Infection Control in Intensive Care Units by Selective Decontamination: The Use of Oral Non-Absorbable and Parenteral Agents

241 Pages·1989·9.99 MB·English

by  I. McA. Ledingham (auth.)

7
Update in Intensive Care
and Emergency Medicine
Edited by J. L.Vincent
Infection Control in
Intensive Care Units by
Selective Decontamination
The Use of Oral Non-Absorbable
and Parenteral Agents
Proceedings of the International Congress on
Selective Decontamination held in Jersey, UK 1988
Edited by
H.K. F. van Saene, C. P. Stoutenbeek
P. Lawin, and I. MeA. Ledingham
With 35 Figures and 30 Tables
Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
Series Editor
Prof. Dr. Jean Louis Vincent
Clinical Director, Department
of Intensive Care, Erasme Hospital,
Free University of Brussels, Route de
Lennik 808, 1070 Brussels, Belgium
Volume Editors
Dr. Hendrik K. F. van Saene Prof. Dr. Dr. h. c. Peter Lawin
Medical Microbiology, Royal Klinik filr Anlisthesiologie und ope
Liverpool Hospital, P.O. Box 147, rative Intensivmedizin der Westfli
Liverpool L69 3BX, UK Iischen Wilhelms-Universitat,
A1bert-Schweitzer-StraBe 33,
4400 Munster, FRG
Dr. C. P. Stoutenbeek Prof. Dr. I. McA Ledingham
Intensieve Zorgen, Ooze Lieve The Faculty of Medicine and
Vrouw Gasthuis, Ie Oosterpark Health Sciences University,
straat 179, 1091 HA Amsterdam, P.O. Box 15551, AI Ain,
The Netherlands United Arab Emirates
ISBN -13 :978-3-540-51 041-3 e-ISBN-13:978-3-642-83752-4
DOl: 10.1007/978-3-642-83752-4
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Contents
List of Contributors . . . . . . . . xi
Editorial Committee. . . . . . . . xv
Foreword (l. MeA. Ledingham) . 1
Introduction (H. K. F. van Saene) 3
Part One: Pathogenesis
Host-microorganism Relationship in Healthy People
(S. P. Borriello and D. A. Lloyd) . . . . . . . . . . . . . 7
Classification of Microorganisms Based on Intrinsic
Pathogenicity (J. A. Washington) ........... . 8
Defence Against Colonization and Infection
(c .
A. Hart) . . . . . . . . . . . . . . . . . . . . . . . . . 13
Oropharyngeal/Gastrointestinal Carriage: Role in Endogenous
Colonization and Infection (W G. Johanson) . . . . . 22
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Host-microorganism Relationship in the Critically III
(B. J. Rowlands) . . . . . . . . . . . . . . . . . . . . . . . 27
Impaired Colonization Defence of the Oropharynx
(W G. Johanson). . . . . . . . . . . . . . . . . . . . . . . 28
Impairment of Defence of the Stomach and Intestine against
Colonization in the Critically m Patient (L D. Hudson) . . . .. 34
Pathogenesis of Colonizationiinfection of Lower Airways
(Endogenous vs Exogenous): Conventional Approaches to
Infection Control (M. S. Niederman) . . . . . . . . . . . . 42
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Part Two: The Conventional Approach to Infection
Control
Clinical Studies (M. Hemmer and E. S. Caplan) . . . . . . 53
vi Contents
Prospective Study of Colonization, Infection and Mortality
Rates during Conventional Therapy: Glasgow Data
(G. Ramsay) .............................. 54
Infection and Mortality Rates in Critically III Patients during
Conventional Antibiotic Regimen (M. Sydow, H. Burchardi,
T. A. Crozier, R. Ruchel, C. Busse and W. Seyde) . . . . . . . .. 56
A Prospective Study of Colonization and Infection in the
Neonatal Surgical Unit at Alder Hey Children's Hospital,
Liverpool, UK (J. Walker) ...................... 57
Surveillance of Nosocomial Infections in a Surgical ICU: A
Prospective Study (U. Hartenauer) . . . . . . . . . . . . . . . .. 58
Prospective Study of Colonization, Infection and Mortality
Rates during Conventional Therapy (H. Wiedeck) . . . . . . .. 59
Infection Control in the ICU: Pattern of Colonization and
Infection in Surgical Intensive Care Patients - a Prospective
Study (A. J. H. Kerver, J. H. Rommes and
E. A. E. Verhage). . . . . . . . . . . . . . . . . . . . . . . . . . .. 60
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61
Antibiotic Resistance
(H. A. L. Clasener and J. W. Costerton). . . . . . . . . . . . . .. 65
