Selective digestive decontamination, a seemingly effective regimen with individual benefit or a flawed concept with population harm?

AbstractSelective digestive decontamination (SDD) regimens, variously constituted with topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP), appear highly effective for preventing ICU-acquired infections but only within randomized concurrent control trials (RCCT’s). Confusingly, SDD is also a concept which, if true, implies population benefit. The SDD concept can finally be reified in humans using the broad accumulated evidence base, including studies of TAP and PPAP that used non-concurrent controls (NCC), as a natural experiment. However, this test implicates overall population harm with higher event rates associated with SDD use within the ICU context.

Download Full-text

Studies of selective digestive decontamination as a natural experiment to evaluate topical antibiotic prophylaxis and cephalosporin use as population-level risk factors for enterococcal bacteraemia among ICU patients

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dkz300 ◽

2019 ◽

Vol 74 (10) ◽

pp. 3087-3094 ◽

Cited By ~ 3

Author(s):

James C Hurley

Keyword(s):

Risk Factors ◽

Antibiotic Prophylaxis ◽

Population Level ◽

Study Groups ◽

Selective Digestive Decontamination ◽

Topical Antibiotic ◽

Icu Patients ◽

Concurrent Control ◽

Incidence Data ◽

The Impact

AbstractBackgroundSelective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) regimens appear protective against ICU-acquired overall bacteraemia. These regimens can be factorized as topical antibiotic prophylaxis (TAP) with (SDD) or without (SOD) protocolized parenteral antibiotic prophylaxis (PPAP) using cephalosporins. Both TAP and cephalosporins are risk factors for enterococcal colonization although their impact on enterococcal bacteraemia within studies of SDD/SOD remains unclear.ObjectivesTo benchmark the enterococcal bacteraemia incidence within component (control and intervention) groups of SDD/SOD studies among ICU patients versus studies without intervention (observational groups).MethodsThe literature was searched for SDD/SOD studies reporting enterococcal bacteraemia incidence data. In addition, component groups of studies of various non-antibiotic interventions served to provide additional points of reference.ResultsThe mean incidence per 100 patients (and 95% CI) for enterococcal bacteraemia among 19 SDD/SOD studies was equally increased among concurrent control (2.1; 1.0%–4.7%) and intervention (2.3; 2.0%–2.7%) groups versus the benchmark incidence (0.8; 0.6%–1.2%) derived from 16 observational study groups and also versus 9 component groups from non-antibiotic studies. These higher incidences remained apparent (P < 0.02) in a meta-regression model adjusting for groupwide factors such as PPAP use, mechanical ventilation proportion, group mean length of stay >7 days and publication year.ConclusionsThe incidences of enterococcal bacteraemia within both concurrent control and intervention groups of SDD/SOD studies are unusually high compared with the literature-derived benchmark. The impact of parenteral cephalosporin used as PPAP additional to TAP on enterococcal bacteraemia incidence was indeterminate in this analysis.

Download Full-text

Asymmetric Effects of Decontamination Using Topical Antibiotics for the ICU Patient

Symmetry ◽

10.3390/sym13061027 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1027

Author(s):

James C. Hurley

Keyword(s):

Infection Prevention ◽

Natural Experiment ◽

Antibiotic Use ◽

Ventilator Associated Pneumonia ◽

Control Groups ◽

Topical Antibiotic ◽

Topical Antibiotics ◽

Concurrent Control ◽

Asymmetric Effects ◽

Prevention Studies

There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection. These have been evaluated in >200 studies. Infection prevention using topical antibiotic prophylaxis (TAP) appears to be the most effective. Whether antibiotic use in the ICU may influence the risk of infection among concurrent control patients within the same ICU and result in asymmetrical herd effects cannot be resolved with individual studies examined in isolation. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-center natural experiment enabling the herd effects of antibiotics to be evaluated. Among the TAP control groups, the incidences for both ventilator associated pneumonia (VAP) and mortality are unusually high in comparison to literature-derived benchmarks. Paradoxically, amongst the TAP intervention groups, the incidences of mortality are also unusually high and the VAP incidences are similar (i.e., not lower) compared to the incidences among studies of other interventions. By contrast, the mortality incidences among the intervention groups of other studies are similar to those among the intervention groups of TAP studies. Using topical antibiotics to prevent infections acquired within the ICU environment may result in profoundly asymmetrical effects.

Download Full-text

Structural equation modelling the ‘control of gut overgrowth’ in the prevention of ICU acquired Gram-negative infection.

