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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 !!!