Where and How does Antimicrobial Resistance Develop in the
Critically Ill? Studies in Neonatal Patients
(P. Shears, M. Leonard and J. Walker) . . . . . . . . . . . . . .. 66
Do Conventional Policies Control Antibiotic-resistant
Bacteria? (R. A. Weinstein) . . . . . . . . . . . . . . . . . . . . .. 74
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 83
Part Three: An Alternative Approach - Selective
Decontamination ofthe Digestive Tract (SDD);
the Use of Non-absorbable and Parenteral Agents
Philosophy of SDD (R. G. Finch and K. Unertl) ......... 87
Concept of Selective Decontamination in the Critically III
(H. K. F. van Saene, C. P. Stoutenbeek and D. F. Zandstra) . .. 88
Topical Antibiotic Regimen (c. P. Stoutenbeek) ......... 95
Use of a Short-term Parenteral Antibiotic as a Supplement to
SDD (S. R. Alcock) . . . . . . . . . . . . . . . . . . . . . . . . .. 102
Pharmaceutical Technology' in Selective Decontamination
(D. Crome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 109
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 113
Contents vii
Clinical Studies (P. Lawin and P. Suter) . . . . . . . . . . . . .. 115
Prospective Study of Colonization, Infection and Mortality in
ICU Patients Treated with SDD and Systemic Cefotaxime:
Glasgow Results (S. R. Alcock) ................... 117
Prospective Study of Mortality Rates in Critically III Patients
During SDD Regimen (M. Sydow, H. Burchardi, T. A. Crozier,
R. Ruchel, C. Busse and W. Seyde) ................. 118
Prospective Studies of Colonization, Infection and Mortality
Rates: Liverpool Data (M. Leonard) ................ 119
Infection Control by Selective Flora Suppression in Critically III
Patients (B. Thulig, U. Hartenauer, W. Diemer, P. Lawin,
W. Fegeler and W. RitzerJeld) . . . . . . . . . . . . . . . . . . . .. 120
Prospective Studies of Colonization, Infection and Mortality
Rates in ICU Patients Receiving SDD: Ulm Results
(F. Konrad, H. Wiedeck and K. Heeg). . . . . . . . . . . . . . .. 121
Prevention of Colonization and Subsequent Infection in
Critically III Patients: a Prospective, Randomized Study
(A. 1. H. Kerver, 1. H. Rommes and E. A. E. Verhage) . . . . .. 122
The Effect of a Novel Regimen of Selective Decontamination
on the Incidence of Unit-Acquired Lower Respiratory Tract
Infection in Mechanically Ventilated Patients (S. 1. A. Aerdts,
R. van Dalen, H. A. L. Clasener and E. 1. Vollaard) ....... 123
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124
Role of Endotoxin (1. W. ten Cate and 1. Cohen) . . . . . . . .. 127
Significant Reduction of Faecal Endotoxin Pool by Oral
Polymyxin E and Tobramycin in Human Volunteers
(1.1. M. van Sa ene, C. P. Stoutenbeek and H. K. F. van Saene)" 128
Endotoxaemia in Multiple Organ Failure: A Secondary Role
forSDD? (G. Ramsay) ........................ 135
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 143
Emergence of Resistance during SDD
(A. M. Emmerson and E. Yourrasowski) . . . . . . . . . . . . .. 145
Cefotaxime Combined with Selective Decontamination in
Long-Term Intensive Care Unit Patients: Virtual Absence of
Emergence of Resistance (H. K. F. van Sa ene,
C. P. Stoutenbeek and D. F. Zandstra) ............... 146
Emergence of Resistance During Selective Decontamination:
Glasgow Results (A. T. Eastaway) . . . . . . . . . . . . . . . . .. 154
viii Contents
Changes in Antibiotic Resistance in Tracheal Aspirates
Following Selective Decontamination of the Digestive Tract
(M. Sydow, H. Burchardi, T. A. Crozier, R. Ruchel, C. Busse
and W. Seyde). . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 155
The Liverpool Experience, 1987-1988 (A. E. Murray) . . . .. 156
Colonization and Resistance Patterns of Microbial Isolates
Following SDD in Association with Short-Course Cefotaxime
(K. Heeg, K. Bigos, F. Konrad, H. Wiedeck and H. Wagner). .. 158
Gram-negative Bacillary Resistance in a Surgical Intensive Care
Unit: A Four-Year Surveillance (E. A. E. Verhage,
A. J. H. KerverandJ. H. Rommes) ................. 159
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 160
Part Four: Stress Ulcer Prophylaxis and Pneumonia
