Advertisement

Gut Microbiology: How to Use Surveillance Samples for the Detection of the Carrier Status of Abnormal Flora

  • Hendrick K.F. van Saene

Abstract

Critical illness impacts on all organ systems, such as lungs, heart and gut. This last organ also includes the vast living microbial tissue of the indigenous, mainly anaerobic, flora. That enormous bacterial tissue is embedded in the mucous layer and covers the inner wall of the gut. Of all aerobic Gram-negative bacilli (AGNB), the indigenous Escherichia coli is the only one carried in the gut by healthy people. It is critical illness that converts the status of normal carriage of E. coli into carriage of abnormal AGNB, including Klebsiella, Enterobacter, Pseudomonas species and methicillin-resistant Staphylococcus aureus (MRSA) [1]. It is hypothesised that receptors for AGNB and MRSA are constitutively expressed on the mucosal lining, but are covered by a protective layer of fibronectin in the healthy mucosa. Significantly increased levels of salivary elastase have been shown to precede AGNB carriage in the oropharynx in postoperative patients and in the elderly [2, 3]. It is probable that in individuals suffering both acute and chronic underlying illness, activated macrophages release elastase into mucosal secretions, thereby denuding the protective fibronectin layer. It is thought that this possible mechanism is a deleterious consequence of the inflammatory response encountered during and after illness. This shift towards abnormal flora as a result of underlying disease is aggravated by most iatrogenic interventions in the septic patient. Gut protection using H2 antagonists raises gastric pH, thereby impairing the gastric acidity barrier [4].

