Prevention of cross-transmission of antibiotic-resistant pathogens by using closed instead of open endotracheal suction systems in mechanically ventilated intensive care patients

Cross-transmission (patient to patient spread) of antibiotic-resistant bacteria frequently occurs in intensive care units (ICU). Among mechanically ventilated patients the respiratory tract is a preferential site for colonization with such pathogens. For these patients, endotracheal suctioning (ES) is an essential and frequently performed procedure. Yet, disconnection of the ventilation system and endotracheal tube during ES exposes colonized airways and contaminated material to open air with ongoing ventilation, and creates an optimal situation for air-borne spread of pathogens and cross-transmission. Controlling spread of antibiotic-resistant pathogens is of utmost importance in ICUs. Nowadays, two systems are available for ES: the single use open suction system (OSS) and the 'newer' multiple use closed suction system (CSS). CSS is increasingly used due to presumed patient benefits with regard to adverse physiolgic events and outcome, though we could not confirm these claims upon a systematic review. Importantly, the effects of CSS on reducing cross-transmission have never been evaluated. In a randomized cross-over study in 2 ICUs we will determine to what extent CSS, as compared to OSS, reduces the incidence of cross-transmission (as a proxy for reductions in ICU-acquired infections). Cross-transmission of 3 relevant marker pathogens will be determined upon surveillance cultures in combination with state-of-the-art molecular genotyping. All known confounders for cross-transmission will be determined prospectively. Secondary outcomes are length of ICU-stay, antibiotic use, cardio-respiratory adverse events and costs. As CSS is over 75 times as expensive as OSS a detailed cost-efficacy analysis is included. If CSS reduces cross-transmission in a cost-effective way this would be a feasible intervention for all ICUs that should become standard of care.