The largest study to date of SDD was conducted in 13 ICUs in the Netherlands and showed a 28-day mortality reduction with the use of SDD and SOD of 3.5 and 2.9 per cent, respectively. In this trial, SDD consisted of four days of intravenous cefotaxime and topical application of tobramycin, colistin and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics.While rigorous, a significant limitation to this study was that it did not address the impact of antibiotic resistance. A follow up study was, therefore, conducted and showed that bacterial resistance in fact increased in the ICUs that used SDD/SOD. At this time, despite repeated and rigorous studies, SDD/SOD cannot be recommended for the prevention of VAP due to concern for emergence of antibiotic-resistant pathogens.