Avtor/Urednik		Wittekamp, Bastiaan H.; Plantinga, Nienke L.; Cooper, Ben S.; Lopez-Contreras, Joaquin; Coll, Pere; Mancebo, Jordi; Wise, Matt P.; Morgan, Matt P. G.; Depuydt, Pieter; Boelens, Jerina; Tomič, Viktorija; Šifrer, Franc
Naslov		Decontamination strategies and bloodstream infections with antibiotic-resistant microorganisms in ventilated patients
Tip		članek
Vol. in št.		Letnik 320, št. 20
Leto izdaje		2018
Obseg		str. 2087-2098
ISSN		1538-3598 - JAMA : the journal of the American Medical Association
Jezik		eng
Abstrakt		Importance: The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective: To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, setting, and participants: Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum [beta]-lactamase-producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions: Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main outcomes and measures: The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results: A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, -0.6% to 1.1%), 0.6% (95% CI, -0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and relevance: Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care.
Deskriptorji		Anti-infective agents Bacteremia Chlorhexidine Cross infection Disinfection Drug resistance, bacterial Gastrointestinal tract Gram-negative bacterial infections Hospital mortality Intensive care units Mouthwashes Oropharynx Respiration, artificial Sredstva proti okužbam Bakteriemija Klorheksidin Navzkrižne okužbe Razkuževanje Bakterijska odpornost na zdravila Gastrointestinalni trakt Gramnegativne bakterijske okužbe Bolnišnična umrljivost Enote za intenzivno oskrbo Ustne vode Orofarinks Umetna respiracija Therapeutic use Prevention and control Therapeutic use Prevention and control Methods Microbiology Prevention and control Therapeutic use Microbiology terapevtska raba preprečevanje in nadzor terapevtska raba preprečevanje in nadzor metode mikrobiologija preprečevanje in nadzor terapevtska raba mikrobiologija