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Philippe Eggimann, MD Adult Intensive Care Medicine www.soins-intensifs.chuv.ch
Update on controversies about SDD
Switzerland
Dr Eggimann collaborated to several industry- sponsorized clinical trials since 1990.
Dr Eggimann served on advisory board for and/or sponsorized lectures for Pfizer, MSD, Astellas, Roche, Weyth-Lederle, Lilly, Medex Kenta-Biotech
DISCLOSURE
Eggimann
Anything I say can be highly biased Welcome to the ICU
www.chuv.ch/soinsintensifs Welcome to the ICU
EPIC II study Vincent JAMA 2009
ICUs, the world of infections 1’265 worldwide ICU 14’414 patients 51% with infection (08.05.2007)
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EPIC II study Vincent JAMA 2009
80%
70%
60%
50%
40%
30%
20%
10%
0% 0 -‐ 1 2 -‐ 3 4 -‐ 6 7 -‐ 10 11 -‐ 5 16 -‐ 21
Days in the ICU before the study day
Infec@on
rate
The world of nosocomial infections 1’265 worldwide ICU 14’414 patients
?? How did we reach that ??
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1928: Alexander Fleming
1940: Ernst Chain
43-year-old Oxford policeman who had nicked the corner of his mouth shaving. ->Facial and orbital cellulitis -> improvement ->relapse and death
1940: Hrward Foley
75 years ago Destroying bugs was easy
May be too easy !!!
Publicity in the 50’s
â RESISTANCES INFECTIONS â ANTIBIOTICS
â RESISTANCES INFECTIONS â ANTIBIOTICS â RESISTANCES INFECTIONS â ANTIBIOTICS
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â RESISTANCES INFECTIONS â ANTIBIOTICS â RESISTANCE INFECTIONS â ANTIBIOTICS
prophylaxis
â RESISTANCES INFECTIONS â ANTIBIOTICS
Inappropriate Antibiotic treatment
æ Resistant microorganisms
Broad spectrum antibiotics
æ Mortality sepsis/VAP peritonitis
Celis et al.Chest 1988 Alvares-L. et al. ICM 1996
Luna et al. Chest 1997 Kollef et al. Chest 1999 Rello et al. Chest 2002 Leroy et al. ICM 2003 Clec’h et al. ICM 2004
â RESISTANCES INFECTIONS â ANTIBIOTICS
Resistant microorganisms
â RESISTANCES INFECTIONS â ANTIBIOTICS Escherichia Coli
6.4%
requires carbapenem
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Escherichia Coli
requires carbapenem or colistin
Escherichia Coli
Escherichia Coli Escherichia Coli
Human adult: 1013 cells
Bowel:1014 bacteria Obligate anaerobes 1011
Bifidobacterium, lactobacilli, Bacteroides, clostridia
Facultative anaerobes 107
enterobacteria, staphylococci, streptococci,
Fungi <104
Skin:1012 bacteria
Corynebacterium Staphylococci Streptococci Fungi
Unrecognized major role of the bowel flora
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Antibiotics, promote resistance !! What is SDD ? SDD
SOD
Ventilator-associated pneumonia
aspirations
translocation
Bloodstream infections Craven, et al. Chest. 1995;108:s1-s16
Van Sane HKF et al. ICM 2003;29:677-90
Objective: prevention of secondary colonization with potential pathogens
What is SDD ?
Craven, et al. Chest. 1995;108:s1-s16 4.Surveillance cultures
Throat and rectum, on admission and twice weekly Van Sane HKF et al. ICM 2003;29:677-90
1. Enteral (topical) non-absorbable antibiotics Applied to throat and gut throughout ICU stay polymyxin E/ tobramycin /amphotericin B / (vancomycin) 2.Parenteral antibiotics Short (4 days), cephalo /quinolone/…
Antibiotics used should preserve the anaerobic intestinal flora
3.Hand hygiene
antibiotics
What is SDD ?
Antibiotics: fuel on the fire !!
SDD
Unrecognized major role of the bowel flora
SDD
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SDD University
Over the last 25 years
57 randomized trials
22 editorials 15 meta-analyses 47 letters 110 reviews WAS HIGHLY
CONTROVERSIAL A. no B. in selected patients C. yes
Did you use SDD ?
Strong evidence for SDD
Kescogliou & Eggimann What’s new in SDD (ICM 2015)
Strongest evidence for SDD
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SDD not-‐colonized
Crit Care Med 2011; 39:961-6
SOD
Standard care
Strong evidence for SDD, but…
SDD not-‐colonized
Crit Care Med 2011; 39:961-6
SDD remaınıng colonized
SOD
Standard care
Strong evidence for SDD, but…
Resistant rectal samples Resistant respiratory samples ce>azidime ce>azidime
tobramycin tobramycin
ciprofloxacin ciprofloxacin
Pre-intervention Intervention SDD/SOD
Post-intervention Pre-intervention Intervention SDD/SOD
Post-intervention
Oos$djik EAN, AJRCCM 10
Ecological effects of SDD
Rebound effect
SDD may promote resistance !!
SDD
Ecological effects of SDD
MIC
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Impact of SDD out of the Nederland island ?
77%
27%
49%
Doubts on real SDD effect
SDD
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SDD may promote resistance !!
The Nederlands
Back to the gut Escherichia Coli
Escherichia Coli Clostridium difficile
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Clostridium difficile Clostridium difficile
Owens RC et al. CID 2008;46:S19-31
Clostridium difficile
20 patients
Responders n=14
Non-responders n=6
Further teatment
First treatment
Responders n=4
Non-responders n=2
To summarize
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A. no B. in selected patients C. yes
Did you use SDD ?
SDD ? According to 1) evidence 2) local situation
General measures Surveillance Isolation precautions
Specific strategies Specifically targeted against VAP Specifically targeted against BSI Specifically targeted against ….
Antibiotic control Combination therapy SDD; probiotics Guidelines; deescalation Antibiotic stewardship Therapeutic drug monitoring
Strategies for infection control
Eggimann P et al. Rev Med Sui 05
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Probiotic University
Over the next 25 years
xx randomized trials
xx editorials xx meta-analyses xx letters xx reviews HIGHLY
CONTROVERSIAL !!!