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Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis
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  • Published on:
    Author's response to Dr. Hurley

    We thank Dr. Hurley for his interest in the manuscript and, hereby, respond to his 3 questions.
    1) We consider the in-hospital mortality of the patients included in both studies that were included in this individual patient-data cost-effectiveness meta-analysis to be representative for that patient population (i.e. ICU patients with an expected length of stay >48h) in Dutch ICUs. Due to the cluster design of both trials almost all eligible patients were enrolled in the De Smet study and all eligible patients were automatically included in the Oostdijk study.
    2) As mentioned in the Introduction, SDD is recommended by our national guidelines and is thus the standard of care in Dutch ICUs. The domain of our CEA was – as noted throughout the paper – ICU settings with low levels of AMR. The study that Dr. Hurley refers to (ref 20; Wittekamp et al. JAMA 2018) did not meet that domain, and was, therefore, not included.
    3) Current direct medical costs of SDD surveillance cultures were included in our bottom-up calculations (Table 3). Hypotheses on potential future scenarios due to potential increased antibiotic resistance were not explored. So far there is no scientific evidence that the long-term use of SDD or SOD leads to increased resistance to colistin or tobramycin in the setting of the included studies (Wittekamp et al. Critical Care 2015; Houben et al. JAC 2014; Buitinck et al. Crit Care 2019). Furthermore, the proportion of surveillance costs in total...

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    Conflict of Interest:
    None declared.
  • Published on:
    Three questions

    The findings here by Denise van Hout et al that in Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD is of great interest. However, do their findings support the implementation of SDD in settings with low levels of antimicrobial resistance? There are three specific questions.
    Firstly, is the hospital mortality of the SDD and SOD groups comparable to expected? In this regard, the untreated group from the original de Smet et al study [ref 13] had an in-hospital mortality that was not significantly different to either the SDD or SOD groups in an unadjusted analysis. Of note, Denise van Hout et al concede the play of chance as the best explanation for the difference in the findings of two included studies even with the two studies as large as they were.
    Second, why has the standard care group from the original de Smet et al study [ref 13] not been included in their analysis? As they note, SDD is not yet widely implemented in the Netherlands due to concerns in relation to prolonged selective antibiotic pressure. So, with this in mind, what is standard care in this context? Moreover, a large multi-center comparison to standard care [ref 20] has been excluded after failing to meet the study inclusion criteria. This [ref 20] study failed to demonstrate a mortality difference between these groups in a crude or an adjusted analysis.
    Thirdly, as the authors note, surveillance of respiratory and rectal carriage with Gram-negative ba...

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    Conflict of Interest:
    None declared.