10.21203/rs.2.21941/v3 ◽

2020 ◽

Author(s):

James C Hurley

Keyword(s):

Antibiotic Prophylaxis ◽

Structural Equation Modelling ◽

Latent Variables ◽

Structural Equation ◽

Infection Prevention ◽

Topical Antibiotic ◽

Parenteral Antibiotic ◽

Gram Negative ◽

Positive Effects ◽

Equation Modelling

Abstract Background: Conceptually, the ‘control of gut overgrowth’ (COGO) is key in mediating prevention against infection with Gram-negative bacilli by topical antibiotic prophylaxis, a common constituent of Selective Digestive Decontamination (SDD) regimens. However, the relative importance of the other SDD components; enteral and protocolized parenteral antibiotic prophylaxis, versus other methods of infection prevention and versus other contextual exposures cannot be resolved within individual studies. Methods: Seven candidate generalized structural equation models founded on COGO concepts were confronted with Pseudomonas and Acinetobacter bacteremia as well as ventilator associated pneumonia data derived from >200 infection prevention studies. The following group level exposures were included in the models; use and mode of antibiotic prophylaxis, antiseptic and non-decontamination methods of infection prevention; proportion receiving mechanical ventilation; trauma ICU; mean length of ICU stay and concurrency versus non-concurrency of topical antibiotic prophylaxis study control groups. Results: In modelling Pseudomonas and Acinetobacter gut overgrowth as latent variables, anti-septic interventions had the strongest negative effect against Pseudomonas gut overgrowth but no intervention was significantly negative against Acinetobacter gut overgrowth. Strikingly, protocolized parenteral antibiotic prophylaxis and concurrency each have positive effects in the model, enteral antibiotic prophylaxis is neutral and Acinetobacter bacteremia incidences are high within topical antibiotic prophylaxis studies, moreso with protocolized parenteral antibiotic prophylaxis exposure. Paradoxically, topical antibiotic prophylaxis (moreso with protocolized parenteral antibiotic prophylaxis) appears to provide the strongest summary prevention effects against overall bacteremia and overall VAP. Conclusions: Structural equation modelling of published Gram-negative bacilli infection data enables a test of the COGO concept. Paradoxically, Acinetobacter and Pseudomonas bacteremia incidences are unusually high among studies of topical antibiotic prophylaxis.

Download Full-text

Post-injection endophthalmitis in eyes receiving vs. not receiving topical antibiotic prophylaxis in Northern Thailand

Eye ◽

10.1038/s41433-018-0187-z ◽

2018 ◽

Vol 32 (12) ◽

pp. 1911-1913

Author(s):

Voraporn Chaikitmongkol ◽

Onnisa Nanegrungsunk ◽

Direk Patikulsila ◽

Janejit Choovuthayakorn ◽

Nawat Watanachai ◽

...

Keyword(s):

Antibiotic Prophylaxis ◽

Post Injection ◽

Topical Antibiotic ◽

Northern Thailand

Download Full-text

The evidence base for the efficacy of antibiotic prophylaxis in dental practice

The Journal of the American Dental Association ◽

10.14219/jada.archive.2007.0198 ◽

2007 ◽

Vol 138 (4) ◽

pp. 458-474 ◽

Cited By ~ 84

Author(s):

Peter B. Lockhart ◽

Bridget Loven ◽

Michael T. Brennan ◽

Philip C. Fox

Keyword(s):

Antibiotic Prophylaxis ◽

Evidence Base ◽

Dental Practice

Download Full-text

Antibiotic prophylaxis for surgical procedures: a scoping review

Revista Panamericana de Salud Pública ◽

10.26633/rpsp.2021.62 ◽

2021 ◽

Vol 45 ◽

pp. 1

Author(s):

Eva Brocard ◽

Ludovic Reveiz ◽

Jean-Philippe Régnaux ◽

Veronica Abdala ◽

Pilar Ramón-Pardo ◽

...

Keyword(s):

Antibiotic Prophylaxis ◽

Systematic Reviews ◽

Scoping Review ◽

First Generation ◽

Evidence Base ◽

Current Evidence ◽

Cochrane Library ◽

Antibiotic Administration ◽

Significant Difference ◽

Surgical Antibiotic Prophylaxis

Objectives. To map the current evidence on surgical antibiotic prophylaxis (SAP) administration and identify knowledge gaps in the literature available in this field. Methods. The PubMed, Cochrane Library, Epistemonikos, and Health Systems Evidence databases were searched from January 2015 to March 2020 for systematic reviews published in English, French, Portuguese, and Spanish. Results. Eighty-three systematic reviews were included, the quality of the reviews was assessed using AMSTAR 2, and data were extracted for all primary outcomes. Perioperative antibiotic administration, the use of first generation cephalosporins, and surgical site infection (SSI) were the most commonly reported for timing of antibiotic administration, drug class, and primary outcome, respectively. Findings showed that, overall, SAP may reduce SSIs compared with a placebo or with no SAP. Results suggested that intraoperative SAP may lower SSI, while postoperative SAP did not show a statistically significant difference. Conclusions. Findings have confirmed the role of SAP in reducing postoperative SSI across various surgeries and do not support the use of antibiotics after surgery to prevent infections. The findings of this scoping review have enhanced the evidence base that can inform decisions regarding the development of global guidelines for the prevention of SSI. However, high-quality systematic reviews and research reflecting diverse populations and settings are needed.

