122 multiple trauma patients staying in the ICU for 5 or more days and needing mechanical ventilation were investigated to determine the effect of selective decontamination of the digestive tract on prevention of infection. The (retrospectively studied) control group of 59 patients received no antibiotic prophylaxis. The infection rate during ICU-stay was 81%. Most infections were caused by potentially pathogenic microorganisms (PPM) from the oral cavity or the intestines (i.e. endogenous infections). The oropharynx and the intestines were rapidly colonised with ICU-associated gram-negative bacilli. After 2 weeks more than 80% of patients were found colonised. This secondary colonisation of the digestive tract is a very important stage in the pathogenesis of infections. Sixty-three patients were selectively decontaminated with nonabsorbable antibiotics, administered through the gastric tube even if peristalsis was absent. Emphasis was laid on the selective decontamination of the oral cavity, using topical application of an antibiotic paste. With this technique the oral cavity was free of PPM within 3 days in most patients. No secondary colonisation was found. Rectal colonisation decreased significantly after 5 days. Secondary colonisation occurred in 9 patients with PPM sensitive to the antibiotics used. The prophylactic regimen included systemic cefotaxim, directed against early endogenous infection. The suppression and after some time the absence of the endogenous source of PPM resulted in a significant reduction of colonisation and infection. The total infection rate decreased to 16%.

The effect of selective decontamination of the digestive tract on colonisation and infection rate in multiple trauma patients.

• We prospectively studied 526 patients admitted to the medical intensive care unit (MICU) and 799 patients admitted to the surgical intensive care unit (SICU) at a municipal hospital over a 20-month period. Rates of nosocomial infection were higher in the SICU patients (31% vs 24%). The SICU patients had more urinary tract infections, bacteremias, and wound infections, and the MICU patients were older, had higher acute physiology scores on admission and were more often admitted with shock or coma. The SICU patients were more likely to have received prior antibiotic therapy and had significantly higher numbers of endotracheal tubes, arterial lines, central venous lines, and indwelling bladder catheters. Of the 23 variables univariately associated with nosocomial infection, only five remained significant after entry into stepwise regression models. The MICU patients had a higher fatality rate in the MICU than did the SICU patients (18% vs 10%), but the relative risk of a death following nosocomial infection was 3.5 for both groups. Thirty variables were significantly associated with hospital fatality; nine remained significant after analysis by stepwise logistic regression. (Arch intern Med1988;148:1161-1168)

Nosocomial infection and fatality in medical and surgical intensive care unit patients.

The septic multiple-trauma patient.

Selective intestinal decontamination in the prevention of bacterial infection in patients with acute liver failure

In the 20 years 1958-77 598 deaths were registered as due to accidental poisoning in British children under the age of 10-343 boys and 255 girls. Drugs caused 484 deaths, non-medicinal products 111, and plants three. The annual number of deaths reached a peak in 1964 but fell steadily thereafter; 16 deaths occurred in 1977. After 1970 tricyclic antidepressants replaced salicylates as the most commonly fatal poison. The next ten drugs most often recorded in 1970-7 were, in order, opiates (including diphenoxylate/atropine (Lomotil)), barbiturates, digoxin, orphenadrine (Disipal), quinine, potassium, iron, fenfluramine (Ponderax), antihistamines, and phenothiazines. In 20 years paracetamol caused one death, and before 1976 deaths caused by aspirin had fallen to fewer than two a year. Thus the introduction in 1976 and 1977 of safety packaging of these drugs can be expected to have little impact on the mortality from them in childhood.

https://www.bmj.com/content/bmj/280/6231/1595.full.pdf

Accidental poisoning deaths in British children 1958-77

The infection (36%) and mortality rates (28%) were investigated in 433 patients admitted to a Respiratory Intensive Care Unit. It was found that the mortality rate was higher (45%) in the infected group than in the non-infected group (19%) and particularly so in patients who had had intra-abdominal surgery or who remained in the unit for longer than a week.

A survey of infection in an intensive care unit. "Forewarned is forearmed".

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A survey of infection in an intensive care unit. "Forewarned is forearmed".