Stress Ulcer Prophylaxis and Pneumonia
(M. Tryba and 1. MeA. Ledingham) . . . . . . . . . . . . . . . .. 165
m
Pathogenesis of Stress Ulcer Bleeding in the Critically
(D. F. Zandstra, C. P. Stoutenbeek,
H. M. Oudemans-vanStraaten) ................... 166
Gastric Colonization and Nosocomial Pneumonia in the
Mechanically Ventilated Patient (D. E. Craven) ........ , 173
New Approaches to the Prevention of Infection in Intensive
Care Unit Patients (J. Flaherty, S. A. Kabins and
R. A. Weinstein) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 184
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 189
Part Five: Analysis of Conventional and SDD
Approaches
A Possible Explanation for the Success of SDD
(H. K. F. van Saene, C. P. Stoutenbeek and D. F. Zandstra) 193
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 197
Impact of Parenteral Cephalosporins on Human
Oropharyngeal and Faecal Flora (J. C. Pichere) ......... 198
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203
Development of Antibiotic Resistance During Conventional
and SDD (c. A. Hart). . . . . . . . . . . . . . . . . . . . . . . .. 205
m
The Gut and Sepsis in the Critically (J. R. Border) . . . . . .. 211
Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 214
Contents ix
Conclusions (w. G. Johanson) . . . . . . . . . . . . . . . . . . .. 215
Close(H.K.F.vanSaene) ...................... 220
Bibliography 223
Appendices
Appendix I: Formulations Used in Selective
Decontamination . . . . . . . . . . . . . . . . . .. 231
Appendix II: List of Abbreviations ................ 232
Appendix ill: Trials of Infection Rates Following
Conventional Treatment and Selective
Decontamination . . . . . . . . . . . . . . . . . .. 233
List of Contributors
Aerdts, S. J. A.
Department of Internal Medicine, Canisius Wilhelmina Hospital,
PB 9015,6500 GS Nijmegen, The Netherlands
Alcock,S.R.
Department of Bacteriology and Immunology, Western Infirmary,
Glasgow G 11 6NT, UK
Border, J. R.
Department of Surgery, Erie County Medical Center,
462 Grider Street, Buffalo, New York 14215, USA
Borriello, S. P.
Clinical Research Centre, Watford Road, Harrow,
Middlesex HAl 3UJ, UK
Caplan, E. S.
Maryland Institute of Emergency Medical Service Systems,
University of Maryland, 22 South Green Street, Baltimore,
Maryland 21201, USA
Clasener, H. A. L.
Laboratorium voor Medische Microbiologie,
Canisius-Wilhelmina Ziekenhuis, S1. Annastraat 289IPostbus 9015,
6500 GS Nijmegen, The Netherlands
Cohen,J.
Infectious Diseases Unit, Royal Postgraduate Medical School,
150 Du Cane Road, London W12 ONN, UK
Costerton, J. W.
Department of Biological Sciences, University of Calgary,
Calgary, Alberta, Canada
Craven, D. E.
Boston City Hospital, 818 Harrison Avenue, House Officers Building,
Room 411, Boston, Massachusetts 02118, USA
xii List of Contributors
Crome,D.
Department of Pharmacy, Royal Liverpool Hospital,
Prescott Street, Liverpool L 7, UK
Eastaway, A. T.
Department of Bacteriology and Immunology,
Western Infirmary, Glasgow, UK
Emmerson, A. M.
Department of Microbiology and Immunology,
The Queen's University of Belfast,
GrosvenorRoad,BelfastBTl2 6BN, UK
Finch,R.G.
Department of Microbial Diseases,
The City Hospital and University of Nottingham,
Hucknall Road, Nottingham NG5 IPB, UK
Hart, c.A.
Department of Medical Microbiology, University of Liverpool,
PO Box 147, Liverpool L69 3BX, UK
Hartenauer, U.
Klinik fur Anasthesiologie, Westfalischen Wilhelms-Universitat,
Albert-Schweitzer-Strasse 33, 4400 Munster, FRG
Heeg,K.
Institute for Microbiology, University ofUlm,
Oberer Eselsberg, D-7900 Ulm, FRG
Hemmer,M.
Anesthesiologie, Centre Hospitalier,
Rue BarbIe 4, Luxembourg
Hudson, L. D.
Division of Pulmonary and Critical Care Medicine,
Harborview Medical Center, 325 9th A venue,
Seattle, Washington 98104, USA
Johanson, W. G.
Department of Internal Medicine, 4.1 08 John Sealy Hospital,
E-67 Galveston, Texas 77550-2778, USA
Kerver, A. J. H.
University Hospital Utrecht, Catharijnesingell 0 1,
3511 GV Utrecht, The Netherlands
Konrad,F.
University ofUlm, Steinhovelstrasse 9,
Anasthesie St. L D.7900 Ulm, FRG