Download Full-text

Post-surgical management of cataract: Light and dark in the 2020s

European Journal of Ophthalmology ◽

10.1177/1120672120963458 ◽

2020 ◽

pp. 112067212096345

Author(s):

Pasquale Aragona ◽

Elisa Imelde Postorino ◽

Emanuela Aragona

Keyword(s):

Cataract Surgery ◽

Antibiotic Prophylaxis ◽

Bacterial Resistance ◽

Elective Surgery ◽

Signs And Symptoms ◽

Corticosteroid Treatment ◽

Eye Drops ◽

Safe Procedure ◽

Topical Antibiotic ◽

Significant Step

Cataract surgery is the most frequently performed elective surgery worldwide. Although considered a safe procedure, potentially sight-threatening adverse events are possible. Among these, post-surgical inflammation and infections are the most relevant. Anti-inflammatory drugs, such as corticosteroids, and topical antibiotics are the pillars for the treatment of inflammation and for the prevention of infections. However, uncertainties remain regarding the duration of both topical antibiotic prophylaxis and corticosteroid treatment. LEADER7, a recent international clinical study conducted with the new fixed combination of levofloxacin and dexamethasone eye drops in patients undergoing uncomplicated cataract surgery, found that 1-week topical antibiotic prophylaxis is just as effective as the 2-week course commonly used in clinical practice. The study also showed that treatment for 1 week with dexamethasone results in complete resolution of inflammatory signs and symptoms in over 85% of patients, for whom further prolongation of corticosteroid treatment is, therefore, not necessary. This new treatment strategy can represent a significant step forward to reduce the unjustified use of prophylactic antibiotics after cataract surgery, limiting the emergence of bacterial resistance, as well as representing an opportunity to optimize the use and safety of the corticosteroid treatment.

Download Full-text

Longitudinal access and exposure to green-blue spaces and individual-level mental health and well-being: protocol for a longitudinal, population-wide record-linked natural experiment

BMJ Open ◽

10.1136/bmjopen-2018-027289 ◽

2019 ◽

Vol 9 (4) ◽

pp. e027289 ◽

Cited By ~ 1

Author(s):

Amy Mizen ◽

Jiao Song ◽

Richard Fry ◽

Ashley Akbari ◽

Damon Berridge ◽

...

Keyword(s):

Mental Health ◽

Natural Experiment ◽

Research Programme ◽

Well Being ◽

Evidence Base ◽

Academic Community ◽

Subjective Well Being ◽

Cross Sectional ◽

Individual Level ◽

The Impact

IntroductionStudies suggest that access and exposure to green-blue spaces (GBS) have beneficial impacts on mental health. However, the evidence base is limited with respect to longitudinal studies. The main aim of this longitudinal, population-wide, record-linked natural experiment, is to model the daily lived experience by linking GBS accessibility indices, residential GBS exposure and health data; to enable quantification of the impact of GBS on well-being and common mental health disorders, for a national population.Methods and analysisThis research will estimate the impact of neighbourhood GBS access, GBS exposure and visits to GBS on the risk of common mental health conditions and the opportunity for promoting subjective well-being (SWB); both key priorities for public health. We will use a Geographic Information System (GIS) to create quarterly household GBS accessibility indices and GBS exposure using digital map and satellite data for 1.4 million homes in Wales, UK (2008–2018). We will link the GBS accessibility indices and GBS exposures to individual-level mental health outcomes for 1.7 million people with general practitioner (GP) data and data from the National Survey for Wales (n=~12 000) on well-being in the Secure Anonymised Information Linkage (SAIL) Databank. We will examine if these associations are modified by multiple sociophysical variables, migration and socioeconomic disadvantage. Subgroup analyses will examine associations by different types of GBS. This longitudinal study will be augmented by cross-sectional research using survey data on self-reported visits to GBS and SWB.Ethics and disseminationAll data will be anonymised and linked within the privacy protecting SAIL Databank. We will be using anonymised data and therefore we are exempt from National Research Ethics Committee (NREC). An Information Governance Review Panel (IGRP) application (Project ID: 0562) to link these data has been approved.The research programme will be undertaken in close collaboration with public/patient involvement groups. A multistrategy programme of dissemination is planned with the academic community, policy-makers, practitioners and the public.

Download Full-text