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Its been a rotten couple of years for evidence based ICU medicine. It seems that we've systematically knocked down the pillars that support our practice. Just think - tight glycaemic control, activated protein C, steroids in severe sepsis, higher volume haemofiltration, higher PEEP - the list goes on. Yet one intervention with a strong evidence base has not been adopted - Selective Digestive tract Decontamination. Practiced with passion in many units in Europe, particularly in the Netherlands, it is virtually friendless in the UK, USA and Australia. But the available evidence seems to support its use. After numerous meta-analyses, randomised controlled trials and other studies, in 2008 the Cochrane Collaborative released its analysis of 36 trials comprising 6914 patients. They found that SDD (including systemic cefotaxime) reduced respiratory tract infections and mortality compared to controls. In those studies where systemic antibiotics are not used, the incidence of RTIs was reduced though mortality was not. Still, adoption of this technique has been slow. Commonly the reasons cited for this include fear of generating resistant organisms, cost and increased nursing workload. Soon after the release of the Cochrane review, de Smet et al released the largest RCT conducted thus far. Almost 6000 patients were randomised to SDD, selective oral decontamination (SOD) and standard oral care. They found that mortality was reduced equally in the SDD and SOD group compared with standard (a finding that was only apparent after correcting for co-variates). The authors conclude that systemic antibiotics do not add anything and it may be possible to omit them. This is of considerable importance given the association between cefotaxime and multi-resistant organism acquisition. So what are we to do with this? It is unlikely that further studies will clarify the situation further - so do we adopt SDD, SOD or not?