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Protective isolation and antimicrobial decontamination in patients with high susceptibility to infection. A prospective cooperative study of gnotobiotic care in acute leukaemia patients. III: The quality of isolation and decontamination.

In a cooperative study, the quality of protective isolation and of antibiotic decontamination of the digestive tract was studied in patients with acute leukaemia by (bio)-typing of Enterobacteriaceae species, Pseudomonas aeruginosa and Staphylococcus aureus isolated from oral washings and faecal samples. These samples were collected before and during treatment of 82 patients who were either isolated and decontaminated for which latter purposes a combination of neomycin, polymyxin, bacitracin and nystatin was used (group A); isolated without decontamination (Group B) or treated on the ward without decontamination (Group C). The results indicated that protective isolation had only been completely successful during the entire (remission induction) treatment period in one of the 32 patients in Group B. In Group A patients, who underwent antibiotic decontamination in addition, successful isolation was achieved in 57% of 28 patients. Successful antibiotic decontamination of the digestive tract for the entire treatment period as far as all potentially pathogenic species are concerned, was realized in 4 (14%) of the 28 patients of Group A. Bacteriologically confirmed infections occurred in 50% of Group A patients, in 59% Group B patients and in 64% of Group C patients. It is concluded that the quality of isolation had in general been insufficient but that it was improved by oral nonabsorbable antibiotics and, furthermore, that the antibiotic decontamination procedure also requires improvement.

Adolescent

A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract.

BACKGROUND: Selective decontamination of the digestive tract with topical nonabsorbable antibiotics has been reported to prevent nosocomial infections in patients receiving mechanical ventilation, and the procedure is used widely in Europe. However, it is unclear whether selective decontamination improves survival. METHODS: We conducted a randomized, double-blind multicenter study in which 445 patients receiving mechanical ventilation in 15 intensive care units were given either prophylactic nonabsorbable antibiotics (n = 220) or a placebo (n = 225). Topical antibiotics (tobramycin, colistin sulfate, and amphotericin B) or a placebo was administered through a nasogastric tube and applied to the oropharynx throughout the period of ventilation. The main end points were the mortality rate in the intensive care unit and within 60 days of randomization. RESULTS: A total of 142 patients died in the intensive care unit; 75 (34 percent) in the treatment group and 67 (30 percent) in the placebo group (P = 0.37). Mortality within 60 days of randomization was similar in the two groups (P = 0.40), even after adjustment for factors that were either unbalanced or individually predictive of survival in the two groups (P = 0.70). Pneumonia developed in 59 patients (13 percent) in the intensive care unit within 30 days of enrollment in the study (33 in the placebo group and 26 in the treatment group, P = 0.42). Pneumonia acquired in the intensive care unit and due to gram-negative bacilli was less frequent (P = 0.01) in the treatment group than in the placebo group. The total charges for antibiotics were 2.2 times higher in the treatment group. CONCLUSIONS: Selective decontamination of the digestive tract does not improve survival among patients receiving mechanical ventilation in the intensive care unit, although it substantially increases the cost of their care.

Administration, Topical

Role of selective digestive decontamination (SDD) in the prevention of nosocomial pneumonia (NP): is gastric decontamination necessary?

In the course of a prospective selective digestive decontamination (SDD) trial to prevent nosocomial pneumonia (NP) during mechanical ventilation (MV), we carried out serial cultures of gastric aspirate to assess the importance of gastric colonization for potential respiratory pathogens and its relationship to the simultaneous gastric pH, to whether the patients were receiving Sucralfate or Ranitidine and to the nutritional biochemical parameters. If NP developed, a bronchial sample was taken by fibreoptic bronchoscopy to determine the causal organisms and its relationship to the previous gastric isolated. Results show: 1) Increase in aerobic Gram negative bacilli colonization during hospitalization. 2) Direct relationship between colonization level and gastric pH. 3) Greater pH in ranitidine vs sucralfate group. 4) Low incidence of NP (11%), the majority of these (66%) being early. 5) No bacteriological correlation between gastric colonization and aetiological agents of NP. 6) Close relationship between pharyngeal colonization and causative germs of pulmonary infection (40%).

Adolescent

Selective decontamination of the digestive tract in the intensive care unit: current status and future prospects.

