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Decontaminate inside and out: two is better than one.

Healthcare-associated infections (HAIs) are an important threat to patient safety and constitute a major public health problem. More than half of cases of the most common HAIs maybe preventable with current evidencebased strategies (1). Many deaths related to catheter-associated bloodstream infections (CABSI) and ventilator-associated pneumonia (VAP) may be preventable. These HAIs, especially CABSI, are also very costly (1, 2). ICU patients are at high risk of HAIs due to intrinsic and extrinsic risk factors, including severity of illness, immunocompromise, and invasive devices. Pathogenic microorganisms of HAIs often come from endogenous fiora of patients or from an exogenous source. Thus, eradication of colonizing organisms that usually cause HAIs is used as a prevention strategy. This is achieved by decontamination. Decontamination regimens are combined with hand hygiene and barrier precautions, which protect patients from exogenous organisms as well. Many infections during ICU stay, especially VAP, are endogenous, that is, caused by microorganisms from the oropharynx or the digestive tract. Pathogens may be part of patient's resident ñora (primary endogenous infections) or be caused by new organisms that have colonized the patient (secondary endogenous infections) (3). The former usually occur early, whereas the latter are generally diagnosed after 7 days of ICU stay. Early administration of IV antibiotics can prevent primary endogenous infections, and antimicrobials applied in oral cavity and given enterally may prevent secondary endogenous infections. Exogenous infections are less fi'equent, directly caused by pathogens without prior colonization, and controlled by hygiene measures. Selective decontamination of the digestive (SDD) tract is an antimicrobial prophylaxis against bronchopulmonary and bloodstream infections whose protocol generally combines the use of parenterai (short-course cefotaxime) and nonabsorbible antimicrobials (amphotericin-B or nystatin, polymyxin, and tobramycin, via enterai and applied in the oropharynx), together with hygiene and surveillance cultures (3).