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Probiotics versus antibiotic decontamination of the digestive tract: infection and mortalityOpen access

Guy J. Oudhuis| Dennis C. Bergmans| Tom Dormans| Jan-Harm Zwaveling| Alfons Kessels| Martin H. Prins| Ellen E. Stobberingh| Annelies Verbon
Original
Volume 37, Issue 1 / January , 2011

Pages 110 - 117

Abstract

Purpose

Selective decontamination of the digestive tract (SDD) has been shown to decrease the infection rate and mortality in intensive care units (ICUs); Lactobacillus plantarum 299/299v plus fibre (LAB) has been used for infection prevention and does not harbour the potential disadvantages of antibiotics. The objective was to assess whether LAB is not inferior to SDD in infection prevention.

Methods

Two hundred fifty-four consecutive ICU patients with expected mechanical ventilation ≥48 h and/or expected ICU stay ≥72 h were assigned to receive SDD: four times daily an oral paste (polymyxin E, gentamicin, amphotericin B), enteral solution (same antibiotics), intravenous cefotaxime (first 4 days) or LAB: two times daily L. plantarum 299/299v with rose-hip.

Results

The primary endpoint was infection rate. A difference <12% between both groups indicated non-inferiority of LAB. The trial was prematurely stopped after a study reporting increased mortality in critically ill pancreatitis patients receiving probiotics. No significant difference in infection rate [31% in the LAB group, 24% in the SDD group (OR 1.68, 95% CI 0.91–3.08; p = 0.10)] was found. ICU mortality was 26% and not significantly different between the LAB and SDD groups. Gram-positive cocci and Pseudomonas aeruginosa were significantly more frequently isolated from surveillance cultures in the SDD group compared to the LAB group (for sputum: 18 vs. 10% and 33 vs. 14%). Significantly more Enterobacteriaceae were found in the LAB group (23 vs. 50%). No increase in antibiotic resistance was found during and after SDD or LAB use.

Conclusions

The trial could not demonstrate the non-inferiority of LAB compared with SDD in infection prevention. Results suggest no increased ICU mortality risk in the LAB group.

