patients: selective decontamination or selective cross-infection?Antimicrob Agents Chemother1995; 39: 941–947.
8.
D'AmicoR., PifferiS., LeonettiC., TorriV., TinazziA., LiberatiA.Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials.BMJ1998; 316: 1275–1285.
9.
NathensA.B., MarshallJ.C.Selective decontamination of the digestive tract in surgical patients. A systematic review of the evidence.Arch Surg1999; 134: 170–176.
10.
RedmanR., LudingtonE., CrockerM.Analysis of respiratory and non-respiratory infections in published trials of selective digestive decontamination.Intensive Care Med2001; 27(Suppl 2): S285.
11.
SafdarN., SaidA., LuceyM.R.The role of selective digestive decontamination for reducing infection in patients undergoing liver transplantation: a systematic review and meta-analysis.Liver Transpl2004; 10: 817–827.
12.
LiberatiA., D'AmicoR., PifferiS., LeonettiC., TorriV., BrazziL.Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care.Cochrane Database Syst Rev2004; 1: CD000022.
13.
SilvestriL., van SaeneH.K., MilaneseM., GregoriD.Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomised controlled trials.Intensive Care Med2005; 31: 898–910.
14.
SilvestriL., van SaeneH.K., MilaneseM., GregoriD., GulloA.Selective decontamination of the digestive tract reduces bacterial bloodstream infections and mortality in critically ill patients. Systematic review of randomized, controlled trials.J Hosp Infect2007; 65: 187–203.
15.
BrazziL., LiberatiA.A review of design and conduct of the available studies on selective decontamination of the digestive tract.Reanimation Urgences1992; 1: 501–507.
16.
HeylandD.K., NovakF., DroverJ.W., JainM., SuX., SuchnerU.Should immunonutrition become routine in critically ill patients? A systematic review of the evidence.JAMA2001; 286: 944–953.
17.
HigginsJ.P., ThompsonS.G., DeeksJ.J., AltmanD.G.Measuring inconsistency in meta-analyses.BMJ2003; 327: 557–560.
18.
CucheratM., BoisselJ.P., LeizoroviczA.EasyMA: a program for the meta-analysis of clinical trials.Comput Methods Programs Biomed1997; 53: 187–190.
19.
Martinez-PellusA.E., MerinoP., BruM., ConejeroR., SellerG., MunozC.Can selective digestive decontamination avoid the endotoxemia and cytokine activation promoted by cardiopulmonary bypass?Crit Care Med1993; 21: 1684–1891.
20.
Martinez-PellusA.E., MerinoP., BruM., CanovasJ., SellerG., SapinaJ.Endogenous endotoxemia of intestinal origin during cardiopulmonary bypass. Role of type of flow and protective effect of selective digestive decontamination.Intensive Care Med1997; 23: 1251–1257.
21.
Abele-HornM., DauberA., BauernfeindA., RusswurmW., Seyfarth-MetzgerI., GleichP.Decrease in nosocomial pneumonia in ventilated patients by selective oropharyngeal decontamination (SOD).Intensive Care Med1997; 23: 187–195.
22.
AerdtsS.J., van DalenR., ClasenerH.A., FestenJ., van LierH.J., VollaardE.J.Antibiotic prophylaxis of respiratory tract infection in mechanically ventilated patients. A prospective, blinded, randomized trial of the effect of a novel regimen.Chest1991; 100: 783–791.
23.
ArnowP.M., CarandangG.C., ZabnerR., IrwinM.E.Randomized controlled trial of selective decontamination for prevention of infections following liver transplantation.Clin Infect Dis1996; 22: 997–1003.
24.
BarretJ.P., JeschkeM.G., HerndonD.N.Selective decontamination of the digestive tract on severely burned pediatric patients.Burns2001; 27: 439–445.
25.
BergmansD.C., BontenM.J., GaillardC.A., PalingJ.C., van der GeestS., van TielF.H.Prevention of ventilator-associated pneumonia by oral decontamination. A prospective, randomized, double-blind, placebo-controlled study.Am J Respir Crit Care Med2001; 164: 382–388.
26.
BionJ.F., BadgerI., CrosbyH.A., HutchingsP., KongK.L., BakerJ.Selective decontamination of the digestive tract reduces Gram-negative pulmonary colonization but not systemic endotoxemia in patients undergoing elective liver transplantation.Crit Care Med1994; 22: 40–49.
