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as colistin) instead. Although there is a more robust experience with selective digestive rather than oral

decontamination, both strategies are associated with a reduction in ventilator-associated pneumonia

without a concomitant change in mortality.165 Another systematic review demonstrated a reduction in

multiorgan failure rates, but not of mortality.166 A large crossover cluster trial of nearly 6,000 ICU

patients in Denmark demonstrated that SOD and SDD both decreased mortality by roughly 15%,

although SOD was markedly less expensive. For whatever reason, perhaps the concern for antibiotic

resistance, the practice of decontamination by either route has not garnered interest in the United

States. The Danish group has noted, however, that antibiotic resistance was actually lower after

institution of decontamination.167 However, another large Danish trial demonstrated that SDD patients

did experience higher rates of aminoglycoside resistance by gram negative organisms.168 Specific

strategies to provide MRSA decontamination are focused on certain principles: that MRSA colonization

can be rapidly identified by aggressive screening protocols using polymerase chain reaction (PCR)

technology, that MRSA colonization ultimately leads to bacteremia and that therapies exist to

successfully decolonize patients. The clinical data are confusing and various society guidelines have

reached different conclusions regarding universal screening. Nonetheless, in the United States, 35% or

more of all precaution days are due to MRSA and screening increases these contact days by 15%. A large

Veterans Affairs initiative involving both ward and ICU patients demonstrated that MRSA screening

decreased infection rates.169 Two other large studies, one of surgical patients

170 and another of mixed

ICU patients

171 did not show benefit of MRSA screening in lowering infection rate. Several studies have

investigated the role of MRSA-directed decontamination, using such agents as topical chlorhexidine on

washcloths and intranasal mupirocin with or without oral rifampin and doxycycline. This strategy has

been successful in liver transplant patients

172 and in mixed ICU patients

173 in terms of decreasing

colonization, infection, and bacteremia. A multicenter US study randomized ICUs to MRSA screening

and isolation, targeted decolonization, or universal decolonization with topical chlorhexidine and nasal

mupirocin. Interestingly, the latter strategy was associated with reduced MRSA colonization and allcause infections (but not MRSA), suggesting that chlorhexidine is the most efficacious component of the

strategy.173 Chlorhexidine can also decrease colonization, and perhaps infection, with VRE, but its effect

of gram negative organisms is less certain.174

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