OBJECTIVE: To evaluate the available data on selective decontamination of the digestive tract. This therapy aims to prevent infection in critically ill patients admitted to ICUs. Microbial carriage in the oropharynx, stomach, and gut; infection; mortality rate; and antibiotic resistance are the outcome events that are being reviewed. DATA SOURCES: Published indices, abstract booklets, and conference proceedings up to the end of 1990. STUDY SELECTION: Sixteen controlled trials of selective decontamination were identified. None of these trials was conducted as a randomized, placebo-controlled, double-blind trial. DATA EXTRACTION: Each of the three authors independently conducted a meta-analysis (thorough review) of the data from the 16 studies. DATA SYNTHESIS: Of the 16 trials, 15 show significant reduction of acquired infection among patients who received selective decontamination. Of the 14 studies that consider carriage of disease-causing microorganisms as an outcome event, 13 demonstrate a reduction in carriage of Gram-negative bacilli. Only ten studies consider mortality as an end-point, of which four demonstrate that the administration of selective decontamination is associated with decreased mortality rates in certain subgroups but not in the overall mortality rate. Of 11 studies that provide data about antibiotic resistance during selective decontamination, ten reported no increase in resistant microorganisms. Selective decontamination has been reported to be effective in controlling an outbreak of multi-resistant microorganisms. CONCLUSIONS: There is a general consensus about the efficacy of selective decontamination in diminishing microbial carriage and acquired infection rates, although conclusions about benefits related to mortality rates vary. Differences in mortality rate are found in the selective decontamination studies of patients with curable diseases, including multitrauma and cardiovascular patients. More data on resistance, collected over a longer period of time, are needed. Practical problems of blinding and the major ecological effect of selective decontamination may explain the lack of a randomized, placebo-controlled, double-blind trial.

Anti-Bacterial Agents

Decontamination of chemical protective clothing.

This study explored decontamination procedures for removing some organic solvents from protective clothing. The permeation experiments were performed on new and decontaminated specimens in seven polymer/chemical pairs. The decontamination methods investigated were thermal decontamination and air drying at room temperatures followed by detergent washing. Breakthrough time and steady-state permeation rate were determined by two different methods for new and decontaminated materials. The results showed that unless the contamination is limited to the outside surface of an elastomer (a material found in most barrier fabrics used in chemical protective clothing) or the chemical has a very large diffusion coefficient in the material, aeration and washing with detergent may not be an effective decontamination procedure for the type of solvent studied. On the other hand, thermal decontamination was shown to be effective in removing the contaminant from the matrix of the elastomers, and the decontaminated materials had permeation parameters similar to the new materials.

Decontamination

Emergency department external decontamination for hazardous chemical exposure.

Although external decontamination is an integral aspect of the emergency management of hazardous chemicals exposure, no standard protocol or report of human experience is available. We performed a retrospective review of all patients decontaminated in our emergency department over a 6-y period for hazardous chemicals exposure. Patients were treated by a universal substances protocol in a specially designed decontamination area. Ocular irrigation utilizing 1500 ml of normal saline po was employed in 27 patients. Oral mucosal irrigation utilizing 1500 ml water was employed in 2 patients. All 72 patients received skin and hair decontamination. Skin was washed 3 times with detergent and cornmeal mixture, and water irrigation or shower for 3 min. Hair was shampooed 3 times with mild soap for 3 min. A subset of patients (n = 31) received pre-decontamination and post-decontamination skin swabbing. Swabs were analyzed by a certified analytical chemistry laboratory utilizing gas chromatography/mass spectrometry. Positive pre-decontamination swabs were seen for pesticides and PCBs. All post-decontamination swab analyses were negative, indicating that the method utilized was effective.

Clinical Protocols

Bacterial decontamination and antileukemic therapy of AKR mice.

