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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Gut overgrowth harms the critically ill patient requiring treatment on the intensive care unit

Abstract

Overgrowth is defined as ≥105 potential pathogens per ml of saliva and/or per g of faeces. There are six ‘normal’ potential pathogens carried by healthy individuals and nine ‘abnormal’ potential pathogens carried by individuals with underlying disease both chronic and acute. Surveillance cultures of throat and/or rectum are required to identify overgrowth of ‘normal’ and/or ‘abnormal’ potential pathogens. There is a qualitative and quantitative relationship between surveillance samples and diagnostic samples of tracheal aspirate and blood, i.e., as soon as potential pathogens reach overgrowth concentrations in the surveillance samples, the diagnostic samples become positive for identical potential pathogens. Digestive tract decontamination aims at the eradication of overgrowth in order to prevent severe infections of lower airways and blood. Parenteral cefotaxime controls overgrowth of ‘normal’ bacteria, and enteral polyenes control overgrowth of ‘normal’ Candida species. Enteral polymyxin and tobramycin (with or without) vancomycin control ‘abnormal’ overgrowth.

Key words: overgrowth, ‘normal’ potential pathogens, ‘abnormal’ potential pathogens, surveillance samples, diagnostic samples, selective digestive decontamination (SDD)

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The addition of enteral to parenteral antimicrobials may prolong antibiotic era

Abstract

Resistance to parenteral antimicrobials generally occurs within two years after introduction into general use. The site where de novo resistance develops has been acknowledged to be the gut. Overgrowth of abnormal flora, defined as 105 potential pathogens per g of faeces is a risk factor for resistance following increased spontaneous mutation leading to polyclonality and antimicrobial resistance. As parenteral antimicrobials generally fail to eradicate the abnormal carrier state in overgrowth concentrations due to sub-lethal concentrations in bile and mucus the enteral antimicrobials polymyxin/tobramycin aiming at converting the abnormal carrier state into normal carriage, are the essential component of selective decontamination of the digestive tract (SDD), because they eradicate carriage and overgrowth including resistant mutants, maintaining the usefulness of parenteral antimicrobials.

Keywords: normal carriage, abnormal carriage, overgrowth, mutation, polyclonality, resistance, selective decontamination of the digestive tract, parenteral antimicrobials, enteral antimicrobials

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