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Treatment options for multidrug-resistant (MDR) bacterial infections are limited and often less effective. Non-pharmacologic approaches to preventing or treating MDR infections are currently restricted to improved antimicrobial stewardship and infection control practices. Fecal microbiota transplantation (FMT), a highly effective treatment for recurrentClostridium difficileinfection, has emerged as a promising therapy for intestinal MDR bacterial decolonization. A total of eight case reports have been published showing FMT resulted in intestinal decolonization of extended spectrum β-lactamase (ESBL)-producing and carbapenemase-producing Enterobacteriaceae, vancomycin-resistant Enterococci, or methicillin-resistantStaphylococcus aureus. The procedure has been shown to work even in immunocompromised patients and those experiencing medical crises without any adverse events. Five trials are currently underway to further investigate the use of FMT for MDR bacterial decolonization. FMT is a completely novel way to eradicate drug-resistant bacteria from the intestinal reservoir and should be further investigated to address the global problem of difficult-to-treat, MDR bacterial infections. [ABSTRACT FROM PUBLISHER]

Pediatric patients undergoing small bowel transplantation are susceptible to postoperative CLABSI. SDD directed against enteric microbes is a strategy for reducing CLABSI. We hypothesized that SDD reduces the frequency of CLABSI, infections outside the bloodstream, and allograft rejection during the first 30 days following transplant. A retrospective chart review of 38 pediatric small bowel transplant recipients at CCHMC from 2003 to 2011 was conducted. SDD antimicrobials were oral colistin, tobramycin, and amphotericin B. The incidence of CLABSI, infections outside the bloodstream, and rejection episodes were compared between study periods. The incidence of CLABSI did not differ between study periods (6.9 CLABSI vs. 4.6 CLABSI per 1000 catheter days; p = 0.727), but gram positives and Candida predominated in the first 30 days. Incidence of bacterial infections outside the bloodstream did not differ (p = 0.227). Rejection occurred more frequently during the first month following transplant (p = 0.302). SDD does not alter the incidence of CLABSI, bacterial infections outside the bloodstream, or allograft rejection in the immediate 30 days post-transplantation. However, SDD does influence CLABSI organism types (favoring gram positives and Candida) and Candidal infections outside the bloodstream. [ABSTRACT FROM AUTHOR]

We performed a meta-analysis to determine strategies for preventing hospital-acquired pneumonia that reduce mortality rates in critically ill patients. Selective digestive decontamination with systemic antimicrobial therapy is the sole intervention that reduces mortality, and its implementation should be a priority.Background. To determine the strategies of prevention of hospital-acquired pneumonia that reduce mortality in intensive care unit (ICU).Methods. We followed PRISMA (Preferred Reported Items for Systemic Reviews and Meta-Analyses) guidelines. We searched MEDLINE and the Cochrane Controlled Trials Register (through 10 June 2014) as well as reference lists of articles. We included all randomized controlled trials conducted in critically ill adult patients hospitalized in ICUs and evaluating digestive prophylactic methods (selective digestive decontamination [SDD], acidification of gastric content, early enteral feeding, prevention of microinhalation); circuit prophylactic methods (closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes) or oropharyngeal prophylactic methods (selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, tracheal cuff monitoring). One reviewer extracted data that were checked by 3 others. The primary outcome was the mortality rate in the ICU.Results. We identified 157 randomized trials to pool in a meta-analysis. The primary outcome was available in 145 studies (n = 37 156). The risk ratio (RR) for death was 0.95 (95% confidence interval [CI], .92–.99; P = .02) in the intervention groups. In subgroup analysis, only SDD significantly decreased mortality compared with control (n = 10 227; RR, 0.84 [95% CI, .76–.92; P < .001]). The RR for in-ICU death was 0.78 (95% CI, .69–.89; P < .001; I2 = 33%) in trials investigating SDD with systemic antimicrobial therapy and 1.00 (.84–1.21; P = .96; I2 = 0%) without systemic antimicrobial therapy.Conclusions. Selective digestive decontamination with systemic antimicrobial therapy reduced mortality and should be considered in critically ill patients at high risk for death. [ABSTRACT FROM PUBLISHER]

