New England Journal of Medicine Volume 394 Issue 15 Page 1543-1545 April 16 2026

An editorial published in the New England Journal of Medicine on April 16, 2026, calls for renewed attention to selective digestive decontamination (SDD) as a strategy to prevent infections in critically ill patients receiving mechanical ventilation in intensive care units.

The article, authored by Michael Klompas and colleagues, reviews the evolving evidence on SDD, a prophylactic approach that involves applying non-absorbable antibiotics to the oropharynx and gastrointestinal tract to reduce bacterial overgrowth and translocation that can lead to ventilator-associated pneumonia and bloodstream infections.

According to the editorial, SDD has demonstrated consistent benefits in reducing infection rates and mortality in multiple randomized controlled trials and meta-analyses conducted primarily in European intensive care settings, where the practice has been more widely adopted.

The authors note that despite this evidence, SDD remains underutilized in many parts of the world, including the United States, due to concerns about antimicrobial resistance, variability in local epidemiology, and differences in ICU practices and antibiotic stewardship frameworks.

The editorial emphasizes that modern SDD protocols use topical, non-systemic antibiotics such as colistin, tobramycin, and amphotericin B, which are not absorbed in significant amounts and therefore pose a lower risk of driving systemic resistance compared to intravenous antibiotics.

Klompas and colleagues argue that fears about resistance should be weighed against the proven clinical benefits of SDD, particularly in high-risk populations, and that ongoing surveillance data from countries with long-term SDD use have not shown clear increases in resistance to systemic antibiotics attributable to the practice.

The authors call for further research to identify which patient populations benefit most from SDD, to refine protocols based on local microbiome data, and to integrate SDD into broader antimicrobial stewardship programs that monitor both clinical outcomes and resistance patterns.

They also highlight the need for standardized definitions and reporting in future studies to allow for better comparison across trials and settings, and suggest that SDD should be considered as part of a multifaceted approach to preventing ICU-acquired infections, alongside measures such as elevation of the head of the bed, oral care with chlorhexidine, and daily sedation interruptions.

The editorial concludes that while SDD is not a one-size-fits-all solution, the accumulating evidence supports its reconsideration as a valuable tool in infection prevention for mechanically ventilated patients, particularly in settings with high baseline rates of ventilator-associated infections.