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Selective digestive decontamination in ICU patients clinical results in trauma and general ICU patients
SELECTIVE DIGESTIVE DECONTAMINATION IN ICU PATIENTS CLINICAL RESULTS IN TRAUMA ND GENERAL ICU PATIENTS ____ U N E R T L * , F.-P. L E N H A R T * , C. H O L Z E L #, G. R U C K D E S C H E L 1-
•
Introduction
Critically ill t r a u m a patients and patients in ICUs are at high risk of developing nosocomial infections. Infections occur at rates of approximately 15-20 per 100 admissions, b u t substantially higher rates m a y be observed in some high risk groups as in p a t i e n t s with long I C U - s t a y (> 7 days) or in patients with prolonged ventilatory assistance (> 24 hours). Intubated patients exhibit an extraordinary high risk of developing respiratory infections. Rates of pneumonia in patients with ventilatory support are increased about ten-fold as compared to patients with no respiratory device, so t h a t the majority of pneumonia in ICUs occur in ventilated patients. Bacteremias and pneumonias are not only the predominant infections in ICU patients b u t are also associated with the highest mortality rate. The great majority of the nosocomial infections are caused by gram-negative bacilli and staphylococci. Gram-negative rods continue to be the most frequent pathogens of respiratory tract infections and u r i n a r y tract infections, whereas staphylococci predominate in infections related to intravascular devices. Gram-negative • pathogens derive mainly from the microbial flora that colonizes the patients' gut. The technique of selective decontamination (SDD) is aimed to suppress and eliminate the potentially pathogenic flora of the gut and to prevent the acquisition of nosocomial pathogens by use of topical and eventually systemic antibacterial regimens. * Institut fer Anaesthesiologie.
# Institut fL~rBiomathematik und Epidemiologie. t Max von Pettenkofer-lnstitut. Ludwig-Maximilians-Universit~it, Klinikum Grol~hadern, D-Munich.
In this abstract we summarize the effects of SDD on t h e four m o s t c o m m o n infections in ICUs, as there are respiratory infections, bloodst r e a m infections, urinary tract infections and wound infections. We performed a meta-analysis of 14 clinical studies, published b e t w e e n 1984 and 1991 in which SDD was compared with untreated controls.
•
Methods
Comparative clinical SDD trials published between 1984 and 1991 were identified in the medical literature by using the Medline system. In addition published trials have been made available by the organizer of the conference (J. Carlet). Studies published until M a y 1991 were included in this preliminary analysis. Studies published later will be included in the final analysis which will be presented on the Consensus Conference. Overall we considered a total of 14 fully published studies including a total of 1526 patients. 6 studies were prospective randomized controlled trials, 8 studies were non-randomized clinical trials. 9 studies used a topical antibiotic regimen combined with initial systemic antibiotic prophylaxis. In 5 studies topical antibiotic prophylaxis without systemic prophylaxis was used. Studies were classified into two categories, those using a topical antibiotic regimen plus systemic antibiotics (9 studies) [1, 2, 3, 4, 5, 6, 7, 8, 9] and those with topical antibiotic prophylaxis only (5 studies) [10, 11, 12, 13, 14] and then listed according to the year of publication