Keywords

Rectal Swab Surveillance Culture Selective Decontamination Diagnostic Sample Endogenous Infection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    van Saene HKF, Damjanovic V, Alcock SR (2001) Basics in microbiology for the patient requiring intensive care. Curr Anaesth Crit Care12:6–17CrossRefGoogle Scholar
  2. 2.
    Dal Nogare AR, Toews GB, Pierce AK (1987) Increased salivary elastase precedes Gram-negative bacillary colonization in postoperative patients. Am Rev Respir Dis 135:671–675Google Scholar
  3. 3.
    Palmer LB, Albulak K, Fields S et al (2001) Oral clearance and pathological oropharyngeal colonisation in the elderly. Am J Respir Crit Care Med 164:464–468PubMedGoogle Scholar
  4. 4.
    Hillman KM, Riordan T, O’Farrell SM et al (1982) Colonization of the gastric contents in critically ill patients. Crit Care Med 10:444–447PubMedCrossRefGoogle Scholar
  5. 5.
    Vollaard EJ, Clasener HAL (1994) Colonization resistance. Antimicrob Agents Chemother 38:409–414PubMedGoogle Scholar
  6. 6.
    Husebye E (1995) Gastro-intestinal motility disorders and bacterial overgrowth. J Intern Med 237:419–427PubMedCrossRefGoogle Scholar
  7. 7.
    Marshall JC, Christou NV, Meakins JL (1988) Small-bowel bacterial overgrowth and systemic immuno-suppression in experimental peritonitis. Surgery 104:404–411PubMedGoogle Scholar
  8. 8.
    van Uffelen R, van Saene HKF, Fidler V et al (1984) Oropharyngeal flora as a source of bacteria colonizing the lower airways in patients on artificial ventilation. Intensive Care Med 10:233–237PubMedCrossRefGoogle Scholar
  9. 9.
    Luiten EJT, Hop WCJ, Endtz HP et al (1998) Prognostic importance of gram-negative intestinal colonization preceding pancreatic infection in severe acute pancreatitis. Intensive Care Med 24:438–445PubMedCrossRefGoogle Scholar
  10. 10.
    Damjanovic V, Van Saene HKF (2005) Microbial mutation as a source of polyclonality in the gut of the critically ill. J Hosp Infect 59:374–375PubMedCrossRefGoogle Scholar
  11. 11.
    Tayler ME, Oppenheim BA (1991) Selective decontamination of the digestive tract as an infection control measure. J Hosp Infect 71:271–278CrossRefGoogle Scholar
  12. 12.
    Damjanovic V, Connolly CM, van Saene HKF et al (1993) Selective decontamination with nystatin for control of a Candida outbreak in a neonatal intensive care unit. J Hosp Infect 24:245–259PubMedCrossRefGoogle Scholar
  13. 13.
    Silvestri L, Milanese M, Oblach L et al (2002) Enteral vancomycin to control methicillin-resistant Staphylococcus aureus outbreak in mechanically ventilated patients. Am J Infect Control 30:391–399PubMedCrossRefGoogle Scholar
  14. 14.
    Go ES, Urban C, Burns J et al (1994) Clinical and molecular epidemiology of Acinetobacter infections sensitive only to polymyxin B and sulbactam. Lancet 344:1329–1332PubMedCrossRefGoogle Scholar
  15. 15.
    Damjanovic V, van Saene HKF, Weindling AM (1994) The multiple value of surveillance cultures: an alternative view. J Hosp Infect 28:71–78PubMedCrossRefGoogle Scholar
  16. 16.
    Mobbs KJ, van Saene HKF, Sunderland D et al (1999) Oropharyngeal Gram-negative bacillary carriage. A survey of 120 healthy individuals. Chest 115:1570–1575PubMedCrossRefGoogle Scholar
  17. 17.
    Crossley K, Solliday J (1980) Comparison of rectal swabs and stool cultures for the detection of gastro-intestinal carriage of Staphylococcus aureus. J Clin Microbiol 11:433–434PubMedGoogle Scholar
  18. 18.
    Mobbs KJ, van Saene HKF, Sunderland D et al (1999) Oropharyngeal Gram-negative bacillary carriage in chronic obstructive pulmonary disease: relation to severity of disease. Respir Med 93:540–545PubMedCrossRefGoogle Scholar
  19. 19.
    van der Spoel JI, Oudemans-van Straaten HM, Stoutenbeek CP et al (2001) Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure — a prospective, double-blind, placebo-controlled trial. Intensive Care Med 27:822–827PubMedCrossRefGoogle Scholar
  20. 20.
    Toltzis P, Yamashita T, Vilt L et al (1997) Colonization with antibiotic-resistant Gram-negative organisms in a pediatric intensive care unit. Crit Care Med 25:538–544PubMedCrossRefGoogle Scholar
  21. 21.
    Viviani M, van Saene HKF, Dezzoni R et al (2005) Control of imported and acquired methicillin-resistant Staphylococcus aureus (MRSA) in mechanically ventilated patients: a dose-response study of enteral vancomycin to reduce absolute carriage and infection. Anaesth Intensive Care 33:361–372PubMedGoogle Scholar
  22. 22.
