Controlling antibiotic resistance in intensive care units

Colonisation with multidrug resistant bacteria, especially resistant Gram-negatives, occurs frequently and increasingly in intensive care units (ICUs), also in the Netherlands. Infections caused by (resistant) microorganisms increase morbidity and mortality in this vulnerable patient group. This necessitates more effective control measures. Current infection control strategies include hand hygiene programs, body washing with chlorhexidine, screening plus isolation of identified carriers and selective digestive (and oral) decontamination. Hand hygiene is generally low in ICUs. Most evidence on the effect of improved hand hygiene on infection rates stems from observational studies. However, it is likely futile to implement costly, labour-intensive interventions without optimising basic hygiene. Chlorhexidine body washing has been proven effective in reducing methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci, but not resistant Gramnegatives. Reported effects of rapid screening plus isolation are conflicting, and mostly include just MRSA. Selective digestive (and oral) decontamination reduced the 28-day mortality in Dutch ICUs in a large trial, and is considered standard of care in most ICUs in the Netherlands. Hand hygiene, despite a lack of rigorously performed trials, should be improved in ICUs as part of normal hygienic measures. Our findings do not support the use of chlorhexidine body washing in Dutch ICUs, as MRSA prevalence is low. For patients at high risk for MRSA carriage, rapid screening can reduce unnecessary isolation days. The control of resistant Gram-negative bacteria will be a major challenge in the coming years, also in the Netherlands. We will need new methods to control the spread of these microorganisms, as current strategies have not proven effective.