Target PPM, antimicrobials, manoeuvres
Total daily dosea
<5 years
5–12 years
>12 years
Parenteral antimicrobials
–
–
–
Cefotaxime, mg
150/kg
200/kg
4,000
Enteral antimicrobials
–
–
–
Oropharynx
–
–
–
AGNB: polymyxin E with tobramycin
2 g of 2 % paste or gel
Yeasts: amphotericin B or nystatin
2 g of 2 % paste or gel
MRSA: vancomycin
2 g of 4 % paste or gel
Gut
–
–
–
AGNB: polymyxin Eb, mg
100
200
400
With tobramycin, mg
80
160
320
Yeasts: amphotericin B, mg
500
1,000
2,000
OR nystatin units
2 × 106
4 × 106
8 × 106
MRSA: vancomycin, mg
20–40/kg
20–40/kg
500–2,000
Hygiene (with topical antimicrobials)
(2 g of 2 % PTA paste/gel or 4 % vancomycin paste/gel)
Surveillance swabs of throat and rectum on admission, Monday, Thursday
–
–
–
1.
Parenteral antibiotics given immediately on admission for 4 days to control primary endogenous infections due to PPMs already present in the patient’s admission flora. Previously, healthy patients with normal flora can be treated with cefotaxime 80–100 mg/kg/day. Patients with a chronic underlying disease and patients transferred from other ICUs or general wards may carry both normal and abnormal flora in throat and gut and may require an antipseudomonal cephalosporin.
2.
Enteral non-absorbable antimicrobials, i.e. polymyxin E (colistin), tobramycin and amphotericin B (PTA), given throughout the treatment in the ICU, to control secondary carriage and subsequent secondary endogenous infections due to PPMs acquired in the ICU. Half a gram of gel or paste containing 2 % PTA is applied to the oropharyngeal mucosa with a spatula or a gloved finger four times a day; additionally, 10 ml of a suspension containing 100 mg of polymyxin E, 80 mg of tobramycin and 500 mg of amphotericin B is administered into the gut through the nasogastric tube four times a day. In properly decontaminated patients, surveillance samples of throat and rectum are free from AGNB, S. aureus and yeasts. In case of methicillin-resistant S. aureus (MRSA) endemicity, oropharyngeal gel and/or intestinal solution of vancomycin can be added to the classical PTA regimen to prevent the possible selection of MRSA.
3.
High standards of hygiene to control exogenous infections due to transmission of ICU-associated microorganisms. Identical antimicrobials of PTA and/or vancomycin as gel/paste are indicated for topical use on the tracheostomy in tracheostomized patients to control exogenous lower airway infections.
4.
Surveillance cultures of throat and rectum on admission and, afterwards, twice weekly to monitor the efficacy of SDD and to detect the emergence of resistance at an early stage.
The combination of polymyxin and tobramycin was chosen because it covers most abnormal AGNB including Pseudomonas species, and it is an in vitro synergistic combination. The use of a polyene, such as amphotericin B or nystatin, eradicates fungal overgrowth.
Experts are concerned that SDD may lead to an ecological catastrophe. In contrast, the best evidence is that the use of SDD is generally safe, and resistance is under control [16, 17]. This is mainly due to the control of gut overgrowth, reducing spontaneous mutations, polyclonality and resistance [1, 18]. Two large Dutch RCTs had resistance as endpoint [3, 4]. Both RCTs showed significantly less resistance in patients receiving SDD than in those receiving standard care. Additionally, the incidence of bacteremia and lower respiratory tract colonization due to highly resistant AGNB was significantly reduced by SDD compared to standard care [17]. Two recent meta-analyses explored the impact of SDD on resistance [18, 19]. In the first meta-analysis, including only RCTs, resistance was reduced in patients receiving SDD compared with controls (OR 0.56, 95 % CI, 0.41–0.76) [18]. Another systematic review [19], including both randomized and not randomized studies, showed a reduction in polymyxin and third-generation cephalosporin resistance to AGNB in patients receiving SDD compared with those who received no intervention.
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