(Tables I-IV). For estimation of the effects of SDD on the various categories on infections, the difference of
1re conf6rence de consensus europ~enne en reanimation- 5 1 7 Table I Effect of selective decontamination on the rate of ICU - acquired respiratory infections
Study
Ratio of treatment to control infection rates
No. of p with pneumonias/total.no.of p Treatment
Control
Konrad Sydow Tetteroo Mc Cleliand
5/63 3/98 6/49 7/48 10/99 5/82 3/45 1/56 1/15
35/59 18/94 40/47 29/52 46/101 35/83 36/48 8/58 6/12
Unertl Brun-Buisson Godard Flaherty Rod-Roldan
1/19 3/36 2/93 1/51 0/13
9/20 6/50 13/84 5/56 11/15
3.9 0.8 5.9 1.9 4.8
1.9 2.0 3.4 1.4 1.7
48/759
257/767
-103.7
61.0
Stoutenbeek Ledingham Kerver Ulrich
Th01ig
All Studies
O-E
-15.7 7.7 -17.5 -10.3 -17.7 -14.9 -15.9 3.4 2.3
Var
Decrease
-.I
6.8 4.7 6.1 5.8 10.1 7.6 5.7 2.1 1.3
Increase
--I-I
-II I I -I-I I
I I
"---T
T - -
0,0
0,5
1,0
1,5
2,0
Table II Effect of selective decontamination on the rate o f ICU - acquired bacteremias
Study
Ratio of treatment to control infection rates
No. of p with bacteremia/total no.of p
Stoutenbeek Ledingham Kerver Ulrich
Th01ig Konrad
Sydow Tetteroo Mc Clelland
Unertl Brun-Buisson Godard Flaherty Rod-Roldan
Treatment
Control
O-E
Var
2/63 8/98 15/49 10/48 11/99 ND 3/45 1/56 3/15
25/59 11/94 27/47 12/52 7/101
-11.9 -1.7 -6.4 -0.6 2.1
5.3 4.3 6.0 4.3 4.1
4/48 1/58 3/12
-0.4 0.0 -0.3
1.6 0.5 1.2
2/19 7/36 10/93 1/51
3/20 5/50 10/84 3/56
-0.4 2.0 -0.5 -0.9
1.1 2.5 4.4 1.0
111/681
-28.5
36.1
All Studies 53/672 ND = No data
Decrease
Increase
I ~1------I
t'--'-
I--
T
0,0
0,5
1,0
1,5
2,0
R6an. Urg., 1992, 1 (3 bis), 516-520
- 518 - I re conf6rence de consensus europ6enne en r6animation Table III Effect of selective decontamination on the rate of ICU - acquired urinary tract infections (UTI)
Study
Ratio of treatmentto control infection rates Decrease Increase
No. of p with UTI/totalno.ofp Treatment
Control
O- E
Var
19/59 3/94 6•47 26•52 24/101
-9.3 -1.0 -1.6 -6.8 -7.3
4.2 1.0 2.1 5.9 6.9
15•48 13/58 6/12
-4.7 -3.8 -2.4
4.0 3.8 1.4
.-----t
I
Stoutenbeek Ledingham Kerver Ulrich Th01ig Konrad Sydow Tetteroo Mc Clelland
1/63 1/98 3•49 11/48 9•99 ND 5/45 5•56 2/15
Unertl Brun-Buisson
8/19 ND
15/20
-3.2
2.4
Godard Flaherty Rod-Roldan
18/93 3/51 ND
21/84 6/56
-2.5 -1.3
7.6 2.1
All Studies
66/639
-54.2
44.3
154/531
-I
I I
I !
ND = No data 0,0
0,5
1,0
1,5
2,0
Table IV Effect of selective decontamination on the rate of ICU - acquired wound infections (Wl)
Study
Ratio of treatmentto control infection rates
No. of p with Wl/no.of patients Treatment
Stoutenbeek
3/63
Ledingham
ND
Control
O- E
15/59
-6.3
Var
Decrease
3.9
Kerver
1/49
7/47
-3.1
1.9
Ulrich
4•48
6/52
-0.8
2.3
Th01ig Konrad Sydow
ND ND 7/45
9/48
-0.7
3.3
m + _ _
Tetteroo Mc Clelland
6•56 0115
20/58 1/12
-6.8 -0.3
5.1 0.4
I
UnerU Brun-Buisson Godard Flaherty Rod-Roldan
1/19 ND 1/93 2/51 ND
1/20
0.0
0.5
4184 6•56
1.6 1.8
1.2 1.9
63/436
-22.2
21.0
All Studies
25•439
ND = No data
--.-I
~ 0,0
R6an. Urg., 1992, 1 (3 bis), 516-520
Increase
I
r
~ 0,5
"
' 1,o
-
~ 1,5
2,0
1~ c o n ~ r e n c e d e c o n s e n s u s
t h e observed (O) and expected (E) n u m b e r of infected patients in each category of infection and its variances were calculated. The odds ratio with 95% confidence limits was calculated for each trial and t h e n combined to estimate a typical odds ratio with its 95% confidence limits [15, 16]. Odds ratios less t h a n 1 m e a n t h a t SDD prevented infections. An odds ratio of 0.5 corresponds to a 50% reduction. Results were considered statistically significant if the 95% confidence interval did not override the ratio of 1.
