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Intensive care patients should be given prophylactic antibiotics

BMJ 2003; 327 doi: (Published 02 October 2003) Cite this as: BMJ 2003;327:770
  1. Tony Sheldon
  1. Utrecht

    Hospital deaths among patients in intensive care units could be cut by a quarter if patients were given a cocktail of prophylactic antibiotics, a large randomised controlled study in the Netherlands has said (Lancet 2003;362: 1011–6).

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    Advocating the use of prophylactic antibiotics in intensive care has been described as like “swearing in church”


    Amsterdam's Academic Medical Centre, which carried out the study, believes it has put the treatment back on the agenda by showing an “impressive reduction” in mortality in longer stay intensive care patients. It also shows that the rates of colonisation by resistant bacteria are lower and the stays in intensive care shorter. Giving intensive care patients antibiotics prophylactically resulted in an overall drop in the cost of antibiotics of more than 10%.

    The medical centre argues that restricting antibiotic use because of the dangers of growing resistance may not always be correct.

    The arguments for using prophylactic antibiotics with intensive care patients has a controversial 20 year history in the Netherlands, where the practice has been described as “like swearing in church.” Figures from the European Surveillance of Antimicrobial Consumption (an international network of surveillance systems) show that in 2001, Dutch hospitals were among the lowest consumers of antibiotics by volume in Europe. French hospitals consumed more than double the Dutch hospitals.

    In 1984, Chris Stoutenbeek, who was professor in intensive care and head of the centre's intensive care department (but who has since died), developed the selective decontamination of the digestive tract. He argued that intensive care patients ran a risk of dying from hospital infections, mostly preceded by pathogenic micro-organisms colonising the throat, stomach, and gut. A combination of antibiotics could kill these potentially dangerous aerobic bacteria while leaving undisturbed the normally present anaerobic intestinal bacteria that protect against potential infection.

    Between 1999 and 2001 the centre selected a group of more than 900 intensive care patients who were expected either to be on ventilation for at least two days or to remain in intensive care for at least three. Half were given normal treatment, the other half four antibiotics (polymyxin E, tobramycin, amphotericin B, and cefotaxime).

    Intensive care death rates among patients given prophylactic antibiotics were 15% (69/466) compared with 23% (107/468) among the control group (P=0.002). During the whole hospital stay, deaths were 24% (113) and 31% (146) respectively (P=0.02). The study also found unexpectedly lower rates of infection with antibiotic resistant bacteria—16% (61/378) v 26% (104/395) (P=0.001). Average stays in intensive care were also shorter (6.8 days v 8.5 days).

    Dr Evert de Jonge from the hospital's intensive care department, who led the research, said it shows an “impressive reduction in mortality” in a Dutch setting where there are very low levels of vancomycin-resistant enterococcus and methicillin resistant Staphylococcus aureas (MRSA).

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