Elective Digestive Decontamination in the ICU: A Dynamic Population, Microsimulation Model
CCCF ePoster library. Schmidt M. Nov 8, 2018; 233365
Disclosure(s): Nothing to disclose
Dr. Marcello Schmidt
Dr. Marcello Schmidt
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Abstract
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Background: Selective digestive decontamination (SDD) – a  prophylactic use of oral and intravenously administered antibiotics at the onset of critical illness for patients at high risk of infection – decreases the number of infections and mortality. However, concern of antimicrobial resistance has prevented adoption of SDD. We aimed to determine the resulting level of colonization with antimicrobial resistant (AMR) pathogens at which SDD will no longer be beneficial to a patient.

Methods: We designed a microsimulation model to estimate the impact of SDD on antimicrobial resistance and health outcomes in the intensive care unit (ICU) setting compared to standard of care. We simulated a typical 12-bed ICU, utilizing 100% of its capacity over a ten-year period. Patients were admitted for a period of ten years and followed them until death. The model accounts for colonization with methicillin resistant Staphylococcus aureus (MRSA), vancomycin resistant enterococci (VRE), Clostridium difficile (CD), carbapenem resistant enterobacteriaceae (CRE), resistant gram-negative bacteria (RGNB) For the base-case, we assumed a “base case” two-fold increase in AMR colonization among newly admitted patients over the 10-year program period in the SDD arm. Outcome measures included infection and mortality rates, life years (LYs) and quality-adjusted life years (QALYs), discounted at 1.5%. We assessed parameter uncertainty in one-way sensitivity analyses.

Results: The overall infection rates in ICUs administering SDD were lower than standard of care (27.7% vs 35.3%). Mortality rates were also lower in the SDD group (ICU mortality: 23.3% vs 24.3%). Over a lifetime time horizon, SDD was associated with a mean expected gain of 0.24 LYs and 0.19 QALYs per patient. The results were sensitive to the relative risk of acquiring infection with SDD and increase in colonization rates. Threshold analysis indicated that a 270% increase in the prevalence of colonization with AMR pathogens over 10 years would mitigate the benefits of SDD.

Conclusion: Our study shows that SDD is beneficial from a health outcome perspective over a long period of time and accounting for a large increase in the rate of colonization with AMR pathogens. Evidence is needed to contextualize the thresholds for colonization with AMR pathogens at which SDD remains beneficial



 

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