Four nonabsorbable antibiotics (streptomycin, neomycin, bacitracin, and amphotericin B) and a germicidal dip solution (Zephiran chloride/water) were used to eliminate all the detectable bacteria from conventional AKR mice. Control mice were not decontaminated and were used as such. When antibiotic-decontaminated and control mice developed clinical manifestations of spontaneous lymphatic leukemia, each was treated for the disease with an antitumor drug (cyclophosphamide [CP]) at weekly intervals. With the decontamination procedure, mice of each of the two groups became bacteria-free after 16 weeks of continuous oral administration of the antibiotics and two separate germicidal dippings. All decontaminated mice remained free of bacteria throughout the experiment. The bacterial flora of the control mice remained unaltered. With CP therapy, the mean survival time of the female decontaminated mice was 65 days, whereas that of male mice was 218 days. The average survival time of the CP-treated control leukemic mice was 51 days. Untreated decontaminated or control mice usually died of leukemia within 7 days after the onset of symptoms of leukemia. Although CP therapy was not curative, it did prolong the life expectancy of the decontaminated mice significantly.

Amphotericin B

Pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit.

Selective decontamination of the oropharynx and gastrointestinal tract with nonabsorbable antimicrobials and sucralfate, a stress ulcer prophylactic that maintains the normal gastric acid bacterial barrier, were compared for prevention of pneumonia in a cardiac surgery intensive care unit. Over 8 months, 51 patients received selective decontamination and 56 received sucralfate. The selective decontamination regimen included polymyxin, gentamicin, and nystatin given as an oral paste and as a solution; patients also received standard antacid or histamine2 blocker stress ulcer prophylaxis. Patients in the selective decontamination group had significantly less colonization of the oropharynx and stomach by gram-negative bacilli (12% vs. 55%, P less than .001), significantly fewer infections due to gram-negative bacilli (6% vs. 20%, P = .02), and fewer infections overall (12% vs. 27%, P = .04). There was one episode of pneumonia in the selective decontamination group and five in the sucralfate group. Mortality and length of stay did not differ between the groups, but those receiving selective decontamination had less than one-third as many days of systemic antibiotic therapy with no increase in colonization or infection with resistant gram-negative bacilli. Thus, selective decontamination appeared to reduce both extrapulmonary and pulmonary infections.

Anti-Bacterial Agents

Selective decontamination of the digestive tract in cardiac surgical patients.

OBJECTIVE: To test the hypothesis that selective decontamination of the digestive tract improves outcome in cardiac surgical patients. DESIGN: Prospective, consecutive, controlled trial over two 4-month periods. SETTING: Eight-bed, open-plan postcardiac surgery ICU. PATIENTS: All patients undergoing cardiac bypass surgery were eligible. Patients requiring endotracheal intubation for greater than 4 days were included in the analysis. In the initial 4 months, 12 (8.5%) of 141 patients required greater than 4 days of intubation. These 12 patients were not treated with selective decontamination of the digestive tract. We therefore used these patients as the control group. In the second 4-month period, 12 (6.6%) of 180 patients were treated with selective decontamination of the digestive tract and formed the study group. MAIN OUTCOME MEASURES: The primary measure was mortality. Secondary measures included oropharyngeal decontamination and the presence of lower airway infection. INTERVENTIONS: Cephradine prophylaxis. The study group received every 6 hrs 4 mL orally and 20 mL intragastrically a suspension of antimicrobial agents (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg), starting on postoperative day 1. The control group did not receive any oral antimicrobial agents. RESULTS: Mortality rate was significantly (p less than .05) reduced from eight (66%) of 12 patients in the control group to two (16.7%) of 12 patients in the selective decontamination of the digestive tract group. No differences in oropharyngeal decontamination or lower airway infection rates between the two groups were found. CONCLUSIONS: There is a reduced mortality rate in patients receiving selective decontamination of the digestive tract. However, the reader should recognize the small sample size studied. A simple suspension of the antimicrobial agents failed to rid the oropharynx of bacteria.

Administration, Oral

Techniques for radioactive decontamination in nuclear medicine.

