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Because of the proven clinical benefits in the clear absence of toxicity, we fail to understand why this method has not gained acceptance in the United States, a country known to prefer practicing medicine based on evidence rather than expert opinion.
H.K.F. van Saene, M.D., Ph.D.
Paul B. Baines, M.R.C.P.
Royal Liverpool Children's Hospital
Liverpool L12 2AP, United Kingdom
References
To the Editor: Drs. van Saene and Baines suggest that selective decontamination of the digestive tract reduces mortality and should therefore gain clinical acceptance for the prevention of ventilator-associated pneumonia in the United States. Their recommendation is based on the results of two recent meta-analyses.1,2 Unfortunately, it is not clear from these meta-analyses whether the use of this method was responsible for the reported reductions in mortality.
D'Amico and colleagues1 observed a reduction in mortality only when the use of topical and systemic antibiotic prophylaxis was compared with no use of prophylaxis (16 studies). There were no differences in mortality when topical and systemic antibiotic prophylaxis was compared with systemic antibiotic prophylaxis alone (7 studies) and when topical antibiotic prophylaxis was compared with no antibiotic prophylaxis (11 studies). These findings would suggest that systemic antibiotic prophylaxis — not the topical administration of antibiotics — is responsible for the reduction in mortality. Interestingly, the majority of patients in the meta-analysis who had a survival advantage were surgical and trauma patients (>70 percent), groups for which systemic antibiotic prophylaxis has already been shown to be advantageous.3
Nathens and Marshall2 had similar findings in their meta-analysis. Antibiotic prophylaxis was not found to influence survival in the 10 studies with no more than 25 percent postoperative and trauma patients. A survival advantage was found in the 11 studies with more than 75 percent postoperative and trauma patients. This meta-analysis also showed that the survival advantage was greatest in studies in which both topical and systemic antibiotic prophylaxis was used. These two meta-analyses add support for the use of parenteral antibiotic prophylaxis in surgical and trauma patients, which is common practice in the United States.
The emergence of antibiotic-resistant bacterial infections has become a pivotal issue in the care of critically ill patients. There are increasing calls to limit rather than increase the use of antibiotics in order to restrain such emerging resistance.4 The use of selective decontamination of the digestive tract has been associated with antibiotic-resistant infections. In fact, one of the journal articles cited by Drs. van Saene and Baines showed a statistically significant increase in infections due to acinetobacter species after the use of this method.5 Other experiences with selective decontamination of the digestive tract have also shown greater rates of subsequent infection due to antibiotic-resistant gram-positive bacteria. For these reasons, practitioners in the United States have resisted the routine application of topical antibiotic prophylaxis.
Finally, in my review I mistakenly referred to histamine H2-receptor antagonists and antacids as gastric pH–lowering drugs; in fact, they increase gastric pH.
Marin H. Kollef, M.D.
Washington University School of Medicine
St. Louis, MO 63110-1093
References
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