Keywords

References

  1. Inan D, Saba R, Gunseren F, Ongut G, Turhan O, Yalcin AN, Mamikoglu L (2005) Daily antibiotic cost of nosocomial infections in a Turkish university hospital. BMC Infect Dis 5:5
    • View reference on publisher's website
    • View reference on PubMed
  2. Vincent JL (2003) Nosocomial infections in adult intensive-care units. Lancet 361:2068–2077
    • View reference on publisher's website
    • View reference on PubMed
  3. Park DR (2005) The microbiology of ventilator-associated pneumonia. Respir Care 50:742–763 (discussion 763–745)
    • View reference on PubMed
  4. Stoutenbeek CP, van Saene HK, Miranda DR, Zandstra DF (1984) The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients. Intensive Care Med 10:185–192
  5. De Jonge E, Schultz MJ, Spanjaard L, Bossuyt PM, Vroom MB, Dankert J, Kesecioglu J (2003) Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 362:1011–1016
    • View reference on publisher's website
    • View reference on PubMed
  6. De La Cal MA, Cerda E, Garcia-Hierro P, van Saene HK, Gomez-Santos D, Negro E, Lorente JA (2005) Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg 241:424–430
    • View reference on publisher's website
  7. De Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, van der Hoeven JG, Pickkers P, Bogaers-Hofman D, van der Meer NJ, Bernards AT, Kuijper EJ, Joore JC, Leverstein-van Hall MA, Bindels AJ, Jansz AR, Wesselink RM, de Jongh BM, Dennesen PJ, van Asselt GJ, te Velde LF, Frenay IH, Kaasjager K, Bosch FH, van Iterson M, Thijsen SF, Kluge GH, Pauw W, de Vries JW, Kaan JA, Arends JP, Aarts LP, Sturm PD, Harinck HI, Voss A, Uijtendaal EV, Blok HE, Thieme Groen ES, Pouw ME, Kalkman CJ, Bonten MJ (2009) Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 360:20–31
    • View reference on publisher's website
    • View reference on PubMed
  8. Liberati A, D’Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E (2009) Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev CD000022
  9. Oostdijk EA, de Smet AM, Blok HE, Thieme Groen ES, van Asselt GJ, Benus RF, Bernards SA, Frenay IH, Jansz AR, de Jongh BM, Kaan JA, Leverstein-van Hall MA, Mascini EM, Pauw W, Sturm PD, Thijsen SF, Kluytmans JA, Bonten MJ (2010) Ecological effects of selective decontamination on resistant Gram-negative bacterial colonization. Am J Respir Crit Care Med 181:452–457
    • View reference on publisher's website
    • View reference on PubMed
  10. Isakow W, Morrow LE, Kollef MH (2007) Probiotics for preventing and treating nosocomial infections: review of current evidence and recommendations. Chest 132:286–294
    • View reference on publisher's website
    • View reference on PubMed
  11. Madsen K (2008) Probiotics in critically ill patients. J Clin Gastroenterol 42(Suppl 3 Pt 1):S116–S118
    • View reference on publisher's website
    • View reference on PubMed
  12. Rayes N, Hansen S, Seehofer D, Muller AR, Serke S, Bengmark S, Neuhaus P (2002) Early enteral supply of fiber and lactobacilli versus conventional nutrition: a controlled trial in patients with major abdominal surgery. Nutrition 18:609–615
    • View reference on publisher's website
    • View reference on PubMed
  13. Olah A, Belagyi T, Issekutz A, Gamal ME, Bengmark S (2002) Randomized clinical trial of specific Lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis. Br J Surg 89:1103–1107
    • View reference on publisher's website
    • View reference on PubMed
  14. Rayes N, Seehofer D, Hansen S, Boucsein K, Muller AR, Serke S, Bengmark S, Neuhaus P (2002) Early enteral supply of Lactobacillus and fiber versus selective bowel decontamination: a controlled trial in liver transplant recipients. Transplantation 74:123–127
    • View reference on publisher's website
    • View reference on PubMed
  15. Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink MA, Schaapherder AF, Dejong CH, Wahab PJ, van Laarhoven CJ, van der Harst E, van Eijck CH, Cuesta MA, Akkermans LM, Gooszen HG (2008) Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 371:651–659
    • View reference on publisher's website
    • View reference on PubMed
  16. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM (1988) CDC definitions for nosocomial infections. Am J Infect Control 16:128–140
    • View reference on publisher's website
    • View reference on PubMed
  17. Linssen CF, Jacobs JA, Schouten JS, van Mook WN, Ramsay G, Drent M (2008) Influence of antibiotic therapy on the cytological diagnosis of ventilator-associated pneumonia. Intensive Care Med 34:865–872