Introduction Among methods for preventing pneumonia and possibly also bacteremia in intensive care unit (ICU) patients, Selective Digestive Decontamination (SDD) appears most effective within randomized concurrent controlled trials (RCCT?s) although more recent trials have been cluster randomized. However, of the SDD components, whether protocolized parenteral antibiotic prophylaxis (PPAP) is required, and whether the topical antibiotic actually presents a contextual hazard, remain unresolved. The objective here is to compare the bacteremia rates and patterns of isolates in SDD-RCCT?s versus the broader evidence base. Methods Bacteremia incidence proportion data were extracted from component (control and intervention) groups decanted from studies investigating antibiotic (SDD) or non-antibiotic methods of VAP prevention and summarized using random effects meta-analysis of study and group level data. A reference category of groups derived from purely observational studies without any prevention method under study provided a benchmark incidence. Results Within SDD RCCTs, the mean bacteremia incidence among concurrent component groups not exposed to PPAP (27 control; 17.1%; 13.1-22.1% and 12 intervention groups; 16.2%; 9.1-27.3%) is double that of the benchmark bacteremia incidence derived from 39 benchmark groups (8.3; 6.8-10.2%) and also 20 control groups from studies of non-antibiotic methods (7.1%; 4.8 ? 10.5). There is a selective increase in coagulase negative staphylococci (CNS) but not in Pseudomonas aeruginosa among bacteremia isolates within control groups of SDD-RCCT?s versus benchmark groups with data available. Conclusion The topical antibiotic component of SDD presents a major contextual hazard toward bacteremia against which the PPAP component partially mitigates. [ABSTRACT FROM AUTHOR]

Purpose: Gut overgrowth is the pathophysiological event in the critically ill requiring intensive care. In relation to the risk of developing a clinically important outcome, gut overgrowth is defined as ≥10 potential pathogens including 'abnormal' aerobic Gram-negative bacilli (AGNB), 'normal' bacteria and yeasts, per mL of digestive tract secretion. Surveillance samples of throat and gut are the only samples to detect overgrowth. Gut overgrowth is the crucial event which precedes both primary and secondary endogenous infection, and a risk factor for the development of de novo resistance. Selective decontamination of the digestive tract (SDD) is an antimicrobial prophylaxis designed to control overgrowth. Methods: There have been 65 randomised controlled trials of SDD in 15,000 patients over 25 years and 11 meta-analyses, which are reviewed. Results and conclusions: These trials demonstrate that the full SDD regimen using parenteral and enteral antimicrobials reduces lower airway infection by 72 %, blood stream infection by 37 %, and mortality by 29 %. Resistance is also controlled. Parenteral cefotaxime which reaches high salivary and biliary concentrations eradicates overgrowth of 'normal' bacteria such as Staphylococcus aureus in the throat. Enteral polyenes control 'normal' Candida species. Enteral polymyxin and tobramycin, eradicate, or prevent gut overgrowth of 'abnormal' AGNB. Enteral vancomycin controls overgrowth of 'abnormal' methicillin-resistant S. aureus. SDD controls overgrowth by achieving high antimicrobial concentrations effective against 'normal' and 'abnormal' potential pathogens rather than by selectivity. [ABSTRACT FROM AUTHOR]

Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients. [ABSTRACT FROM AUTHOR]

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Discusses invasive fungal infections and the recurrence of hepatitis B virus and hepatitis C virus infections in orthotopic liver transplant recipients. Risk factors for fungal infections; Background and epidemiology of Candida species infection; Preventive measures.

