SELECTIVE DECONTAMINATION OF THE DIGESTIVE-TRACT IN MULTIPLE TRAUMA PATIENTS - A PROSPECTIVE DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED STUDY

Study objective: The aims of the study were to evaluate the technique of selective digestion decontamination (SDD) in preventing the develop ment of nosocomial infections in a selected population and to assess t he effects on colonization of the oropharynx, nares, and bronchi. A fi nancial assessment was also performed. Design: Prospective, double-bli nd, randomized, placebo-controlled trial using amphotericin B, colisti n sulfate (polymixin E), and gentamicin applied to the nares, the orop harynx, and enterally; no parenteral antibiotics were given during the study period. The SDD was applied every 6 h during the study period. Setting: Multidisciplinary ICU in a university hospital. Patients: A t otal of 148 trauma patients admitted emergently and intubated within l ess than 24 h were enrolled. Seventy-two patients who received placebo and 76 treated patients were analyzed on an ''intention-to-treat'' ba sis. Interventions: Microbiologic surveillance samples of oropharyngea l and bronchial secretions, urine, and any other potentially infected sites were taken at the time of ICU admission and twice weekly thereaf ter until discharge from the unit. Measurements and results: With the use of SDD, colonization was significantly reduced in the oropharynx a nd nares (p<0.05) but not in bronchi. However, episodes of bronchopneu monia were significantly reduced (19 in the active group vs 37 in the placebo group; p<0.01). Staphylococcus aureus remained the main potent ial pathogen causing bronchial colonization and subsequent bronchopneu monia, There was no reduction in the incidence of other infections. Da ys in the ICU, duration of mechanical ventilation, and mortality rate were unchanged. After the use of SDD, Gram-positive colonization tende d to increase and this was mainly due to methicillin-resistant coagula se-negative staphylococci. The total cost of antibiotic therapy ($62,1 17 [US] in the placebo group and $36,008 in the SDD group) was decreas ed by 42% with the use of SDD. Clinically important complications of S DD were not encountered. Conclusions: The use of SDD in this populatio n of trauma patients reduced the incidence of bronchopneumonia and the total charge for antibiotics. Stay in the ICU, mechanical ventilation duration, and mortality rate were unchanged. Methicillin-resistant co agulase-negative staphylococci were selected by SDD in some patients a nd the clinical relevance of this colonization needs further evaluatio n.