Todd Fraser on 16-07-2013
Selective Digestive Decontamination, or SDD, remains one of the most maligned therapeutic strategies going around.
Rumour is that a major international multi centre randomised controlled trial is about to be launched. There has been a truckload of evidence in support of this preventative strategy yet except for isolated pockets of enthusiasm, it remains largely shunned.
In coming months, information will be circulated and centres approached to participate in the trial, which aims to be the definitive work on the topic. Hopefully this will answer the question once and for all.
Would you participate? The answer depends on the questions being asked I guess.
Is there equipoise? There seems already to be enough evidence that it works, but perhaps the question is "does it work enough?". In other words, is the benefit sufficient to overcome the reluctance to implement the strategy due to concerns over resistance, cost and imposed workload.
Another interesting question for the investigators will be the regimen that is used in the trial, and the sites chosen. Will the regimen contain IV antibiotics? Will the sites be representative of areas where antibiotic resistance is high?
To answer these and many other questions, we'll soon conduct an interview with one of the principle investigators, and bring that to you soon.
In the mean time, let me know your thoughts on SDD, whether you use it, what your concerns are, and whether you'd participate in the trial.
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There is no doubt in my mind the major reason this has not taken off is the concerns over resistance generation. I can't see how this question can be answered even in a big RCT as the time to develop resistance might be longer than the duration of the study. I'd love to hear from the investigators how they plan to overcome this limitation.
I don't know that antibiotic resistance has never been associated with SDD. These claims are more scare tactics than real life. It has been practiced in Netherlands for decades without concerns
I'll declare my COI up front, as one of the SuDDICU Investigators. We are a multinational collaboration of intensivists, infectious diseases physicians, microbiologists, nurses, ethicists, statisticians, health economists, clinical trial methodologists .... Our goal is to do not just the next (37th) RCT for the next Cochrane metaanalysis, but to do the DEFINITIVE trial which answers the question, one way or the other.
I'll be really interested to hear what the responses from most centres is to this trial. For everybody's sake, I hope that the collective opinion of our senior group ("I want this question answered, I just want somebody else to get it for me") is not too pervasive! I for one would not be too worried if I lost colistin and nystatin from my armamentarium. I was much more concerned by the use of lost 3rd gen cephalosporins and quinolones - losing them would be scary!
Sounds interesting. Will you be doing surveillance cultures as part of SDD or only if clinical indication?
Interesting that you say that the research coordinator will be doing all the work - not entirely true. You're also going to have a job on your hands convincing the nursing staff in the unit to do it. My understanding is that this can be laborious, unpleasant and time consuming, so winning the "hearts and minds" of the RNs might be difficult.
Okay, so I have the same conflict as Ian. I am one of the investigators. I also have a confession - I wish SDD was sexy. People think SDD is boring. This is the largest challenge in designing a trial in SDD. David is right. Winning hearts and minds is crucial.
Is it really boring? I wouldn't have thought so.
That's a very interesting point Freddo. It would be great to know what the issues are that have prevented SDD from becoming more widely adopted. I would imagine someone would have looked into this in more detail.
Thanks for all the comments to date.