Working with unsealed radioactive sources in nuclear medicine carries the potential risk of contamination. Careful design of a department and its operational procedures will minimize but never completely eliminate the possibility of such incidents occurring. Contingency planning forms as important a part of handling such incidents as the procedures to reduce the hazard once an incident has occurred. It should include anticipating where such incidents are likely to occur, training and exercising staff in the appropriate procedures to deal with these incidents, providing a comprehensive decontamination kit, and implementing a routine contamination monitoring survey. Assessing the magnitude of the radiation hazard and the effect of decontamination efforts, containing the spread of contamination, minimizing the radiation dose to individuals, and continuing to decontaminate to the lowest level possible are principles to follow in managing any incident. Nuclear medicine staff should be familiar with techniques for decontaminating different anatomical sites on the body; for eliminating or reducing the uptake of radioactivity absorbed into the body; and for decontaminating dry and wet surfaces, equipment, clothing, and bedding. Radiopharmaceutical dispensing procedures, ventilation scanning, and decontaminating 131I treatment areas are identified as the most likely causes of body surface and internal contamination of nuclear medicine staff.

Decontamination

Cutaneous absorption and decontamination of [3H]T-2 toxin in the rat model.

Cutaneous absorption and decontamination of [3H]T-2 mycotoxin using various treatment modalities incorporating water, detergent, sprays, and scrubbing of application sites were examined in the rat model at 5, 30, 60, and 1440 min (24 h) postexposure. Rats were killed immediately after treatment and radiolabeled T-2 remaining in full-thickness skin samples were determined. Absorption and decontamination were followed over time, and decontaminating treatment modalities were evaluated for efficacy. Less than 1% of the applied dose was absorbed in 5 min, and 50% was absorbed in 24 h. At 5 min, 99.5 +/- 0.05% of nonabsorbed (residual) [3H]T-2 was removed, and 58 +/- 5.2% of residual toxin was removed at 24 h with a 2.5% detergent/water spray. When treatment modalities were evaluated at 60 min, a 2.5% detergent/water scrub followed by a detergent/water spray produced optimal decontamination by removing 81 +/- 2.2% of residual toxin. All treatment modalities using detergent and/or water removed significant amounts of toxin (p less than or equal to .0001); a dry scrub was not efficacious. Treatment should be initiated as soon as possible after exposure for best results. However, the stratum corneum acts as a reservoir for the toxin, and decontamination should be carried out even if delayed several hours or days after exposure. Dermal absorption pharmacokinetics found in these studies are similar to those described for other low-molecular-weight compounds, and the decontamination results from T-2 toxin should be applicable to other, similar toxic substances.

Animals

Decontamination of aqueous solutions of biological stains.

Aqueous solutions of a number of biological stains were completely decontaminated to the limit of detection using Amberlite resins. Amberlite XAD-16 was the most generally applicable resin but Amberlite XAD-2, Amberlite XAD-4, and Amberlite XAD-7 could be used to decontaminate some solutions. Solutions of acridine orange, alcian blue 8GX, alizarin red S, azure A, azure B, Congo red, cresyl violet acetate, crystal violet, eosin B, erythrosin B, ethidium bromide, Janus green B, methylene blue, neutral red, nigrosin, orcein, propidium iodide, rose Bengal, safranine O, toluidine blue O, and trypan blue could be completely decontaminated to the limit of detection and solutions of eosin Y and Giemsa stain were decontaminated to very low levels (less than 0.02 ppm) using Amberlite XAD-16. Reaction times varied from 10 min to 18 hr. Up to 500 ml of a 100 micrograms/ml solution could be decontaminated per gram of Amberlite XAD-16. Fourteen of the 23 stains tested were found to be mutagenic to Salmonella typhimurium. None of the completely decontaminated solutions were found to be mutagenic.

Acrylic Resins

Selective decontamination of the digestive tract prevents secondary infection of the abdominal cavity, and endotoxemia and mortality in sterile peritonitis in laboratory rats.

BACKGROUND AND METHODS: This study was undertaken to find out whether translocation of bacteria to the abdominal cavity and endotoxemia in rats with sterile peritonitis could be prevented by selective decontamination of the digestive tract. Sterile peritonitis was caused by the intraperitoneal injection of either 100, 150, 200, or 300 mg of zymosan suspended in paraffin. RESULTS: The frequency of infection of the abdominal cavity depended on the dose of zymosan given, ranging from 20% in rats receiving 100 mg to 89% in rats receiving 300 mg of zymosan. In rats not receiving antibiotics for selective decontamination of the digestive tract (the control group). Gram-negative bacilli were isolated from the digestive tract in all rats, and Gram-negative bacilli were isolated from the abdominal cavity in ten of 19 rats. In rats receiving antibiotics for selective decontamination of the digestive tract, Gram-negative bacilli were isolated from the digestive tract in none of the 14 rats, and likewise, Gram-negative bacilli were isolated from the abdominal cavity in none of the 14 rats (p < .005). Moreover, in rats receiving antibiotics for selective decontamination of the digestive tract, endotoxin levels in feces and plasma were significantly lower, as compared with rats not receiving antibiotics for selective decontamination of the digestive tract. CONCLUSION: Selective decontamination of the digestive tract prevents translocation of Gram-negative bacilli to the abdominal cavity, and endotoxemia and mortality in rats with sterile peritonitis.

