关于ICU目标监测——VAP：话题一、什么是选择性消化道脱污染

桃子妖妖

在做ICU目标性监测过程中，作为感控人员，其实有许多概念也需要我们去知晓，这样才能很好地与临床达到真正平等、有说服力和实效的沟通、交流。今天和同仁共同学习什么是选择性消化道脱污染（selectiv digestive decontamination,SDD）：SDD是通过局部使用抗生素杀灭口咽部和胃肠道的条件致病性需氧微生物，避免其移行和易位，切断医院内感染的病原菌来源，从而预防VAP的发病。理想的SDD方法所选用的抗生素应具备以下的特点：（1）抗菌谱应覆盖肠杆菌科、假单胞菌属和不动杆菌属的细菌。（2）粘膜表面不或很少吸收，以保证肠腔内较高的抗生素浓度。（3）必须是杀菌剂，因为在胃肠道中没有调节抗菌活性作用的白细胞，其杀菌作用完全有赖于抗菌药物本身的作用。（4）具有选择性的抗菌活性即不影响厌氧菌群药物，不易被胃肠道内容物灭活。目前常用的用药包括种粘膜不吸收抗生素妥布霉素，多粘菌素、二性霉素。一般认为可降低VAP的发病率，但能否降低病死率仍有争议。此外因是一种预防性使用抗生素的措施，耐药性的产生是不少人对持谨慎态度的一个原因。所以目前不作不常规预防感染的方法，仅应用于高危群体的预防。那么适用于什么样的高危群体呢？利弊究竟如何呢？SDD你院又做了么？欢迎大家讨论。

青霉素

用于高位群体？ICU的都应该是高危吧。但我们没有用

bookmountain

循证医学证明SDD不提倡应用，临床应用只是安慰疗法，增加耐药菌株的产生。

蓝鱼o_0

回复 1# 桃子妖妖
非常好的论题。
坦率的说这个话题我不太了解，所以我去查了下文献资料。
1.SDD可以显著降低术后死亡率的证据，SDD对术后病患的预后具有显著的保护效应http://www.ncbi.nlm.nih.gov/pubmed/21162752,free article；
2.最近的REVIEW显示：
Prophylactic use of antibiotics in critically ill patients is effective in reducing the incidence of VAP. Probiotic strategies deserve consideration in future well-powered trials. Future studies are needed to determine if preventive antibiotic and probiotic strategies are safe with regard to development of antibiotic resistance and probiotic infections. It should be determined whether the efficacy of probiotics improves when these agents are provided to the mouth and the intestines。

Abstract:
INTRODUCTION: Mechanically ventilated critically ill patients frequently develop ventilator-associated pneumonia (VAP), a life-threatening complication. Proposed preventive measures against VAP include, but are not restricted to, selective decontamination of the digestive tract (SDD), selective oropharyngeal decontamination (SOD) and the use of probiotics. Probiotics are live bacteria that could have beneficial effects on the host by altering gastrointestinal flora. Similar to SDD and SOD, a prescription of probiotics aims at the prevention of secondary colonization of the upper and/or lower digestive tract.
METHODS: We performed a literature review to describe the differences and similarities between SDD/SOD and probiotic preventive strategies, focusing on (a) efficacy, (b) risks, and (c) the routing of these strategies.
RESULTS: Reductions in the incidence of VAP have been achieved with SDD and SOD. Two large randomized controlled trials even showed reduced mortality with these preventive strategies. Randomized controlled trials of probiotic strategies also showed a reduction of the incidence of VAP, but trials were too small to draw firm conclusions. Preventive strategies with antibiotics and probiotics may be limited due to the risk of emerging resistance to the locally applied antibiotics and the risk of probiotic-related infections, respectively. The majority of trials of SDD and SOD did not exhaustively address the issue of emerging resistance. Likewise, trials of probiotic strategies did not adequately address the risk of colonization with probiotics and probiotic-related infection. In studies of SDD and SOD the preventive strategy aimed at decontamination of the oral cavity, throat, stomach and intestines, and the oral cavity and throat, respectively. In the vast majority of studies of probiotic therapy the preventive strategy aimed at decontamination of the stomach and intestines.
CONCLUSIONS: Prophylactic use of antibiotics in critically ill patients is effective in reducing the incidence of VAP. {Although SOD or SDD is effective, revivewers still have other concerns!}Probiotic strategies deserve consideration in future well-powered trials. Future studies are needed to determine if preventive antibiotic and probiotic strategies are safe with regard to development of antibiotic resistance and probiotic infections. It should be determined whether the efficacy of probiotics improves when these agents are provided to the mouth and the intestines simultaneously.


文献出处：Crit Care. 2011 Jan 13;15(1):R18. [Epub ahead of print]

蓝鱼o_0

PS: Although SOD or SDD is effective," revivewers" still have other concerns!拼错啦~reviewers, instead!

绿茵场

回复 1# 桃子妖妖
以前就听说过这个概念，感觉离我们还比较遥远。
不过在 高危人群 中应用是否利大于弊，需要证据支持。

绿茵场

回复 3# bookmountain
您能否提供相关报道呢？
谢谢

grglk9339

向老师们学习！我将关注该帖，继续学习。

safihu

多粘菌素、二性霉素,就这些药仅从具有选择性的抗菌活性即不影响厌氧菌群药物，不易被胃肠道内容物灭活考虑合适，但是从抗菌药物合理使用来看，肯定不会被使用。

星火

回复 1# 桃子妖妖


    在ICU患者不同存在各个脏器衰竭？早期经验应用抗菌药物目的是预防占主要的？除非明确是严重感染的一开始时治疗用抗菌药，随着各项培养和监测结果出来后，转化治疗方案？脏器衰竭时伴随感染的发生，预防应用抗菌药需要抢先和降阶梯策略。当患者处在僵持状态时，感控措施可能比预防应用抗菌药物还有效？比如排痰和口腔护理等。

桃子妖妖

Oropharyngeal decontamination in intensive care patients:less is not more
Ventilator-associated pneumonia (VAP) is a common cause of morbidity, antibiotic use, increased length of stay and, possibly,increased mortality in ICU patients. Colonization of the oropharyngeal cavity with potentially pathogenic micro-organisms is instrumental in the pathogenesis of VAP, and selective oropharyngeal decontamination (SOD) with antibiotics (AB-SOD) or antiseptics,such as chlorhexidine gluconate (CHX-SOD), has been associated with reduced incidences of VAP. In a recent issue of Critical Care Scannapieco and colleagues investigated differences in oropharyngeal colonization between mechanically ventilated patients receiving oropharyngeal decontamination with 0.12% CHX-SOD either once or twice daily compared to placebo. CHX-SOD was associated with a reduction in Staphylococcus aureus colonization,but the study was underpowered to demonstrate a reduction in VAP incidence. We urgently need well-designed and adequately powered studies to evaluate the potential benefits of CHX-SOD on patient outcome in ICUs.

momi1319

对于新加入院感团队的同志们来说，又学到了不少的知识，希望能更好的用于工作中！