27.
BlairP., RowlandsB.J., LowryK., WebbH., ArmstrongP., SmilieJ.Selective decontamination of the digestive tract: a stratified, randomized, prospective study in a mixed intensive care unit.Surgery1991; 110: 303–310.
28.
BolandJ.P., SadlerD.L., StewartW.Reduction of nosocomial respiratory tract infections in the multiple trauma patients requiring mechanical ventilation by selective parenteral and enteral antisepsis regimen (SPEAR) in the intensive care (abstract). 17th Congress of Chemotherapy, Berlin, 1991; N°0465.
29.
BouterH., SchippersE.F., LuelmoS.A., VersteeghM.I., RosP., GuiotH.F.No effect of preoperative selective gut decontamination on endotoxemia and cytokine activation during cardiopulmonary bypass: a randomized, placebo-controlled study.Crit Care Med2002; 30: 38–43.
30.
Brun-BuissonC., LegrandP., RaussA., RichardC., MontraversF., BesbesM.Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Study of an outbreak in an intensive care unit.Ann Intern Med1989; 110: 873–881.
31.
CamusC., BellissantE., SebilleV., PerrotinD., GaroB., LegrasA.Prevention of acquired infections in intubated patients with the combination of two decontamination regimens.Crit Care Med2005; 33: 307–314.
32.
CerraF.B., MaddausM.A., DunnD.L., WellsC.L., KonstantinidesN.N., LehmannS.L.Selective gut decontamination reduces nosocomial infections and length of stay but not mortality or organ failure in surgical intensive care unit patients.Arch Surg1992; 127: 163–169.
33.
CockerillFR3rd, MullerS.R., AnhaltJ.P., MarshH.M., FarnellM.B., MuchaP.Prevention of infection in critically ill patients by selective decontamination of the digestive tract.Ann Intern Med1992; 117: 545–553.
34.
de la calM.A., CerdáE., García-HierroP., van SaeneH.K., Gomez-SantosD., NegroE.Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract. A randomized, placebo-controlled, double-blind trial.Ann Surg2005; 241: 424–430.
35.
de JongeE., SchultzM.J., SpanjaardL., BossuytP.M., VroomM.B., DankertJ.Effects of selective decontamination of the digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial.Lancet2003; 362: 1011–1016.
36.
FerrerM., TorresA., GonzalezJ., Puig de la BellacasaJ., el-EbiaryM., RocaM.Utility of selective decontamination in mechanically ventilated patients.Ann Intern Med1994; 120: 389–395.
37.
FinchR.G., TomlinsonP., HollidayM.Selective decontamination of the digestive tract (SDD) in the prevention of secondary sepsis in a medical/surgical intensive care unit (abstract). 17th Congress of Chemotherapy, Berlin, 1991; N°0471.
38.
FlahertyJ., NathanC., KabinsS.A., WeinsteinR.A.Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit.J Infect Dis1990; 162: 1393–1397.
39.
GastinneH., WolffM., DelatourF., FaurissonF., ChevretS.A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics.N Engl J Med1992; 326: 594–599.
40.
GaussorguesPh, SalordF., SirodotM.Efficacite de la decontamination digestive sur la survenue des bacteriemies nosocomiales chez les patients sous ventilation mecanique et recevant des betamimetiques.Rean Soins Intens Med Urg1991; 7: 169–174.
41.
GeorgesB., MazerollesM., DecunJ-F. Decontamination digestive selective: resultats d'une etude chez le polytraumatise.Reanimation Urgences1994; 3: 621–627.
42.
GosneyM., MartinM.V., WrightA.E.The role of selective decontamination of the digestive tract in acute stroke.Age Ageing2006; 35: 42–47.
43.
HammondJ.M., PotgieterP.D., SaundersG.L., ForderA.A.Double-blind study of selective decontamination of the digestive tract in intensive care.Lancet1992; 340: 5–9.
44.
HellingerW.C., YaoJ.D., AlvarezS., BlairJ.E., CawleyJ.J., PayaC.V.A randomized, prospective, double blinded evaluation of selective bowel decontamination in liver transplantation.Transplantation2002; 73: 1904–1909.
45.
JacobsS., FowerakerJ.E., RobertsS.E.Effectiveness of selective decontamination of the digestive tract (SDD) in an ICU with a policy encouraging a low gastric pH.Clinical Intensive Care1992; 3: 52–58.