Animals

In vivo percutaneous absorption and skin decontamination of alachlor in rhesus monkey.

The objectives of this study were to determine the percutaneous absorption of alachlor relative to formulation dilution with water, and to determine the ability of soap and water, and of water only, to remove alachlor from skin, relative to time. Alachlor is a preemergence herbicide. The in vivo percutaneous absorption of alachlor in rhesus monkeys was 17.3 +/- 3.3, 15.3 +/- 3.9, and 21.4 +/- 14.2% for 24-h skin exposure to Lasso formulation diluted 1:20, 1:40, and 1:80, respectively. In vivo, there was no support for increased alachlor skin absorption with water dilution, as previously reported for in vitro absorption. The average in vivo absorption of 18% applied dose over 24 h (0.75%/h) was similar to the maximum in vitro rate of 0.8%/h using human skin and human plasma as receptor fluid. Dose accountability in vivo was 80.6-95.2%. [14C]Alachlor in Lasso diluted 1:20 with water was placed on rhesus monkeys at concentrations of 23 micrograms/10 microliters/cm2. Skin decontamination at 0 h with soap and water (50% Ivory liquid 1:1 v/v with water) removed 73 +/- 15.8% (n = 4) of the applied dose with the first wash; this increased to a total of 82.3 +/- 14.8% with two additional washes. Decontamination after 1 h removed 87.5 +/- 12.4% with three successive washes. After 3 h decontamination ability decreased, and after 24 h only 51.9 +/- 12.2% could be recovered with three successive washes. Using water only, at 0 h 36.6 +/- 12.3% alachlor was removed with the first wash and the total increased to 56.0 +/- 14.0% with two additional washes. At 24 h the total amount decreased to 28.7 +/- 12.2% for three successive washes. Alachlor as Lasso in field-use rate (11 micrograms/cm2) and undiluted (217 and 300 micrograms/cm2) proportions were left on rhesus monkey skin for 12 h and decontaminated with soap and water (10% Ivory liquid v/v with water). Continual successive washes (6-8 in sequence) recovered 80-90% of the skin-applied alachlor. These results suggest that simple washing with soap and water is appropriate for removing some chemicals from skin. Decontamination with only water was less effective than with soap and water.

Acetamides

Intestinal decontamination in a polyvalent ICU. A double-blind study.

A double blind, placebo-controlled trial was performed to test the efficacy of prevention of nosocomial infections by selective digestive decontamination. Placebo or tobramycin (80 mg) and colistin (100 mg) was given four times daily via the gastric tube. Amphotericin B (500 mg/6 h) was administered to all patients. As our ICU is divided into two separate subunits, intestinal decontamination or placebo was administered alternatively to patients of the two subunits during two 3-month periods, separated by a 2-month period without prevention. The decontamination (n = 97) and placebo groups (n = 84) were similar with respect to age, sex, severity score and diagnostic categories on admission. Intestinal decontamination alone failed to significantly reduce the number of infected patients (26% vs 34.5%, p = 0.20), but was effective on ICU-acquired infections (0.33 vs 0.60, p = 0.02) especially gram-negative infection rates (0.17 vs 0.43, p = 0.01). The onset of the first ICU-acquired infection was delayed (9 vs 13 days, p less than 0.001) and incidence of pneumonia (2 vs 13 cases, p less than 0.01) including bacterial pneumonia (0 vs 8 cases, p less than 0.01) was significantly decreased. However, mean ICU stay and mortality were not significantly modified by intestinal decontamination.