•
Results and conclusions
The results show a m a r k e d effect of SDD on the infection rate in all 4 categories of infection. The most striking effect was observed with regard to the frequency of respiratory infections which declined by about 80%. A statistically significant decline of the pneumonia rate was seen in all studies except two [10, 11]. The s t u d y of F l a h e r t y was a pilot study which included a limited n u m b e r of patients with an apparently low risk of respiratory infections. In the s t u d y of Brun-Buisson et al. the rate of pneumonia in controls was also relatively low. Furthermore, since the goal of the study was eradication of m u l t i r e s i s t a n t gram-negative strains from the intestines, antibiotics were administered exclusively gastrointestinally and this m a y have reduced t h e effects on oropharyngeal colonization and subsequent pneumonia. With regard to other categories of infections the effects of SDD were less pronounced. The difference from u n t r e a t e d patients was frequently not statistically significant in individual trials. However most studies demonstrated a favorable t r e n d in SDD t r e a t e d patients giving a total which showed a statistically significant reduction in the odds of infection between 60% to 70°/0. The reduction of the infection rate by SDD could be attributed mainly to an almost complete prevention of u n i t acquired gram-negative and mixed infections. SDD h a d h a r d l y an effect on infections caused by gram-positive organisms. Marked differences in the effects of a combined topical and systemic regimen compared to a topical regimen only were not apparent in the various categories of infections. This finding causes some doubt about the role of systemic antibiotics as integral p a r t of this strategy. The results of this meta-analysis clearly suggest t h a t SDD using topical or combined topical and systemic antibiotics is effective in preven-
europ#enne enr6animafion - 519 -
ting common nosocomial infections. However, it is still unclear at present w h e t h e r this reduced morbidity results in a measurable reduction in the length of stay in the ICU, length of ventilatory support, reduction in costs, and ultimately, mortality [17].
References [1] KERVERA.J.H., ROMMESJ.H., MEVlSSEN-VERHAGEE.A.E., et al. - Prevention of colonization and infection in critically ill patients: A prospective randomized study. Crit. Care med., 1988, 16, 1087-1093. [2] KONRAD F., SCHWALBE B., HEEG K. et al. - Kolonisations-, Pneumoniefrequenz und Resistenzentwicklung bei langzeitbeatmeten Intensivpatienten unter selektiver Dekontamination des Verdauungstraktes. An~sthesist, 1989, 38, 99-109. [3] LEDINGHAM I McA, ALCOCK SR EASTAWAYA.T. et al. - Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime and microbiological surveillance for prevention of acquired infections in intensive care. Lancet, 1988,/, 785-790. [4] McCLELLAND P., MURRAYA.E., WILLIAMS P.S. et al. - Reducing sepsis in severe combined acute renal and respiratory failure by selective decontamination of the digestive tract. Crit. Care Med., 1990, 18, 1239-1242. [5] STOUTENBEEKC.P., VAN SAENE H.K.F., MIRANDAD.R., ZANDSTRA D.F. - The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intens. Care Med., 1984, 10, 185192. [6] SYDOWM., BURCHARDI H., CROZIERT.A. et at. - Einftul5 der selektiven Dekontamination auf nosokomiale Infektionen, Erregerspektrum und Antibiotikaresistenz bei tangzeibeatmeten Intensivpatienten. Anasth. Intensivther Notfallmed, 1990, 25, 416-423. [7] TETTEROOG.W.M., WAGENVOORTJ.H.T., CASTELEINA. et al. Selective decontamination to reduce gram-negative colonization and infections after oesophageal resection. Lancet, 1990, 335 (I), 704-707. [8] THOLIGB., HARTENAUERU., DIEMERW. et al. - Seiektive FIorasuppression zur Infektionskontrolle in der operativen Intensivmedizin. Anaesth. Intensivther Notfallmed, 1989, 24, 343-354. [9] ULRICH C., HARINCK-de WEERD J.E., BAKKER N.C., et al. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: A prospective randomized study. Intens. Care Med., 1989, 15, 424-431. [10] BRUN-BuISSON C., LEGRANDP., RAUSSA. et ai. - Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Ann. Intern. Med., 1989, 110, 873881. [11] FLAHERTYJ., NATHANC., KABINSS.A., WEINSTEINR.A. - Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit. J. Infect. Dis., 1990, 162, 1393-1397. [12] GODARDJ., GUILLAUME C., REVERDYM.E. et al. - Intestinal decontamination in a polyvalent ICU. A double-blind study. Intens. Care Med., 1990, 16, 307-311. [13] RODRIGUEZ-ROLDANJ.M., ALTUNA-CUESTAA., LOPEZA. et al. Prevention of nosocomial lung infection in ventilated patients: Use of an antimicrobial pharyngeal nonabsorbable paste. Crit. Care Med., 1990, 18, 1239-1242.
R6an. Urg., 1992, 1 (3 bis), 516-520
-
5 2 0
-
1re c o n f e r e n c e de c o n s e n s u s e u r o p 6 e n n e en r~animation
[14] UNERTLK., RUCKDESCHELG., SELBMANNH.K. et a l . - Prevention of colonization and respiratory infections in long-term ventilated patients by topical antimicrobial prophylaxis. Intens. Care Med., 1987, 13, 106-113. [15] Early breast cancer trialists collaborative group. Effects of adjuvant tamoxifen and of cytotoxic therapy on mortality in early greast cancer. NEJM, 1988, 319, 1681-1692.
limb
R~an. Urg., 1992, 1 (3 bis), 516-520
[16] LACROIXJ., ]NFANTE-RIVARDC., JENICEKM., GAUTHIERM. Prophylaxis of upper gastrointestinal bleeding in intensive care units: A meta-analysis. Crit. Care Med., 1989, 17, 826-869. [17] VANDENBROUCKE-GRAULSCM.J.E., VANDENBROUCKEJ.P. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in intensive care unit. Lancet, 1991, 338 (11), 859-862.
•
Introduction
Critically ill t r a u m a patients and patients in ICUs are at high risk of developing nosocomial infections. Infections occur at rates of approximately 15-20 per 100 admissions, b u t substantially higher rates m a y be observed in some high risk groups as in p a t i e n t s with long I C U - s t a y (> 7 days) or in patients with prolonged ventilatory assistance (> 24 hours). Intubated patients exhibit an extraordinary high risk of developing respiratory infections. Rates of pneumonia in patients with ventilatory support are increased about ten-fold as compared to patients with no respiratory device, so t h a t the majority of pneumonia in ICUs occur in ventilated patients. Bacteremias and pneumonias are not only the predominant infections in ICU patients b u t are also associated with the highest mortality rate. The great majority of the nosocomial infections are caused by gram-negative bacilli and staphylococci. Gram-negative rods continue to be the most frequent pathogens of respiratory tract infections and u r i n a r y tract infections, whereas staphylococci predominate in infections related to intravascular devices. Gram-negative • pathogens derive mainly from the microbial flora that colonizes the patients' gut. The technique of selective decontamination (SDD) is aimed to suppress and eliminate the potentially pathogenic flora of the gut and to prevent the acquisition of nosocomial pathogens by use of topical and eventually systemic antibacterial regimens. * Institut fer Anaesthesiologie.