Objective: To determine the comparative efficacy of selective decontamination of the digestive tract in critically ill surgical and medical patients, and in selected subgroups of surgical patients with pancreatitis, major burn injury, and those undergoing major elective surgery and transplantation. Data Sources: The MEDLINE database was searched from January 1966 to December 1996 using the terms "decontamination or prophylaxis," "intensive care units," and "antibiotics." The search was limited to English-language studies evaluating the efficacy of selective decontamination of the digestive tract in human subjects. Study Selection: The primary review was restricted to prospective randomized trials. Data Extraction: End points of interest included rates of nosocomial pneumonia, bacteremia, urinary tract infection, wound infection, mortality, and length of intensive care unit stay. Methodologic quality of individual studies was assessed using a previously described model. Data Synthesis: Odds ratios (ORs) together with their (95% confidence interval [CIs]) were reported and determined using the Mantel-Haenszel method. Mortality was significantly reduced with the use of selective decontamination of the digestive tract in critically ill surgical patients (OR, 0.7; 95% CI, 0.52-0.93), while no such effect was demonstrated in critically ill medical patients (OR, 0.91; 95% CI, 0.71-1.18). The greatest effect was demonstrated in studies where both the topical and systemic components of the regimen were used. Rates of pneumonia were reduced in both subsets of patients, while those of bacteremia were significantly reduced only in surgical patients. Conclusions: Selective decontamination of the digestive tract notably reduces mortality in critically ill surgical patients, while critically ill medical patients derive no such benefit. These data suggest that the use of selective decontamination of the digestive tract should be limited to those populations in whom rates ... [ABSTRACT FROM AUTHOR]

Selective digestive decontamination (SDD) involves the use of antibiotics to enhance the colonisation resistance of the gastrointestinal (GI) tract. This eradicates the Gram-negative organisms and fungi, if antifungals are used, which colonise the GI tract and subsequently cause infections in susceptible hosts. It has been used in patients who are critically ill and in intensive care units, in those who have multiple trauma or neutropenia and in bone marrow transplant recipients. SDD has been used in liver transplant patients perioperatively, in the prophylaxis of spontaneous bacterial peritonitis (SBP) and in acute liver failure. It has been shown to decrease the number of infections, specifically Gram-negative infections, in patients undergoing liver transplantation. SDD is very effective in the primary and secondary prophylaxis of SBP in cirrhotic patients with ascites. The use of the parenteral component of SDD is adequate in patients with acute liver failure. In both liver transplantation and SBP prophylaxis, mortality benefit has not been shown and the emergence of resistant organisms with the use of SDD is a concern. [ABSTRACT FROM AUTHOR]

These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice provide recommendations for the diagnosis and management of Candida infections in solid organ transplant recipients. Candida infections manifest primarily as candidemia and invasive candidiasis and cause considerable morbidity and mortality. Early diagnosis and initiation of treatment are necessary to reduce mortality. For both candidemia and invasive candidiasis, an echinocandin is recommended for initial therapy. However, early transition to oral therapy is encouraged when patients are stable and the organism is susceptible. Candida prophylaxis should be targeted for high‐risk patients in liver, small bowel, and pancreas transplant recipients. Future research should address which patient groups may benefit most from preventative antifungal therapy strategies. [ABSTRACT FROM AUTHOR]

Background: Bacterial infection in early period after liver transplant (LT) is the main cause of morbidity and mortality; however, data on children is limited. Methods: To investigate the frequency, characteristics, and the associated factors of bacterial infection during hospitalization after LT, we prospectively enrolled all consecutive children with LT for a one‐year, case‐control study at the unique referral center of pediatric LT in Iran. Results: Eighty‐five events of bacterial infection were detected among 51 out of 94 LT recipients (54.3%) (infection group). Forty‐three patients without bacterial infection constituted the control group. The frequency of bacterial infection based on the 51 microbiologically documented events was 31.9% (30 out of 94 patients). Major site of bacterial isolation were abdomen (43.6%). The following variables were associated with bacterial infection in univariate analysis: younger age (5.6 vs 8.9 years old), longer duration of JP Drain (13.4 vs 6.3 days), central venous catheter (14.6 vs 7.6 days), and Foley catheter insertion (7.3 vs 4.5 days), reoperation (57% vs 12% of patients), mean frequency of reoperation (1.1 vs 0.1 times), and intensive care unit stay (12.1 vs 6.5 days). In multivariate analysis, only longer hospital stay after transplant (23.6 vs 10.9 days) was independently associated with bacterial infection. All ten deaths occurred within the infection group and half of which directly caused by infection. Conclusions: These infections were associated with longer hospital stay and higher mortality rate. Conducting further studies with larger sample size and investigating more effective prophylactic measures should be considered in future studies. [ABSTRACT FROM AUTHOR]