Clinical stakeholders' opinions on the use of selective decontamination of the digestive tract in critically ill patients in intensive care units: an international Delphi study

Abstract

Introduction: Selective decontamination of the digestive tract (SDD) is a prophylactic antibiotic regimen that is not widely used in practice. We aimed to describe the opinions of key 'stakeholders' about the validity of the existing evidence base, likely consequences of implementation, relative importance of their opinions in influencing overall practice, likely barriers to implementation and perceptions of the requirement for further research to inform the decision about whether to embark on a further large randomised controlled trial.

Methods: This was a Delphi study informed by comprehensive framework of possible determinants of health professionals' behaviour to study Critical Care practice in four countries. There were four key stakeholder participant groups including ICU physicians, pharmacists, clinical leads, and clinical microbiologists/ infectious disease physicians. Round one comprised participant interviews and Rounds two and three were online questionnaires using Delphi method.

Results: In this study, 141 participants were recruited of whom 82% were retained. Participants rated themselves as knowledgeable about SDD. Antibiotic resistance was identified as the most important issue. SDD was seen as a low clinical priority but few participants reported strong opposition. There was moderate agreement that research to date has not adequately addressed concerns about antibiotic resistance and lacks generalizability. Participants indicated equipoise with regard to benefits and harms of SDD, and indicated strong support for a further randomised trial.

Conclusions: Clinicians have clinical equipoise about the effectiveness of SDD. Future research requires longer follow up to assess antibiotic resistance as well as greater validity/generalizability to provide definitive answers on the effectiveness of decontamination and effects on antibiotic resistance. SDD was regarded as not being a high clinical priority, which may limit future trial participation. These results have identified that further large randomised controlled trial of SDD in critical care is both warranted and appropriate.

Figures

Figure 1

Opinions about the relevance of selective decontamination of the digestive tract. Response format: 1 = ‘strongly disagree’ to 9 = ‘strongly agree’. y axis, percentage of responders. SDD, selective decontamination of the digestive tract; VAP, ventilator-associated pneumonia.

Figure 2

Opinions on the internal and external validity and adequacy of the existing evidence base for selective decontamination of the digestive tract (SDD) and the likely consequences of implementing SDD in ICUs. Top two graphs: opinions on the internal and external validity and adequacy of the existing evidence base for selective decontamination of the digestive tract (SDD). Bottom four graphs: opinions on the likely consequences of implementing SDD in ICUs. Response format: 1 = ‘strongly disagree’ to 9 = ‘strongly agree’. y axis, percentage of responders.

Figure 3

Opinions about the likely barriers to implementing selective decontamination of the digestive tract in ICUs. Response format: 1 = ‘strongly disagree’ to 9 = ‘strongly agree’. y axis, percentage of responders. MM/ID, microbiologist/infectious disease specialists; SDD, selective decontamination of the digestive tract.

Figure 4

Opinions on the feasibility of further selective decontamination of the digestive tract research and whether professional groups are likely to participate. Response format: 1 = ‘strongly disagree’ to 9 = ‘strongly agree’. y axis, percentage of responders. SDD, selective decontamination of the digestive tract; VAP, ventilator-associated pneumonia.