# Institut fL~rBiomathematik und Epidemiologie. t Max von Pettenkofer-lnstitut. Ludwig-Maximilians-Universit~it, Klinikum Grol~hadern, D-Munich.
In this abstract we summarize the effects of SDD on t h e four m o s t c o m m o n infections in ICUs, as there are respiratory infections, bloodst r e a m infections, urinary tract infections and wound infections. We performed a meta-analysis of 14 clinical studies, published b e t w e e n 1984 and 1991 in which SDD was compared with untreated controls.
•
Methods
Comparative clinical SDD trials published between 1984 and 1991 were identified in the medical literature by using the Medline system. In addition published trials have been made available by the organizer of the conference (J. Carlet). Studies published until M a y 1991 were included in this preliminary analysis. Studies published later will be included in the final analysis which will be presented on the Consensus Conference. Overall we considered a total of 14 fully published studies including a total of 1526 patients. 6 studies were prospective randomized controlled trials, 8 studies were non-randomized clinical trials. 9 studies used a topical antibiotic regimen combined with initial systemic antibiotic prophylaxis. In 5 studies topical antibiotic prophylaxis without systemic prophylaxis was used. Studies were classified into two categories, those using a topical antibiotic regimen plus systemic antibiotics (9 studies) [1, 2, 3, 4, 5, 6, 7, 8, 9] and those with topical antibiotic prophylaxis only (5 studies) [10, 11, 12, 13, 14] and then listed according to the year of publication
(Tables I-IV). For estimation of the effects of SDD on the various categories on infections, the difference of
1re conf6rence de consensus europ~enne en reanimation- 5 1 7 Table I Effect of selective decontamination on the rate of ICU - acquired respiratory infections
Study
Ratio of treatment to control infection rates
No. of p with pneumonias/total.no.of p Treatment
Control
Konrad Sydow Tetteroo Mc Cleliand
5/63 3/98 6/49 7/48 10/99 5/82 3/45 1/56 1/15
35/59 18/94 40/47 29/52 46/101 35/83 36/48 8/58 6/12
Unertl Brun-Buisson Godard Flaherty Rod-Roldan
1/19 3/36 2/93 1/51 0/13
9/20 6/50 13/84 5/56 11/15
3.9 0.8 5.9 1.9 4.8
1.9 2.0 3.4 1.4 1.7
48/759
257/767
-103.7
61.0
Stoutenbeek Ledingham Kerver Ulrich
Th01ig
All Studies
O-E
-15.7 7.7 -17.5 -10.3 -17.7 -14.9 -15.9 3.4 2.3
Var
Decrease
-.I
6.8 4.7 6.1 5.8 10.1 7.6 5.7 2.1 1.3
Increase
--I-I
-II I I -I-I I
I I
"---T
T - -
0,0
0,5
1,0
1,5
2,0
Table II Effect of selective decontamination on the rate o f ICU - acquired bacteremias
Study
Ratio of treatment to control infection rates
No. of p with bacteremia/total no.of p
Stoutenbeek Ledingham Kerver Ulrich
Th01ig Konrad
Sydow Tetteroo Mc Clelland
Unertl Brun-Buisson Godard Flaherty Rod-Roldan
Treatment
Control
O-E
Var
2/63 8/98 15/49 10/48 11/99 ND 3/45 1/56 3/15
25/59 11/94 27/47 12/52 7/101
-11.9 -1.7 -6.4 -0.6 2.1
5.3 4.3 6.0 4.3 4.1
4/48 1/58 3/12
-0.4 0.0 -0.3
1.6 0.5 1.2
2/19 7/36 10/93 1/51
3/20 5/50 10/84 3/56
-0.4 2.0 -0.5 -0.9
1.1 2.5 4.4 1.0
111/681
-28.5
36.1
All Studies 53/672 ND = No data
Decrease
Increase
I ~1------I
t'--'-
I--
T
0,0
0,5
1,0
1,5
2,0
R6an. Urg., 1992, 1 (3 bis), 516-520
- 518 - I re conf6rence de consensus europ6enne en r6animation Table III Effect of selective decontamination on the rate of ICU - acquired urinary tract infections (UTI)
Study
Ratio of treatmentto control infection rates Decrease Increase
No. of p with UTI/totalno.ofp Treatment
Control
O- E
Var
19/59 3/94 6•47 26•52 24/101
-9.3 -1.0 -1.6 -6.8 -7.3
4.2 1.0 2.1 5.9 6.9
15•48 13/58 6/12
-4.7 -3.8 -2.4
4.0 3.8 1.4
.-----t
I
Stoutenbeek Ledingham Kerver Ulrich Th01ig Konrad Sydow Tetteroo Mc Clelland
1/63 1/98 3•49 11/48 9•99 ND 5/45 5•56 2/15
Unertl Brun-Buisson
8/19 ND
15/20
-3.2
2.4
Godard Flaherty Rod-Roldan
18/93 3/51 ND
21/84 6/56
-2.5 -1.3
7.6 2.1
All Studies
66/639
-54.2
44.3
154/531
-I
I I
I !
