Mouthwash Is Great for Critically Ill Patients Decontamination of the Digestive Tract and Oropharnyx in ICU Patients

Background: Infectious complications remain a major concern in critically ill patients. Preventive measures are clearly better than treatment. Selective decontamination (SDD) of the upper digestive tract is one method that has had mixed results. Numerous questions exist as to whether or not gastrointestinal (GI) decontamination should be routine or not. Objective: To determine the effectiveness of SDD and selective oral decontamination (SOD) on mortality in critically ill patients. Design: Controlled, crossover, randomized study in 13 ICUs in the Netherlands. Participants: 5,939 patients were enrolled in 3 arms; 1,990 patients had standard care, 1,904 had SOD, and 2045 had SDD. Each ICU used all 3 regimens introduced randomly over a 6-month period. Methods: Patients were eligible on ICU admission if they were expected to be intubated for at least 48 hours or have an ICU stay of >72 hours. Crude mortality and adjusted mortality using a random effects logistic regression model was reported. The primary endpoint was 28-day mortality rates. A secondary end point was the development of antibiotic resistance. Interventions: SDD and SOD included topical application of tobramycin, colistin, and amphotericin B in the oropharynx. This paste was also instilled in the stomach for SDD patients. SDD patients also received 4 days of IV cefuroxime. Cultures were taken for point prevalence studies every third Tuesday of the month. Results: Crude mortality was 27.5% in the standard care patients, 26.9% for SDD patients, and 26.6% for SOD patients. The adjusted reduction in mortality for SDD was 13% and 11% for SOD compared to standard therapy. Antibiotic resistance was not significantly different between SDD and SOD, and both were less than standard care. Conclusions: SDD or SOD reduces mortality in ICU patients without impacting antibiotic resistance. Reviewer's Comments: This well done clinical study showed a beneficial effect for decontamination of the GI tract in critically ill patients. Will it be enough to recruit intensivists to GI decontamination? The major worry for many clinicians has been the use of 4 days of systemic cephalosporins in the SDD approach. The authors properly point out that since there is no difference in the benefit between SDD and SOD and that maybe SOD should be the approach of choice. SOD avoids systemic antibiotics and uses less of the antibiotic paste. Both will make the approach more cost effective. We use antiseptics as the oral "mouthwash." The authors also mention antiseptics as another alternative. While this study controlled many aspects of care, the 10% reduction in antibiotic use in SDD and SOD patients was not in their regression analysis. Could fewer antibiotics be the real answer? Extremely interesting question and one I think we should all ponder. (Reviewer-John A. Weigelt, MD).