  18. Clinical Laboratory Standards Institute (2006) Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically-seventh edition: approved standard M7-A7. CLSI, Wayne, PA
  19. WHO Collaborating Centre for Drug Statistics Methodology (2006) Anatomical therapeutic chemical (ATC) classification index with defined daily doses (DDDs). WHO Collaborating Centre, Oslo, Norway
  20. Filius PM, Liem TB, van der Linden PD, Janknegt R, Natsch S, Vulto AG, Verbrugh HA (2005) An additional measure for quantifying antibiotic use in hospitals. J Antimicrob Chemother 55:805–808
    • View reference on publisher's website
    • View reference on PubMed
  21. Bonten MJ, Kullberg BJ, van Dalen R, Girbes AR, Hoepelman IM, Hustinx W, van der Meer JW, Speelman P, Stobberingh EE, Verbrugh HA, Verhoef J, Zwaveling JH, Consultants of the Dutch Working Group on Antibiotic Policy (2000) Selective digestive decontamination in patients in intensive care. J Antimicrob Chemother 46:351–362
    • View reference on publisher's website
    • View reference on PubMed
  22. Puffer S, Torgerson D, Watson J (2003) Evidence for risk of bias in cluster randomised trials: review of recent trials published in three general medical journals. BMJ 327:785–789
    • View reference on publisher's website
    • View reference on PubMed
  23. Campbell MK, Elbourne DR, Altman DG (2004) CONSORT statement: extension to cluster randomised trials. BMJ 328:702–708
    • View reference on publisher's website
    • View reference on PubMed
  24. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
    • View reference on publisher's website
    • View reference on PubMed
  25. Garrouste-Orgeas M, Troche G, Azoulay E, Caubel A, de Lassence A, Cheval C, Montesino L, Thuong M, Vincent F, Cohen Y, Timsit JF (2004) Body mass index. An additional prognostic factor in ICU patients. Intensive Care Med 30:437–443
  26. Jain PK, McNaught CE, Anderson AD, MacFie J, Mitchell CJ (2004) Influence of synbiotic containing Lactobacillus acidophilus La5, Bifidobacterium lactis Bb 12, Streptococcus thermophilus, Lactobacillus bulgaricus and oligofructose on gut barrier function and sepsis in critically ill patients: a randomised controlled trial. Clin Nutr 23:467–475
    • View reference on publisher's website
    • View reference on PubMed
  27. Kotzampassi K, Giamarellos-Bourboulis EJ, Voudouris A, Kazamias P, Eleftheriadis E (2006) Benefits of a synbiotic formula (Synbiotic 2000Forte) in critically ill trauma patients: early results of a randomized controlled trial. World J Surg 30:1848–1855
    • View reference on publisher's website
    • View reference on PubMed
  28. Krueger WA, Lenhart FP, Neeser G, Ruckdeschel G, Schreckhase H, Eissner HJ, Forst H, Eckart J, Peter K, Unertl KE (2002) 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 Med 166:1029–1037
    • View reference on publisher's website
    • View reference on PubMed
  29. Heininger A, Meyer E, Schwab F, Marschal M, Unertl K, Krueger WA (2006) Effects of long-term routine use of selective digestive decontamination on antimicrobial resistance. Intensive Care Med 32:1569–1576
  30. SWAB (2009) NethMap 2009—consumption of antimicrobial agents and antimicrobial resistance among medically important bacteria in The Netherlands. http://www.swab.nl/swab/cms3.nsf/viewdoc/2E7389A33973953BC12575D1002A01C3. Accessed 03 March 2010
  31. Timmerman HM, Niers LE, Ridwan BU, Koning CJ, Mulder L, Akkermans LM, Rombouts FM, Rijkers GT (2007) Design of a multispecies probiotic mixture to prevent infectious complications in critically ill patients. Clin Nutr 26:450–459
    • View reference on publisher's website
    • View reference on PubMed
  32. Bengmark S (2004) Synbiotics to strengthen gut barrier function and reduce morbidity in critically ill patients. Clin Nutr 23:441–445
    • View reference on publisher's website
    • View reference on PubMed
  33. Melis M, Fichera A, Ferguson MK (2006) Bowel necrosis associated with early jejunal tube feeding: a complication of postoperative enteral nutrition. Arch Surg 141:701–704
    • View reference on publisher's website
    • View reference on PubMed
  34. Bonten MJ, Kluytmans J, De Smet AM, Bootsma M, Hoes A (2003) Selective decontamination of digestive tract in intensive care. Lancet 362:2118–2119 (author reply 2119–2120)
    • View reference on publisher's website
    • View reference on PubMed
  35. Verbrugh HA (2003) Selective decontamination of digestive tract in intensive care. Lancet 362:2117–2118
    • View reference on publisher's website
    • View reference on PubMed

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