ND = No data 0,0
0,5
1,0
1,5
2,0
Table IV Effect of selective decontamination on the rate of ICU - acquired wound infections (Wl)
Study
Ratio of treatmentto control infection rates
No. of p with Wl/no.of patients Treatment
Stoutenbeek
3/63
Ledingham
ND
Control
O- E
15/59
-6.3
Var
Decrease
3.9
Kerver
1/49
7/47
-3.1
1.9
Ulrich
4•48
6/52
-0.8
2.3
Th01ig Konrad Sydow
ND ND 7/45
9/48
-0.7
3.3
m + _ _
Tetteroo Mc Clelland
6•56 0115
20/58 1/12
-6.8 -0.3
5.1 0.4
I
UnerU Brun-Buisson Godard Flaherty Rod-Roldan
1/19 ND 1/93 2/51 ND
1/20
0.0
0.5
4184 6•56
1.6 1.8
1.2 1.9
63/436
-22.2
21.0
All Studies
25•439
ND = No data
--.-I
~ 0,0
R6an. Urg., 1992, 1 (3 bis), 516-520
Increase
I
r
~ 0,5
"
' 1,o
-
~ 1,5
2,0
1~ c o n ~ r e n c e d e c o n s e n s u s
t h e observed (O) and expected (E) n u m b e r of infected patients in each category of infection and its variances were calculated. The odds ratio with 95% confidence limits was calculated for each trial and t h e n combined to estimate a typical odds ratio with its 95% confidence limits [15, 16]. Odds ratios less t h a n 1 m e a n t h a t SDD prevented infections. An odds ratio of 0.5 corresponds to a 50% reduction. Results were considered statistically significant if the 95% confidence interval did not override the ratio of 1.
•
Results and conclusions
The results show a m a r k e d effect of SDD on the infection rate in all 4 categories of infection. The most striking effect was observed with regard to the frequency of respiratory infections which declined by about 80%. A statistically significant decline of the pneumonia rate was seen in all studies except two [10, 11]. The s t u d y of F l a h e r t y was a pilot study which included a limited n u m b e r of patients with an apparently low risk of respiratory infections. In the s t u d y of Brun-Buisson et al. the rate of pneumonia in controls was also relatively low. Furthermore, since the goal of the study was eradication of m u l t i r e s i s t a n t gram-negative strains from the intestines, antibiotics were administered exclusively gastrointestinally and this m a y have reduced t h e effects on oropharyngeal colonization and subsequent pneumonia. With regard to other categories of infections the effects of SDD were less pronounced. The difference from u n t r e a t e d patients was frequently not statistically significant in individual trials. However most studies demonstrated a favorable t r e n d in SDD t r e a t e d patients giving a total which showed a statistically significant reduction in the odds of infection between 60% to 70°/0. The reduction of the infection rate by SDD could be attributed mainly to an almost complete prevention of u n i t acquired gram-negative and mixed infections. SDD h a d h a r d l y an effect on infections caused by gram-positive organisms. Marked differences in the effects of a combined topical and systemic regimen compared to a topical regimen only were not apparent in the various categories of infections. This finding causes some doubt about the role of systemic antibiotics as integral p a r t of this strategy. The results of this meta-analysis clearly suggest t h a t SDD using topical or combined topical and systemic antibiotics is effective in preven-
europ#enne enr6animafion - 519 -
ting common nosocomial infections. However, it is still unclear at present w h e t h e r this reduced morbidity results in a measurable reduction in the length of stay in the ICU, length of ventilatory support, reduction in costs, and ultimately, mortality [17].