Amphotericin B

Intestinal decontamination for control of nosocomial multiresistant gram-negative bacilli. Study of an outbreak in an intensive care unit.

STUDY OBJECTIVE: To study the efficacy of intestinal decontamination by oral nonabsorbable antibiotic agents to control a nosocomial outbreak of intestinal colonization and infection with multiresistant Enterobacteriaceae, and to examine its effects on endemic nosocomial infection rates. DESIGN: A 10-week prospective incidence study (group 1), and then an 8-week randomized, open trial of intestinal decontamination (groups 2 and 3). SETTING: A medical intensive care unit of a tertiary care university hospital. PATIENTS: Consecutive patients with unit stay of over 2 days and a severity score at admission of more than 2; 124 patients were included in group 1, 50 in group 2 (control), and 36 in group 3 (intestinal decontamination). INTERVENTIONS: Neomycin, polymyxin E, and nalidixic acid were given to group 3 patients throughout their stay in the unit. MEASUREMENTS AND MAIN RESULTS: Intestinal colonization with multiresistant strains occurred in 19.6% of patients in group 1, at a mean of 16 days after admission, and preceded detection in clinical samples by a mean of 11 days. During the decontamination trial, intestinal colonization rates decreased to 10% (group 2), and 3% (group 3) (P = 0.12 and P less than 0.01, compared with group 1, respectively). Corresponding infection rates were 9% (group 1), 3% (group 2), and 0 (group 3). No new cases were detected in the following 4 months. The intestinal colonization rate with gram-positive cocci was higher in group 3 than group 2 (P less than 0.001). The overall rate of nosocomial infections was at 28% (group 1), 33% (group 2), and 32% (group 3). CONCLUSIONS: Intestinal decontamination can help to control an outbreak of intestinal colonization and infection with multiresistant gram-negative bacilli in the intensive care unit, but should not be recommended for routine prevention of endemic nosocomial infections.

Adult

Decontamination of human skin exposed to 2,3,7,8-tetrachlorodibenzo-p-Dioxin (TCDD) in vitro.

Human post-mortem skin was exposed in vitro to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) at 32 degrees C, under controlled humidity. In one-half of the samples, damage to the surface of the skin was simulated by stripping of the stratum corneum. After incubation with TCDD for 100 min, four different decontamination protocols were performed: (1) the sample was wiped with dry, adsorbent material (cotton balls); (2) a 10-min topical treatment with mineral oil was followed by dry wiping with cotton balls; (3) a 10-min topical treatment with mineral oil was followed by wiping with acetone-soaked cotton balls; and (4) the sample was washed with water and soap. After decontamination, skin samples were incubated (up to 300 min) again at 32 degrees C. One set of both intact and stripped TCDD-exposed skin samples was incubated for 300 min--absent decontamination--and was used as a control. Mineral oil treatment and acetone wipes, or water and soap, were effective in reducing (i.e., about two-fold) the amount of TCDD in the stratum corneum of intact skin. Mineral oil plus dry wipes reduced the amount of TCDD in the stratum corneum by about one-third, whereas dry wiping alone was ineffective. All protocols, however, were similarly effective in reducing the amount of TCDD in the epidermis and upper dermis; TCDD concentrations were decreased locally by factors of up to ten. In the lower dermis, a minimal effect of the decontamination procedures was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetone

[Study on decontamination of radioactive ruthenium by steel wool in waste solution (author's transl)].

Tracer experiments were done in order to establish a decontamination process of 106Ru in radioactive waste solution by column method paying special attention on the solution of nitratonitrosyl complex of Ru which is often encountered as a low level radioactive waste solution. It turned out that metallic iron was the most effective decontaminating agent among the several tens of materials tested. The decontamination factor (DF) of 106Ru increased in proportion to the total surface area of iron and it sensitively depended on the oxidation state of the surface as revealed by the batchwise and columnwise tests. Iron samples with high corrosiveness gave a much larger DF than those with low corrosiveness. The decontamination process proceeded as iron was being oxidized via Fe(metal)leads toFe(II)leads toFe(III). As the results, the DF initially increased after initiating the passage of water through the column but it then decreased as the oxidation process became inactive. An excellent durability up to 10000 bed volumes was demonstrated by the column method at a high average DF of 150.

Alloys