46.
KerverA.J., RommesJ.H., Mevissen-VerhageE.A., HulstaertP.F., VosA., VerhoefJ.Prevention of colonization and infection in critically ill patients: a prospective randomized study.Crit Care Med1988; 16: 1087–1093.
47.
KorinekA.M., LaisneM.J., NicolasM.H., RaskineL., DeroinV., Sanson-LeporsM.J.Selective decontamination of the digestive tract in neurosurgical intensive care unit patients: a double-blind, randomized, placebo-controlled study.Crit Care Med1993; 21: 1466–1473.
48.
KruegerW.A., LenhartF.P., NeeserG., RuckdeschelG., SchreckhaseH., EissnerH.J.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 Med2002; 166: 1029–1037.
49.
LaggnerA.N., TrybaM., GeorgopoulosA., LenzK., GrimmG., GraningerW.Oropharyngeal decontamination with gen-tamycin for long-stay ventilated patients on stress ulcer prophylaxis with sucralfate?Wien Klin Wochenschr1994; 106: 15–19.
LuitenE.J., HopW.C., LangeJ.F., BruiningH.A.Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis.Ann Surg1995; 222: 57–65.
52.
PalomarM., Alvarez-LermaF., JordaR.Prevention of nosocomial infection in mechanically ventilated patients: selective digestive decontamination versus sucralfate.Clinical Intensive Care1997; 8: 228–235.
53.
PneumatikosI., KoulourasV., NathanailC., GoeD., NakosG.Selective decontamination of subglottic area in mechanically ventilated patients with multiple trauma.Intensive Care Med2002; 28: 432–437.
54.
PuginJ., AuckenthalerR., LewD.P., SuterP.M.Oropharyngeal decontamination decreases incidence of ventilator-associated pneumonia. A randomized, placebo-controlled, double-blind clinical trial.JAMA1991; 265: 2704–2710.
55.
QuinioB., AlbaneseJ., Bues-CharbitM., ViviandX., MartinC.Selective decontamination of the digestive tract in multiple trauma patients. A prospective double-blind, randomized, placebo-controlled study.Chest1996; 109: 765–772.
56.
RayesN., HansenS., SeehoferD., MullerA.R., SerkeS., BengmarkS.Early enteral supply of Lactobacillus and fiber versus selective bowel decontamination: a controlled trial in liver transplant recipients.Transplantation2002; 74: 123–128.
57.
RochaL.A., MartinM.J., PitaS., PazJ., SecoC., MargusinoL.Prevention of nosocomial infection in critically ill patients by selective decontamination of the digestive tract. A randomized, double blind, placebo-controlled study.Intensive Care Med1992; 18: 398–404.
58.
Rodríguez-RoldanJ.M., Altuna-CuestaA., LópezA., CarrilloA., GarciaJ., LeónJ.Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial pharyngeal nonabsorbable paste.Crit Care Med1990; 18: 1239–1242.
59.
RolandoN., GimsonA., WadeJ., Philpott-HowardJ., CasewellM., WilliamsR.Prospective controlled trial of selective parenteral and enteral antimicrobial regimen in fulminant liver failure.Hepatology1993; 17: 196–201.
60.
RolandoN., WadeJ.J., StangouA., GimsonA.E., WendonJ., Philpott-HowardJ.Prospective study comparing the efficacy of prophylactic parenteral antimicrobials, with or without enteral decontamination, in patients with acute liver failure.Liver Transpl Surg1996; 2: 8–13.
61.
RuzaF., AlvaradoF., HerruzoR., DelgadoM.A., GarciaS., DoraoP.Prevention of nosocomial infection in a pediatric intensive care unit (PICU) through the use of selective digestive decontamination.Eur J Epidemiol1998; 14: 719–727.
62.
Sanchez GarciaM., Cambronero GalacheJ.A., López DiazJ., Cerda CerdaE., Rubio BlascoJ., Gómez AguinagaM.A.Effectiveness and cost of selective decontamination of the digestive tract in critically ill intubated patients. A randomized, double-blind, placebo-controlled, multicenter trial.Am J Respir Crit Care Med1998; 158: 908–916.
63.
SchardeyH.M., JoostenU., FinkeU., StaubachK.H., SchauerR., HeissA.The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled, multicenter trial.Ann Surg1997; 225: 172–180.
64.