    van Saene HKF, Damjanovic V, Murray AE et al (1996) How to classify infections in intensive care units — the carrier state, a criterion whose time has come? J Hosp Infect 33:1–12PubMedCrossRefGoogle Scholar
  23. 23.
    Silvestri L, Monti Bragadin C, Milanese M et al (1999) Are most ICU-infections really nosocomial? A prospective observational cohort study in mechanically ventilated patients. J Hosp Infect 42:125–133PubMedCrossRefGoogle Scholar
  24. 24.
    Petros AJ, O’Connell M, Roberts C et al (2001) Systemic antibiotics fail to clear multi-drug-resistant Klebsiella from a pediatric ICU. Chest 119:862–866PubMedCrossRefGoogle Scholar
  25. 25.
    de la Cal MA, Cerda E, Garcia-Hierro P et al (2001) Pneumonia in patients with severe burns. A classification according to the concept of the carrier state. Chest 119:1160–1165CrossRefGoogle Scholar
  26. 26.
    Silvestri L, Sarginson RE, Hughes J et al (2002) Most nosocomial pneumonias are not due to nosocomial bacteria in ventilated patients. Evaluation of the 48h time cut-off using carriage as the gold standard. Anaesth Intensive Care 30:275–282PubMedGoogle Scholar
  27. 27.
    Stoutenbeek CP (1989) The role of systemic antibiotic prophylaxis in infection prevention in intensive care by SDD. Infection 17:418–421PubMedCrossRefGoogle Scholar
  28. 28.
    Sirvent JM, Torres A, El-Ebiary M et al (1997) Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 155:1729–1734PubMedGoogle Scholar
  29. 29.
    Alvarez-Lerma F, and the ICU-pneumonia study group (1996) Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med 22:387–394PubMedCrossRefGoogle Scholar
  30. 30.
    Hammond JMJ, Potgieter PD, Saunders GL et al (1992) Double blind study of selective decontamination of the digestive tract in intensive care. Lancet 340:5–9PubMedCrossRefGoogle Scholar
  31. 31.
    Morar P, Singh V, Makura Z et al (2002) Differing pathways of lower airway colonization and infection according to mode of ventilation (endotracheal versus tracheotomy). Arch Otolaryngol Head Neck Surgery 128:1061–1066Google Scholar
  32. 32.
    Morar P, Makura Z, Jones AS et al (2000) Topical antibiotics on tracheostoma prevents exogenous colonization and infection of lower airways in children. Chest 117:513–518PubMedCrossRefGoogle Scholar
  33. 33.
    Baxby D, van Saene HKF, Stoutenbeek CP et al (1996) Selective decontamination of the digestive tract: 13 years on, what it is and what it is not. Intensive Care Med 22:699–706PubMedCrossRefGoogle Scholar
  34. 34.
    D’Amico R, Pifferi S, Leonetti C et al (1998) Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomized controlled trials. BMJ 316:1275–1285PubMedGoogle Scholar
  35. 35.
    Nathens AB, Marshall JC (1999) Selective decontamination of the digestive tract in surgical patients. A systematic review of the evidence. Arch Surg 134:170–176PubMedCrossRefGoogle Scholar
  36. 36.
    Corbella X, Pujol M, Ayats J et al (1996) Relevance of digestive tract colonization in the epidemiology of nosocomial infections due to multiresistant Acinetobacter baumannii. Clin Infect Dis 23:329–334PubMedGoogle Scholar
  37. 37.
    de la Cal MA, Cerda E, van Saene HKF et al (2004) Effectiveness and safety of oral vancomycin to control endemicity of methicillin-resistant Staphylococcus aureus in a medical/surgical intensive care unit. J Hosp Infect 56:175–183PubMedCrossRefGoogle Scholar
  38. 38.
    Hendrix CW, Hammond JMJ, Swoboda SM et al (2001) Surveillance strategies and impact of vancomycin-resistant enterococcal colonization and infection in critically ill patients. Ann Surg 233:259–265PubMedCrossRefGoogle Scholar
  39. 39.
    Silvestri L, Petros AJ, Sarginson RE et al (2005) Handwashing in the intensive care unit: a big measure with modest effects. J Hosp Infect 59:172–179PubMedCrossRefGoogle Scholar
  40. 40.
    Kollef MH, Sherman G, Ward S et al (1999) Inadequate antimicrobial treatment of infections. Chest 115:462–474PubMedCrossRefGoogle Scholar
  41. 41.
    Richards MJ, Edwards JR, Culver DH et al (1999) Nosocomial infections in medical intensive care units in the United States. Crit Care Med 27:887–892PubMedCrossRefGoogle Scholar
  42. 42.
    Langer M, Carretto E, Haeusler EA (2001) Infection control in ICU: back (forward) to surveillance samples? Intensive Care Med 27:1561–1563PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2008

Authors and Affiliations

  • Hendrick K.F. van Saene
    • 1
  1. 1.Department of Clinical Microbiology and Infection ControlRoyal Liverpool Children’s NHS Trust of Alder HeyLiverpoolUK

Personalised recommendations