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![Page 1: « Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled.](https://reader036.fdocuments.us/reader036/viewer/2022062622/551d9db5497959293b8da4c6/html5/thumbnails/1.jpg)
« Effects of selective decontamination of digestive tracton mortality and acquisition of resistant bacteria in intensivecare: a randomised controlled trial »
Evert de jonge, the lancet 2003; 362: 1011-16
Sébastien DeleuzeDES de néphrologieDESC de réanimation 2004
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INTRODUCTION:
1984: infections nosocomiales précédées par une colonisation
3 Méta analyses: décontamination digestive baisse la mortalitéMéthodologie discutable
12 études prospectives ne trouvent pas de différence significative
Décontamination digestive dans la prévention des infections nosocomiales: sujet très controversé
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BUT DE L’ÉTUDE:
Evaluer le SDD sur
la mortalité Résistance bactérienne aux antibiotiques
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MODALITE DE L’Étude
Prospective
Critères d’inclusions: > 18 ans > 48h de ventilation ou > 72h d’hospitalisation
Critères d’exclusions:Hospitalisation dans les 3 mois hypersensibilité aux produits utilisés femme enceinte inclusion dans une autre étude
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Hôpital:2 unités de réanimation
Unité 1Groupe SDDD
Unité 2Groupe TEMOIN
Taux de mortalitéApache 2
Randomisation
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RANDOMISATION
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BRAS SDDD:
Bouche:4/j2% polymixine E2% tobramicine2% ampho B
PO: 100 mg polymixine E80 mg Tobramicine500 mg Ampho B
Tachéotomie: application pâte
Colostomie:Suppositoire:Polymixine E 42 mgAmpho B 42Tobra 64 mg
Céfotaxime 1g/j pendant les 4 premiers jours
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POPULATION ETUDIEE
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Age
SDDD
Témoin
AGE
60
59,5
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050
100150200250
chir
urg
en
te
chir
pro
gra
mm
é
e
mé
dic
al
SDDD
Témoin
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0
100
200
300
400
500
SDD Témoin
VM
droguesvasopréssives
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0102030405060
SDD
Témoin
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STATISTIQUES
Anticipation: risque alpha 0,05 Puissance de l’étude 90% 503 patients dans chaque groupe
5% enterob.5% Pyoc.2% Staph.88% sans colonisation
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RESULTATS
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Courbe de survie
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RESISTANCES BACTERIENNES
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Résistances à l’inclusion
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Ecologie des servives
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Résistances acquises
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COUT DU TRAITEMENT
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Prix antibiotiques
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DISCUSSION
Sur les résultats:différence de mortalité plus importante que dans la littérature Amico BMJ 1998 316:1275_85
car unités séparées donc moins de contaminations croisées traitement plus completMoins de résistance aux antibiotiques, que prévu.
Sur la présence de biais: 2 unités différentes donc raison de la différence sur la mortalité?
L
Le prix du traitement: Gain économique
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Conclusion
SDDD: semble baissé la mortalité diminue l’acquisition de résistance aux antibiotiques
Préconise un traitement SDDD à tous les patients Ventilation mécanique >48 h ou Hospitalisation prévue > 72h
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Critique de l’article
Étude: bien menée bonne méthodologie bonne puissance statistique
2 biais importants: 2 unités différentes avec des médecins différents le groupe témoin ne connaissait pas les résultats des prélèvements bactério. Aucune mesure d’hygiène en cas de colonisation
Cette étude ne permet pas de conclure sur l’intérêt du SDD.