SmithS.D., JacksonR.J., HannakanC.J., WadowskyR.M., TzakisA.G., RoweM.I.Selective decontamination in pediatric liver transplants. A randomized prospective study.Transplantation1993; 55: 1306–1309.
65.
StoutenbeekC.P., van SaeneH.K.F., ZandstraD.F.Prevention of multiple organ failure by selective decontamination of the digestive tract in multiple trauma patients. In: FaistE., BaueA.E., SchildbergF.W. eds. The immune consequences of trauma, shock and sepsis—mechanisms and therapeutic approach.Lengerich: Pabst Science Publishers1996. p. 1055–1066.
66.
StoutenbeekC.P., van SaeneH.K., LittleR.A., WhiteheadA; Working Group on Selective Decontamination of the Digestive Tract. The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial.Intensive Care Med2007; 33: 261–270.
67.
TetterooG.W., WagenvoortJ.H., CasteleinA., TilanusH.W., InceC., BruiningH.A.Selective decontamination to reduce gram-negative colonisation and infections after oesophageal resection.Lancet1990; 335: 704–707.
68.
UlrichC., Harinck-de WeerdJ.E., BakkerN.C., JaczK., DoornbosL., de RidderV.A.Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: a prospective randomized study.Intensive Care Med1989; 15: 424–431.
69.
UnertlK., RuckdeschelG., SelbmannH.K., JensenU., ForstH., LenhartF.P.Prevention of colonization and respiratory infections in long-term ventilated patients by local antimicrobial prophylaxis.Intensive Care Med1987; 13: 106–113.
70.
VerwaestC., VerhaegenJ., FerdinandeP., SchetzM., van den BergheG., VerbistL.Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit.Crit Care Med1997; 25: 63–71.
71.
WienerJ., ItokazuG., NathanC., KabinsS.A., WeinsteinR.A.A randomized, double-blind, placebo-controlled trial of selective digestive decontamination in a medical-surgical intensive care unit.Clin Infect Dis1995; 20: 861–867.
72.
WinterR., HumphreysH., PickA., MacGowanA.P., WillattsS.M., SpellerD.C.A controlled trial of selective decontamination of the digestive tract in intensive care and its effect on nosocomial infection.J Antimicrob Chemother1992; 30: 73–77.
73.
ZobelG., KuttnigM., GrubbauerH.M., SemmelrockH.J., ThielW.Reduction of colonization and infection rate during pediatric intensive care by selective decontamination of the digestive tract.Crit Care Med1991; 19: 1242–1246.
74.
ZwavelingJ.H., MaringJ.K., KlompmakerI.J., HaagsmaE.B., BottemaJ.T., LaseurM.Selective decontamination of the digestive tract to prevent postoperative infection: a randomized placebo-controlled trial in liver transplant patients.Crit Care Med2002; 30: 1204–1209.
75.
LingnauW., BergerJ., JavorskyF., FilleM., AllerbergerF., BenzerH.Changing bacterial ecology during a five year period of selective intestinal decontamination.J Hosp Infect1998; 39: 195–206.
76.
KuipersJ.S.Combinations of antimicrobial agents. The in-vitro sensitivity of 100 strains of Pseudomonas aeruginosa to polymyxin B, colistin, carbenicillin, gentamicin and doxycycline and to various combinations of theses antibiotics.Archivum Chirurgicum Neerlandicum1975; 27: 257–270.
77.
MulderJ.G., WiersmaW.E., WellingG.W., van der WaaijD.Low dose oral tobramycin treatment for selective decontamination of the digestive tract: a study in human volunteers.J Antimicrob Chemother1984; 13: 495–504.
78.
van SaeneJ.J., van SaeneH.K., Tarko-SmitN.J., BeukeveldG.J.Enterobacteriaceae suppression by three different oral doses of polymyxin E in human volunteers.Epidemiol Infect1988; 100: 407–417.
79.
van SaeneJ.J.M., StoutenbeekC.P., van SaeneH.K.F.Reduction of the intestinal endotoxin pool by three different SDD regimens in human volunteers.J Endotoxin Res1996; 3: 337–343.
80.
van SaeneH.K.F., ReillyN.J., de SilvestreA.Antibiotic policies in the intensive care unit. In: van SaeneH.K.F., SilvestriL., de la CalM.A., eds. Infection Control in the Intensive Care Unit,2nd Ed.Milan, Italy: Springer Verlag2005. p. 231–246.
