Retraction:Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in icus a randomized clinical trial

Abstract

IMPORTANCE Selective 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. OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, 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. INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD. MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabswere significantly lower duringSDDcompared with SOD; for aminoglycoside resistance, average prevalencewas 5.6%(95%CI, 4.6%-6.7%) duringSDDand 11.8%(95%CI, 10.3%-13.2%) duringSOD(P < .001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7%per month (95%CI, 1%-13%) duringSDD(P = .02) and 4%per month (95%CI,0%-8%) duringSOD(P = .046; P = .40for difference).Day 28-mortalitywas 25.4%and 24.1%duringSODandSDD, respectively (adjusted odds ratio,0.96 [95%CI,0.88-1.06]; P = .42), and therewere 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 duringSODandSDD, respectively (odds ratio,0.77 [95%CI,0.65-0.91]; P = .002; number needed to treat, 77). CONCLUSIONS AND RELEVANCE Unit-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 aminoglycosideresistant gram-negative bacteria. TRIAL REGISTRATION trialregister.nl Identifier: NTR1780.