References [1] KERVERA.J.H., ROMMESJ.H., MEVlSSEN-VERHAGEE.A.E., et al. - Prevention of colonization and infection in critically ill patients: A prospective randomized study. Crit. Care med., 1988, 16, 1087-1093. [2] KONRAD F., SCHWALBE B., HEEG K. et al. - Kolonisations-, Pneumoniefrequenz und Resistenzentwicklung bei langzeitbeatmeten Intensivpatienten unter selektiver Dekontamination des Verdauungstraktes. An~sthesist, 1989, 38, 99-109. [3] LEDINGHAM I McA, ALCOCK SR EASTAWAYA.T. et al. - Triple regimen of selective decontamination of the digestive tract, systemic cefotaxime and microbiological surveillance for prevention of acquired infections in intensive care. Lancet, 1988,/, 785-790. [4] McCLELLAND P., MURRAYA.E., WILLIAMS P.S. et al. - Reducing sepsis in severe combined acute renal and respiratory failure by selective decontamination of the digestive tract. Crit. Care Med., 1990, 18, 1239-1242. [5] STOUTENBEEKC.P., VAN SAENE H.K.F., MIRANDAD.R., ZANDSTRA D.F. - The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients. Intens. Care Med., 1984, 10, 185192. [6] SYDOWM., BURCHARDI H., CROZIERT.A. et at. - Einftul5 der selektiven Dekontamination auf nosokomiale Infektionen, Erregerspektrum und Antibiotikaresistenz bei tangzeibeatmeten Intensivpatienten. Anasth. Intensivther Notfallmed, 1990, 25, 416-423. [7] TETTEROOG.W.M., WAGENVOORTJ.H.T., CASTELEINA. et al. Selective decontamination to reduce gram-negative colonization and infections after oesophageal resection. Lancet, 1990, 335 (I), 704-707. [8] THOLIGB., HARTENAUERU., DIEMERW. et al. - Seiektive FIorasuppression zur Infektionskontrolle in der operativen Intensivmedizin. Anaesth. Intensivther Notfallmed, 1989, 24, 343-354. [9] ULRICH C., HARINCK-de WEERD J.E., BAKKER N.C., et al. Selective decontamination of the digestive tract with norfloxacin in the prevention of ICU-acquired infections: A prospective randomized study. Intens. Care Med., 1989, 15, 424-431. [10] BRUN-BuISSON C., LEGRANDP., RAUSSA. et ai. - Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Ann. Intern. Med., 1989, 110, 873881. [11] FLAHERTYJ., NATHANC., KABINSS.A., WEINSTEINR.A. - Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit. J. Infect. Dis., 1990, 162, 1393-1397. [12] GODARDJ., GUILLAUME C., REVERDYM.E. et al. - Intestinal decontamination in a polyvalent ICU. A double-blind study. Intens. Care Med., 1990, 16, 307-311. [13] RODRIGUEZ-ROLDANJ.M., ALTUNA-CUESTAA., LOPEZA. et al. Prevention of nosocomial lung infection in ventilated patients: Use of an antimicrobial pharyngeal nonabsorbable paste. Crit. Care Med., 1990, 18, 1239-1242.
R6an. Urg., 1992, 1 (3 bis), 516-520
-
5 2 0
-
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