81.
LedinghamI.M., AlcockS.R., EastawayA.T., McDonaldJ.C., McKayI.C., RamsayG.Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime, and microbiological surveillance for prevention of acquired infection in intensive care.Lancet1988; 1: 785–790.
82.
SilvestriL., van SaeneH.K.F.Selective decontamination of the digestive tract does not increase resistance in critically ill patients: Evidence from randomised controlled trials.Crit Care Med2006; 34: 2027–2030.
83.
HammondJ.M., PotgieterP.D.Long-term effects of selective decontamination on antimicrobial resistance.Crit Care Med1995; 23: 637–645.
84.
van der VoortP.H., van RoonE.N., KampingaG.A., BoermaE.C., GerritsenR.T., EgbersP.H.A before-after study of multi-resistance and cost of selective decontamination of the digestive tract.Infection2004; 32: 271–277.
85.
VivianiM., van SaeneH.K., DezzoniR., SilvestriL., Di LenardaR., BerlotG.Control of imported methicillin-resistant Staphylococcus aureus (MRSA) on mechanically ventilated patients: a dose-response study of enteral vancomycin to reduce absolute carriage and infection.Anaesth Intensive Care2005; 33: 361–372.
86.
StoutenbeekC.P., van SaeneH.K.F., ZandstraD.F.The effect of oral nonabsorbable antibiotics on the emergence of resistant bacteria in patients in an intensive care unit.J Antimicrob Chemother1987; 19: 513–520.
87.
SarginsonR.E., TaylorN., ReillyN., BainesP.B., van SaeneH.K.Infection in prolonged pediatric critical illness: A prospective four year study based on knowledge of the carrier state.Crit Care Med2004; 32: 839–847.
88.
HeiningerA., MeyerE., SchwabF., MarschalM., UnertlK., KruegerW.A.Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance.Intensive Care Med2006; 32: 1569–1576.
89.
LeoneM., AlbaneseJ., AntoniniF., Nguyen-MichelA., MartinC.Long-term (6-year) effect of selective digestive decontamination on antimicrobial resistance in intensive care, multiple-trauma patients.Crit Care Med2003; 31: 2090–2095.
90.
de la CalM.A., CerdaE., van SaeneH.K., García-HierroP., NegroE., ParraM.L.Effectiveness and safety of enteral vancomycin to control endemicity of methicillin-resistant Staphylococcus aureus in a medical/surgical intensive care unit.J Hosp Infect2004; 56: 175–183.
91.
TetterooG.W.M., WagenvoortJ.H.T., BruiningH.A.Bacteriology of selective decontamination: efficacy and rebound colonisation.J Antimicrob Chemother1994; 34: 139–148.
92.
CerdáE., AbellaA., de la CalM.A., LorenteJ.A., García-HierroP., van SaeneH.K.Enteral vancomycin controls methicillin-resistant Staphylococcus aureus endemicity in an intensive care burn unit: a 9-year prospective study.Ann Surg2007; 245: 397–407.
93.
BontenM.J., van TielF.H., van der GeestS., StobberinghE.E., GaillardC.A.Enterococcus faecalis pneumonia complicating topical antimicrobial prophylaxis.New Engl J Med1993; 328: 209–210.
94.
EbnerW., Kropec-HubnerA., DaschnerF.D.Bacterial resistance and overgrowth due to selective decontamination of the digestive tract.Eur J Clin Microbiol Infect Dis2000; 19: 243–247.
95.
KollefM.H.Selective digestive decontamination should not be routinely employed.Chest2003; 123(5 Suppl): 464S–468S.
96.
TetterooG.W., WagenvoortJ.H., MulderP.G., InceC., BruiningH.A.Decreased mortality rate and length of hospital stay in surgical intensive care unit patients with successful decontamination of the gut.Crit Care Med1993; 21: 1692–1698.
97.
DiveA., ClaveroR., InstalleE.Reduced mortality rate with gut decontamination.Crit Care Med1994; 22: 1887–1888.
98.
StoutenbeekC.P., van SaeneH.K.F.Selective decontamination of the digestive tract. In: PinskyM.R., DahinautJ.F., ArtigasA. eds. The Splanchnic Circulation.Berlin: Springer1995. p. 165–174.
99.
KalletR.H., QuinnT.E.The gastrointestinal tract and ventilator-associated pneumonia.Respir Care2005; 50: 910–921.
